Hepatitis B virus screening before adjuvant chemotherapy in patients with early-stage breast cancer: a cost-effectiveness analysis
- 470 Downloads
Most patients with hepatitis B virus (HBV) have no symptoms, and many are unaware of the infection. However, HBV can reactivate with immunosuppression; chemotherapy causes reactivation in 22 % of hepatitis B surface antigen-positive patients. HBV reactivation can be fatal. HBV reactivation can be prevented, provided that HBV is recognized prior to chemotherapy. The objective of this study is to estimate the health and economic effects of HBV screening strategies in patients receiving adjuvant chemotherapy for breast cancer. We developed a state-transition microsimulation model to examine the cost-effectiveness of three HBV screening strategies: (1) “No screening”; (2) “Screen-and-Treat to prevent reactivation” (screen-all) with either lamivudine/tenofovir (LAM/TDF) or entecavir (ETV); and (3) “Screen-and-Treat high-risk only” (screen-HR) and treat with either LAM/TDF or ETV. Model data were obtained from the published literature. We used a payer’s perspective, a lifetime horizon, and a 5 % discount rate for the analysis. “Screen-all” would prevent at least 38 severe reactivations per 100,000 persons screened over the lifetime of the cohort. “Screen-all” was associated with an increase of 0.0034–0.0035 QALYs and an additional cost of C$164–C$266 per person, which translated into an incremental cost-effectiveness ratio of C$47,808/QALY–C$76,527/QALY gained compared with “No screening” depending on the antiviral therapy received. “Screen-all” was the most cost-effective strategy, while “Screen-HR” was inferior in all scenarios tested. HBV screening before adjuvant chemotherapy for breast cancer patients would prevent a significant number of reactivations, would likely be moderately cost-effective, and may extend the lives of breast cancer patients.
KeywordsHepatitis B reactivation Cost-effectiveness Early-stage breast cancer Adjuvant chemotherapy
Chronic hepatitis B
Hepatitis B virus
Hepatitis B surface antigen
Hepatitis B “e” antigen
Quality-adjusted life years
Incremental cost-effectiveness ratio
This study was supported by Canadian Breast Cancer Foundation (CBCF) Ontario.
Conflict of interest
Dr. Hicks, Dr. Feld, and Dr. Chan have received grant support from Gilead Sciences. Dr. Pritchard has received consulting fee support from Sanofi-Aventis, AstraZeneca, Pfizer, Roche, Amgen, Novartis, GSK, Boehringer Ingelheim, Genomic Health, and Eisai. Other authors declare that they have no conflict of interest.
This study was conducted in compliance with the current laws of Canada.
- 3.Bonneterre J, Roche H, Kerbrat P, Bremond A, Fumoleau P, Namer M et al (2005) Epirubicin increases long-term survival in adjuvant chemotherapy of patients with poor-prognosis, node-positive, early breast cancer: 10-year follow-up results of the French Adjuvant Study Group 05 randomized trial. J Clin Oncol 23:2686–2693CrossRefPubMedGoogle Scholar
- 4.G. Early Breast Cancer Trialists’ Collaborative, Peto R, Davies C, Godwin J, Gray R, Pan HC et al (2012) Comparisons between different polychemotherapy regimens for early breast cancer: meta-analyses of long-term outcome among 100,000 women in 123 randomised trials. Lancet 379:432–444CrossRefGoogle Scholar
- 13.“TreeAge (2013) Professional” Williamstown, MA: TreeAge Software, 2013Google Scholar
- 19.Fattovich G, Giustina G, Schalm SW, Hadziyannis S, Sanchez-Tapias J, Almasio P et al (1995) Occurrence of hepatocellular carcinoma and decompensation in western European patients with cirrhosis type B. The EUROHEP study group on hepatitis B virus and cirrhosis. Hepatology 21:77–82PubMedGoogle Scholar
- 32.Papatheodoridis GV, Manolakopoulos S, Touloumi G, Vourli G, Raptopoulou-Gigi M, Vafiadis-Zoumbouli I et al (2011) Virological suppression does not prevent the development of hepatocellular carcinoma in HBeAg-negative chronic hepatitis B patients with cirrhosis receiving oral antiviral(s) starting with lamivudine monotherapy: results of the nationwide HEPNET. Greece cohort study. Gut 60:1109–1116CrossRefPubMedGoogle Scholar
- 33.Notifiable diseases on-line (Online) Public Health Agency of Canada, Ottawa. http://dsol-smed.phac-aspc.gc.ca/dsol-smed/ndis/c_time-eng.php
- 42.Gigi E, Lalla T, Orphanou E, Sinakos E, Vrettou E, Raptopoulou-Gigi M (2007) Long term follow-up of a large cohort of inactive HBsAg (+)/HBeAg (−)/anti-HBe (+) carriers in Greece. J Gastrointest Liver Dis 16:19–22Google Scholar
- 61.Grieco EM, Acosta YD, Cruz GP, Gambino C, Gryn T, Larsen LJ et al (2012) The foreign-born population in the United States: 2010. U.S. Department of Commerce, Economics and Statistics Administration, U.S. CENSUS BUREAU, Washington, DCGoogle Scholar
- 65.(2005) Choosing interventions that are cost effective (WHO-CHOICE). World Health Organization, GenevaGoogle Scholar
- 68.Artz AS, Somerfield MR, Feld JJ, Giusti AF, Kramer BS, Sabichi AL et al (2010) American Society of Clinical Oncology provisional clinical opinion: chronic hepatitis B virus infection screening in patients receiving cytotoxic chemotherapy for treatment of malignant diseases. J Clin Oncol 28:3199–3202CrossRefPubMedGoogle Scholar
- 69.Hicks LK et al (2015) Estimating the risk of HBV reactivation in patients receiving chemotherapy for solid tumors: a metaanalysis, to be submittedGoogle Scholar
- 71.Common Drug Review Drug Database (Online) Canadian Agency for Drugs and Technologies in Health, Ottawa. https://www.cadth.ca/cdr/reports
- 73.Schedule of Laboratory Fees (Online). Government of Ontario, Toronto. http://www.health.gov.on.ca/english/providers/program/ohip/sob/lab/labfimmu.html
- 75.(2004) In: Healthcare in Canada, Canadian Institute for Health Information, OttawaGoogle Scholar
- 76.Cancer Care Ontario (2014) Drug formulary. https://www.cancercare.on.ca/toolbox/drugformulary/. Accessed 04 Feb 2014
- 81.Hind D, Ward S, De Nigris E, Simpson E, Carroll C, Wyld L (2007) Hormonal therapies for early breast cancer: systematic review and economic evaluation. Health Technol Assess 11:iii–iv, ix–xi, 1–134Google Scholar