Analysis Suggests Screening All Patients Receiving R-CHOP for Lymphoma is Cost Effective

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(ChemotherapyAdvisor) – All patients who receive R-CHOP (rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone) chemotherapy for diffuse large B-cell lymphoma (DLBCL) should be screened for the hepatitis B virus (HBV) because such screening reduced rate of HBV reactivation by ten-fold and is less costly than screening either only patients at high risk or not screening at all, a cost-effective analysis published in the Journal of Clinical Oncology online June 18 has found.

The investigators evaluated a hypothetic cohort of previously untreated Canadian patients (median age, 65 years) with DLBCL undergoing first-line R-CHOP chemotherapy with curative intent. The primary cost outcome was direct medical cost (2011 Canadian dollars), and the primary health outcome was death averted at one year. Using a decision model, the clinical outcomes, costs, and cost effectiveness of three HBV screening strategies were compared: screen all patients for hepatitis B surface antigen, screen those at high risk for HBV infection, or screen no one. If patients tested positive, they were administered antiviral therapy until six months after completing R-CHOP chemotherapy.

Although absolute differences in costs were small, they found that screening everyone was least costly: $32,589 per patient (in Canadian dollars in 2010). The model assumed an incidence of HBV-related hepatitis of 0.6 per 1,000 patients, severe hepatitis of 0.1 per 1,000 patients, and no HBV-related deaths.

Screening only those at high risk would cost $32,598 per patient; the assumption was 2.0 per 1,000 patients would have intermediate rates of complications and 0.2 per 1,000 patients would die. Screening no one would cost $32,657 per patient; 5.9 per 1,000 patients would experience HBV-related hepatitis and 3.0 per 1,000 patients would experience severe hepatitis requiring hospitalization, and 0.8 per 1,000 patients would die as a result of HBV.

Screening all patients was also associated with highest one-year survival rate, 84.99%, vs. 84.96% for screening those at high risk and 84.86% for screening no one.

“Our analysis suggests that universal HBV screening before R-CHOP chemotherapy reduces costs in most settings and avoids morbidity with a small improvement in survival,” they reported. “Given these potential benefits, and the expectation that universal testing is likely easier to implement than targeted testing, consideration should be given to routinely screening for HBsAg in all patients scheduled to receive R-CHOP chemotherapy for non-Hodgkin lymphoma.”


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