Miami, FL—The best bet for preventing the reactivation of latent hepatitis B virus (HBV) infection before adjuvant chemotherapy is to screen patients with early-stage breast cancer for the virus, according to data presented at the 2014 Society for Medical Decision Making annual North American meeting. Lead investigator William W. L. Wong, MMath, PhD, Assistant Professor and Decision Modeller, Toronto Health Economics and Technology Assessment Collaborative, University of Toronto, Ontario, Canada, and his colleagues showed that it is cheaper in the long run to screen everyone than to test only individuals who are most likely to harbor HBV infection.
“There is no consensus on the strategy at the present time,” Dr Wong told Value-Based Cancer Care. “Our data suggest that screening everybody is cost-effective, even if the overall prevalence of hepatitis B virus in the population is only 0.4%.”
Dr Wong pointed out that the results are congruent with a 2012 article published by some of his coinvestigators, which showed that screening all patients with lymphoma for HBV before chemotherapy is cost-effective. Dr Wong also noted that his results mesh with recommendations for routine HBV screening before chemotherapy from the Centers for Disease Control and Prevention and the American Association for the Study of Liver Diseases.
However, the recommendations by Dr Wong and his colleagues are not in line with the American Society of Clinical Oncology provisional clinical opinion, which states that evidence does not support routine screening for HBV in patients receiving treatment for malignancies (Artz AS, et al. J Clin Oncol. 2010;28:3199-3202).
Dr Wong’s group used Markov computer modeling to test which screening strategy is the most cost-effective in women with early-stage breast cancer: not screening any of the patients, screening all patients and treating those who test positive for the HBV surface antigen with either lamivudine (Epivir) plus tenofovir (Viread) or entecavir (Baraclude), or screening only high-risk patients and treating those who test positive for HBV.
The results showed that the screen-all strategy would be associated with 2 severe reactivations of HBV per 100,000 people screened over the lifetime of the cohort, including none that would lead to mortality. By comparison, there would be 40 severe reactivations and 9 deaths with no screening, and 11 reactivations and 2 deaths with the screening of only high-risk patients. There would also be fewer interruptions of chemotherapy as a result of the treatment of HBV and/or its sequelae and fewer liver-related deaths with screening all patients versus screening only high-risk patients or no screening at all.
Furthermore, the screen-all strategy resulted in an increase of 0.0034 to 0.0035 quality-adjusted life-years (QALYs) and an additional cost of $164 to $266 (Canadian dollars) per person. The other 2 strategies would be less costly, but would not result in as large an increase in QALYs.
Overall, there would be a range of an incremental cost-effectiveness ratio of $47,808 per QALY gained to $76,527 per QALY gained with the screen-all strategy compared with no screening, depending on whether lamivudine plus tenofovir is used (lamivudine is much less expensive than entecavir).
Moreover, at a willingness-to-pay threshold of $100,000 per QALY, the screen-all approach was associated with a 97% probability of being cost-effective when the combination of lamivudine plus tenofovir is used compared with no screening.