Breast Cancer Research and Treatment

, Volume 151, Issue 3, pp 639–652 | Cite as

Hepatitis B virus screening before adjuvant chemotherapy in patients with early-stage breast cancer: a cost-effectiveness analysis

  • William W. L. Wong
  • Lisa K. Hicks
  • Hong-Anh Tu
  • Kathleen I. Pritchard
  • Murray D. Krahn
  • Jordan J. Feld
  • Kelvin K. Chan


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.


Hepatitis B reactivation Cost-effectiveness Early-stage breast cancer Adjuvant chemotherapy 



Chronic hepatitis B


Hepatitis B virus


Hepatitis B surface antigen


Hepatitis B “e” antigen


Hepatocellular carcinoma


Alanine transaminase


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.

Ethical standards

This study was conducted in compliance with the current laws of Canada.

Supplementary material

10549_2015_3382_MOESM1_ESM.docx (144 kb)
Supplementary material 1 (DOCX 144 kb)


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Copyright information

© Springer Science+Business Media New York 2015

Authors and Affiliations

  • William W. L. Wong
    • 1
    • 2
  • Lisa K. Hicks
    • 3
  • Hong-Anh Tu
    • 4
  • Kathleen I. Pritchard
    • 5
  • Murray D. Krahn
    • 1
    • 2
    • 4
  • Jordan J. Feld
    • 6
  • Kelvin K. Chan
    • 5
  1. 1.Toronto Health Economics and Technology Assessment Collaborative (THETA)University of TorontoTorontoCanada
  2. 2.Leslie Dan Faculty of PharmacyUniversity of TorontoTorontoCanada
  3. 3.St Michael’s HospitalTorontoCanada
  4. 4.Institute of Health Policy, Management and EvaluationUniversity of TorontoTorontoCanada
  5. 5.Sunnybrook Odette Cancer CenterTorontoCanada
  6. 6.Toronto Centre for Liver DiseaseUniversity Health NetworkTorontoCanada

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