REDucing Unnecessary Coagulation Testing in the Emergency Department (REDUCED)

The PT/INR (prothrombin time/international normalized ratio) and aPTT (activated partial thromboplastin time) were tests developed in the early 20th century for specific and unique indications. Despite this, they are often ordered together routinely. The objective of this study was to determine if a multimodal intervention could reduce PT/INR and aPTT testing in the emergency department (ED). This was a prospective multi-pronged quality improvement study at St. Michael's Hospital. The initiative involved stakeholder engagement, uncoupling of PT/INR and aPTT testing, teaching, and most importantly a revision to the ED order panels. After changes to order panels, weekly rates of PT/INR and aPTT testing per 100 ED patients decreased (17.2 vs 38.4, rate ratio=0.45 (95% CI 0.43-0.47), p<0.001; 16.6 vs 37.8, rate ratio=0.44 (95% CI 0.42-0.46), p<0.001, respectively). Rate of creatinine testing per 100 ED patients, our internal control, increased during the same period (54.0 vs 49.7, rate ratio=1.09 (95% CI 1.06-1.12); p<0.0001) while the weekly rate per 100 ED patients receiving blood transfusions slightly decreased (0.5 vs 0.7, rate ratio=0.66 (95% CI 0.49-0.87), p=0.0034). We found that a simple process change to order panels was associated with meaningful reductions in coagulation testing without obvious adverse effects.

Rituximab in Lymphoma and Chronic Lymphocytic Leukaemia: A Practice Guideline

Rituximab is the first monoclonal antibody to be approved for use by the US Food and Drug Administration in cancer. Its role in the treatment of non-Hodgkin lymphoma, including chronic lymphocytic leukaemia (CLL), has evolved significantly. We aimed to systematically review and update the literature on rituximab in lymphoma and CLL, and provide evidence-based consensus guidelines for its rational use. Validated methodology from the Cancer Care Ontario Program in Evidence-based Care was used. A comprehensive literature search was completed by a methodologist from the Hematology Disease Site Group of Cancer Care Ontario. Data were extracted from randomised controlled trials of rituximab-containing chemotherapy regimens for patients with lymphoma or CLL. Fifty-six primary randomised controlled trials were retrievable and met all inclusion criteria. Clinically important benefits in progression-free survival or overall survival were seen in the following settings: (i) addition of rituximab to combination chemotherapy for initial treatment of aggressive B-cell lymphomas, including diffuse large B-cell lymphoma, Burkitt lymphoma and HIV-related lymphoma with CD4 count ≥50/mm³; (ii) addition of rituximab to combination chemotherapy for initial and subsequent treatment of follicular lymphoma and other indolent B-cell lymphomas; (iii) use of rituximab maintenance in patients with indolent B-cell lymphomas who have responded to chemoimmunotherapy; (iv) addition of rituximab to fludarabine-based chemotherapy or chlorambucil for initial treatment of CLL. The consensus opinion of the Hematology Disease Site Group is that rituximab is recommended for these indications.

Identifying existing Choosing Wisely recommendations of high relevance and importance to hematology

Choosing Wisely (CW) is a medical stewardship initiative led by the American Board of Internal Medicine Foundation in collaboration with professional medical societies in the United States. In an effort to learn from and leverage the work of others, the American Society of Hematology CW Task Force developed a method to identify and prioritize CW recommendations from other medical societies of high relevance and importance to patients with blood disorders and their physicians. All 380 CW recommendations were reviewed and assessed for relevance and importance. Relevance was assessed using the MORE(TM) relevance scale. Importance was assessed with regard to six guiding principles: harm avoidance, evidence, aggregate cost, relevance, frequency and impact. Harm avoidance was considered the most important principle. Ten highly relevant and important recommendations were identified from a variety of professional societies. Recommendations focused on decreasing unnecessary imaging, blood work, treatments and transfusions, as well as on increasing collaboration across disciplines and considering value when recommending treatments. Many CW recommendations have relevance beyond the society of origin. The methods developed by the ASH CW Task Force could be easily adapted by other Societies to identify additional CW recommendations of relevance and importance to their fields. Am. J. Hematol. 91:787-792, 2016. © 2016 Wiley Periodicals, Inc.

Hepatitis B reactivation in patients with solid tumors: A systematic review and meta-analysis

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Background: Hepatitis B virus (HBV) affects over 250 million people worldwide. Most people with chronic HBV (HBsAg positive) have no signs or symptoms of infection. However, when exposed to immunosuppression they are at risk of HBV reactivation which can cause hepatitis, liver failure and death. The risk of HBV reactivation in patients receiving chemotherapy for solid tumors, the efficacy of antiviral prophylaxis, and the clinical impact of HBV reactivation in this setting are uncertain. Primary Aim: To estimate the risk of clinical HBV reactivation (increased HBV DNA + transaminitis) among HBsAg-positive patients administered chemotherapy for a solid tumor. Secondary Aims: To estimate the efficacy of anti-viral prophylaxis and the risk of death from HBV reactivation in patients receiving chemotherapy for solid tumors. Methods: A systematic review and meta-analysis of the English language literature on HBV reactivation was completed (OVID Medline, 1946 to Aug 2013). All citations were reviewed by two or more authors. Data from patients with hematologic malignancies were excluded. Pooled probabilities of HBV reactivation risk, death from HBV reactivation, and odds ratio for the impact of anti-viral prophylaxis were estimated with a random effects model. Results: 2,667 citations were identified; 19 were eligible for inclusion. The pooled estimate for clinical HBV reactivation in HBsAg-positive patients receiving chemotherapy for a solid tumor was 21.9% (95% CI; 16.5% to 27.3%) in those not receiving anti-viral prophylaxis, and 2.4% (95% CI 0.7% to 4.2%) in those receiving anti-viral prophylaxis. The odds ratio for clinical HBV reactivation with antiviral prophylaxis compared to no prophylaxis was 0.12 (95% CI 0.06 to 0.25). In the absence of viral prophylaxis, the risk of dying from HBV reactivation in HBsAg-positive solid tumor patients was estimated at 1.3% with a 95% CI of 0.3% to 2.3%. Conclusions: Patients with chronic HBV who are administered chemotherapy for a solid tumor appear to be at substantial risk of clinical HBV reactivation; this risk may be mitigated by anti-viral prophylaxis. In the absence of anti-viral therapy, patients may experience a small but important risk of dying from HBV reactivation.

Hepatitis B reactivation in HBsAg-negative/HBcAb-positive patients receiving rituximab for lymphoma: a meta-analysis

Patients with chronic hepatitis B (HBsAg-positive) are at risk of viral reactivation if rituximab is administered without antiviral treatment, a potentially fatal complication of treatment. Patients with so-called 'resolved hepatitis B virus infection' (HBsAg-negative/cAb-positive) may also be at risk. We performed a systematic review of the English and Chinese language literature to estimate the risk of hepatitis B virus (HBV) reactivation in HBsAg-negative/cAb-positive patients receiving rituximab for lymphoma. A pooled risk estimate was calculated for HBV reactivation. The impact of HBsAb status and study design on reactivation rates was explored. Data from 578 patients in 15 studies were included. 'Clinical HBV reactivation', (ALT >3 × normal and either an increase in HBV DNA from baseline or HBsAg seroreversion), was estimated at 6.3% (I(2) = 63%, P = 0.006). Significant heterogeneity was detected. Reactivation rates were higher in prospective vs retrospective studies (14.2% vs 3.8%; OR = 4.39, 95% CI 0.83-23.28). Exploratory analyses found no effect of HBsAb status on reactivation risk (OR = 0.083; P = 0.151). Our meta-analysis confirms a measurable and potentially substantial risk of HBV reactivation in HBsAg-negative/cAb-positive patients exposed to rituximab. However, heterogeneity in the existing literature limits the generalizability of our findings. Large, prospective studies, with uniform definitions of HBV reactivation, are needed to clarify the risk of HBV reactivation in HBsAg-negative/cAb-positive patients.

Reframing Overuse in Health Care: Time to Focus on the Harms

The author proposes a shift away from economic arguments toward a focus on patient-level harms caused by overuse, arguing that by focusing on how overuse affects our patients, we may begin to alter the practice.

Poor recognition of risk factors for hepatitis B by physicians prescribing immunosuppressive therapy: a call for universal rather than risk-based screening

Background

Reactivation of hepatitis B virus (HBV) during immunosuppressive therapy (IST) can lead to severe and even fatal hepatitis but can be largely prevented with prophylactic antiviral therapy. Screening for HBV prior to starting IST is recommended. Both risk-based and universal screening have been recommended by different societies. For effective risk-based screening, physicians must be aware of risk factors for chronic HBV infection.

Methods

The HBV screening practices prior to starting IST of rheumatologists, medical and hematological oncologists were evaluated by survey and chart review. Country of origin, the primary risk factor for HBV exposure, was determined in all patients.

Results

Of 140 rheumatology, 79 medical oncology and 53 hematology patients reviewed, 81%, 11% and 81% were deemed to be at high risk of HBV reactivation by their physicians respectively, however only 27%, 6% and 62% (p<0.0001) were actually screened for HBV prior to starting IST. For patients from HBV-endemic regions, more hematology patients (53%) were correctly identified by their physicians as being at high risk of reactivation than rheumatology patients (2.4%, p=0.0001) or medical oncology patients (15%, p=0.009). However actual screening rates were not increased in patients from endemic regions. A total of 81 patients were screened for HBsAg; 2 were positive. Of the 33 patients screened for anti-HBc, 10 (30%) were positive.

Conclusions

Hematologists, rheumatologists and medical oncologists had low rates of screening for HBV prior to prescribing IST, largely due to poor identification of those at risk for infection. Risk-based screening strategies are unlikely to be effective and should be replaced by universal screening.

Five hematologic tests and treatments to question

Choosing Wisely® is a medical stewardship initiative led by the American Board of Internal Medicine Foundation in collaboration with professional medical societies in the United States. The American Society of Hematology (ASH) released its first Choosing Wisely® list in 2013. Using the same evidence-based methodology as in 2013, ASH has identified 5 additional tests and treatments that should be questioned by clinicians and patients under specific, indicated circumstances. The ASH 2014 Choosing Wisely® recommendations include: (1) do not anticoagulate for more than 3 months in patients experiencing a first venous thromboembolic event in the setting of major, transient risk factors for venous thromboembolism; (2) do not routinely transfuse for chronic anemia or uncomplicated pain crises in patients with sickle cell disease; (3) do not perform baseline or surveillance computed tomography scans in patients with asymptomatic, early-stage chronic lymphocytic leukemia; (4) do not test or treat for heparin-induced thrombocytopenia if the clinical pretest probability of heparin-induced thrombocytopenia is low; and (5) do not treat patients with immune thrombocytopenia unless they are bleeding or have very low platelet counts.

An electronic prompt to improve hepatitis B virus screening prior to cancer treatment

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Background: Hepatitis B virus (HBV) reactivation is a potentially fatal complication of cancer therapy that is almost entirely preventable. Despite this, HBV screening rates remain low at many centers. We evaluated the effectiveness of an electronic prompt on HBV screening rates and compared this strategy with education alone. Methods: An education session on HBV reactivation was delivered to all oncology staff at two large, academic oncology centers in the fall of 2010. At one center (study center) an electronic prompt was also introduced. The electronic prompt reminded physicians to screen for HBV when booking a new patient’s first chemotherapy and automatically trigged an electronic order for HBsAg if the physician assented. The prompt was not implemented at the second (control) center. The primary endpoint was the rate of HBV screening. Actual HBV screening rates were determined in both centers for 10 months prior to and for 12 months following the interventions. HBV screening rates were assessed and compared with process control charts (p-charts); 3-sigma limits were employed to define special cause variation. Results: 6,116 new patients received their first chemotherapy during the study period (2,095 study center; 4,021 control center). In the pre-prompt period, the screening rate was stable at 16% at the study center and 25% in the control center. In the prompt period, the screening rate increased to 62% at the study center and was unchanged at 25% in the control center. Special cause variation suggesting a non-random improvement in HBV screening rate was detected at the Study Center two months after the introduction of the electronic prompt. Conclusions: An electronic prompt increased the rate of HBV screening, however screening rates remained relatively low. Education sessions did not appear to improve the HBV screening rate.

HBV screening before adjuvant chemotherapy in patients with early breast cancer: A cost-effectiveness analysis

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Background: The seroprevalence of hepatitis B virus (HBV) infection among Canadian was 0.4%, and 1.6% among immigrants. Most infected individuals have clinically silent disease. Cytotoxic chemotherapy causes reactivation in 30% of the HBV infected patients. This can be severe and fatal, may also lead to interruption of chemotherapy. HBV screening before adjuvant chemotherapy (ADJ) for breast cancer (BC) seems to be a plausible strategy. Our objective is to estimate the health and economic effects of HBV screening strategies. Methods: We developed a state transition microsimulation model to examine the cost effectiveness of 3 strategies for 55 year old BC patients undergoing ADJ: (1) No screen; (2) Screen Imm: Screen immigrant only and treat; (3) Screen all: Screen all and treat; with antiviral therapies. In the model, health states were constructed to reflect the natural history of BC and HBV. Model data were obtained from published literature. We used a payer perspective, a lifetime time horizon, and used a 5% discount rate. Results: Screen all would prevent 43 severe reactivations (SR), 9 deaths from reactivation (DR), 22 chemotherapy interruptions (CI), 36 decompensated cirrhosis (DC), 48 HCCs, and 67 HBV deaths per 100,000 persons screened over the lifetime of the cohort. Screen Imm would prevent 34 SR, 4 DR, 20 CI, 30 DC, 41 HCCs, and 52 HBV deaths. Screen all was associated with an increase of at least 0.00368 quality adjusted life years (QALY) and cost C$116 more per person, translating to an incremental cost effectiveness ratio (ICER) of C$31,518-51,276/QALY gained compared with No screen, depends on different antiviral therapies. Screen all was the most cost effective, while Screen Imm was ruled out due to extended dominance (ED) by No Screen and Screen all. Conclusions: HBV screening before ADJ for BC patients would prevent a significant number of reactivations, and is likely be cost effective. [Table: see text]

Feasibility and utility of influenza vaccination in hematology/oncology clinics

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Background: Seasonal influenza vaccination is recommended for cancer patients. However, many cancer clinics do not routinely offer flu shots. Early in January, 2013, Toronto experienced widespread influenza activity. Approximately 25% of hospitalizations on the hematology/oncology ward at St. Michael's Hospital (SMH) during this time were for suspected influenza. A large number of patients were noted to be unvaccinated. In-response, influenza vaccination was organized in parallel with regular hematology/oncology clinics at SMH. Aims: To determine the feasibility and utility of influenza vaccination in a cancer clinic. Methods: All patients seen in the SMH hematology/oncology clinic between January 14 and February 1, 2013, were eligible for influenza vaccination. A brief survey was administered to obtain vaccination history, willingness to receive flu vaccination, and beliefs about flu vaccination. Information regarding diagnosis, treatment, and family physician was obtained from the medical record. Univariate testing was completed with the Chi-squared and Fisher’s exact tests as appropriate. Results: 555 patients were seen during the period of interest; 206 completed the survey (37% response rate). Median age of respondents was 63 years, 42% were male, and 81% had cancer. 107(52%) of respondents had not received seasonal influenza vaccination of whom 41 (38%) accepted vaccination when offered. Among vaccinated patients, most received the flu shot from a family physician (70%). Reasons for not receiving the flu shot were personal preference (24%), belief that it was not necessary (19%), inconvenience (14%), concerns about side effects (8%), believe that it was contraindicated during chemotherapy (7%) and a perception that a medical practitioner advised against it (7%). Patients without a registered family physician were less likely to have received the seasonal flu shot (p=0.03). Patients with a malignant diagnosis and patients receiving IV chemotherapy tended to have lower rates of seasonal flu vaccination (p=0.09 and p=0.12 respectively). Conclusions: Administering influenza vaccination during hematology/oncology clinics is feasible and may address a care gap in this population.

Screening for hepatitis B virus prior to chemotherapy: A quality improvement project

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Background: Hepatitis B virus (HBV) reactivation is a well-recognized and serious complication of chemotherapy which can be prevented with prophylactic antiviral therapy. St. Michael’s Hospital (SMH) is an academic hospital in Toronto, Canada, serving an inner city population. The prevalence of chronic HBV in populations such as ours is estimated to be > 8%, compared to 2% of all Canadians. In this context, surveillance for HBV prior to chemotherapy is very important. Aim: To increase the HBV screening rate among patients starting IV chemotherapy at SMH to greater than 90% by December 2013. Methods: Repeated plan-do-study-act (PDSA) cycles targeting HBV screening in our chemotherapy unit were initiated in January 2013 and are on-going. Appropriate HBV screening was defined as at least one HBsAg test up to 3 months prior to, or 3 weeks after starting chemotherapy. Interventions included education sessions, posters, standardized HBV lab order sets, and pharmacist review of lab data prior to first chemotherapy with reminders to physicians when HBV testing was absent. Pre and post-intervention HBV screening rates were compared using process control charting. Results: Between January 1, 2012, and June 15, 2013, 407 unique patients started IV chemotherapy at SMH. Prior to our interventions a stable HBV screening rate of approximately 30% was observed. Sequential process improvements were introduced in January and April 2013. Process control charting demonstrated the presence of special cause variation subsequent to our interventions with a significant improvement in the HBV testing rate (post-intervention rate of 70%). The HBV testing rate began to improve in January 2013 and met criteria for special cause variation by February 2013. Conclusions: It is possible to dramatically increase the rate of HBV testing prior to chemotherapy through relatively simple, low tech process improvements. Further improvements are necessary to reach our goal of a 90% HBV screening rate prior to IV chemotherapy. Additional planned interventions include individualized physician report cards on HBV screening rates using achievable benchmark criteria and an education campaign directed at empowering patients to ask about HBV testing.

Hepatitis B reactivation in patients with lymphoma: A meta-analysis

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Background: Patients with hepatitis B virus (HBV) who are HBsAg+ are at risk of HBV reactivation if rituximab is administered in the absence of antiviral treatment. Recently, it has been reported that patients with so-called “resolved HBV infection”(HBsAg-/cAb+) may also be at risk; however, the degree of risk is not known. Methods: We performed a systematic review of the English and Chinese language literature in Medline (1996 to June week 3 2013) and Embase (1996 to 2013 week 26) using the MeSH terms “lymphoma” and “hepatitis B”. Eligible studies were limited to those reporting primary data on HBV reactivation rates in HBsAg-/cAb+ patients receiving rituximab. We excluded case series with less than 5 patients. Pooled estimates were calculated for HBV reactivation and the impact of HBsAb status on HBV reactivation rate was explored. We also examined reactivation in HBsAg+ patients receiving rituximab by performing a systematic review of the English language literature in PubMed (1997 to June 21, 2013) using the terms “hepatitis B virus”, “reactivation” and “lymphoma”. Results: Data from 550 HBsAg-/cAb+ patients in 12 studies were included. Using a standardized definition of HBV reactivation, (increase in HBV DNA from baseline or HBsAg seroreversion +/- ALT >3 x upper limit of normal), the pooled estimate for the risk of HBV reactivation in HBsAg-/cAb+ patients was 8.1% (I2 = 55%, P = 0.007). Significant heterogeneity was apparent. Exploratory analyses suggested that patients were less likely to reactivate if they were HBsAb+ (OR = 0.32; 95% CI 0.12-0.85, P = 0.0285). In HBsAg+ patients we meta-analyzed prospective, controlled studies. Without antiviral prophylaxis, the reactivation rate for HBsAg+ lymphoma patients was 51.0% (I2 = 0%, P = 0.93). Conclusions: Our meta-analyses confirm that there is a risk of HBV reactivation in HBsAg-/cAb+ patients exposed to rituximab. HBsAb+ patients may be at lower risk than those who are HBsAb-. However, heterogeneity in the risk estimates limits their generalizability. Without prophylaxis, significant reactivation in HBsAg+ patients exists. Large prospective studies are needed to clarify the risk of HBV reactivation in HBsAg-/cAb+ patients and to inform decisions about best practice.

High-needs hematology/oncology patients: A quality improvement project

197

Background: St. Michael’s Hospital (SMH) is an academic, inner-city hospital in Toronto, Canada. In the hematology/oncology (hem/onc) program, a small number of patients appeared to contribute disproportionately to hospital admissions and emergency department (ED) visits. We hypothesized that high needs hem/onc patients could be recognized early in their care and that ED visit and admission rates among these patients could be decreased through targeted interventions. Methods: Members of the hem/onc team were interviewed regarding characteristics, which they felt predicted higher needs and greater liklihood for hospital admission/ED visit. A list of high risk features was generated. ED visit and admission rates for a prospectively identified high needs cohort were compared to rates for the entire hem/onc clinic. An intervention targeting high needs hem/onc patients is on-going. Pre and post-intervention ED visit and admission rates will be compared. Results: Interviews with 3 nurses, 1 social worker, 1 discharge planner, and 4 physicians identified 10 factors that the hem/onc team believed were predictive of higher needs and subsequent higher ED visit and admission rates. Between December 1, 2012, and February 28, 2013, 42 high needs hem/onc out-patients were prospectively identified. The ED visit and admission rates for this cohort were retrospectively compared to those of the entire hem/onc clinic and found to be dramatically higher (Table). Begininng in June 2013, hem/onc patients identified as “high needs” were offered enrollment in a NP-based program offering telephone assessments following ED visits, hospital admissions or discharges. Assessment of the impact of this intervention is ongoing. Conclusions: It is possible to prospectively identify hem/onc patients who are at risk of higher than usual ED visit and admission rates. Identifying this population may provide an opportunity to decrease their ED visit and admission rates. An evaluation of an intervention targeting high needs hem/onc patients is ongoing. Preliminary data will be presented. [Table: see text]

Hepatitis B reactivation in HBsAg-/cAb+ patients receiving rituximab: A meta-analysis

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Background: Patients with hepatitis B virus (HBV) who are HBsAg+ are recognized to be at risk of HBV reactivation if rituximab is administered in the absence of antiviral treatment. Recently, it has been reported that patients with so-called “resolved HBV infection”(HBsAg-/cAb+) may also be at risk; however, the degree of risk is not known. Methods: We performed a systematic review of the English and Chinese language literature in Medline (1996 to July week 2 2012) and Embase (1996 to 2012 week 29) using the MeSH terms “lymphoma” and “hepatitis B”. Eligible studies were limited to those reporting primary data on HBV reactivation rates in HBsAg-/cAb+ patients receiving rituximab. We excluded case series with less than 5 patients. Pooled estimates were calculated for HBV reactivation and the impact of HBsAb status on HBV reactivation rate was explored. Results: Data from 445 patients in 12 studies were included. Using a standardized definition of HBV reactivation, (ALT >3 x upper limit of normal AND either an increase in HBV DNA from baseline OR HBsAg seroreversion), the pooled estimate for the risk of HBV reactivation in HBsAg-/cAb+ patients was 5.4% (I2 = 63%, P = 0.009). Significant heterogeneity was apparent. Exploratory analyses suggested that patients were less likely to reactivate if they were HBsAb+ (OR = 0.32; 95% CI 0.12-0.85, P = 0.0285). Conclusions: Our meta-analysis confirms that there is a measurable risk of HBV reactivation in HBsAg-/cAb+ patients exposed to rituximab HBsAb+ patients may be at lower risk than those who are HBsAb-. However, heterogeneity in the risk estimates limits their generalizability. Large prospective studies are needed to clarify the risk of HBV reactivation in HBsAg-/cAb+ patients and to inform decisions about best practice.

Hepatitis B screening before chemotherapy: a survey of practitioners' knowledge, beliefs, and screening practices

PURPOSE

Hepatitis B virus (HBV) reactivation is a potentially fatal complication of chemotherapy that can be largely prevented with medication, provided that asymptomatic HBV carriers are identified. We explored the knowledge, beliefs, and practices of Canadian oncologists/hematologists regarding HBV screening before chemotherapy.

METHODS

A novel questionnaire was mailed to all practicing hematologists/oncologists, where publicly accessible online physician registries facilitated identification of these specialists (71% of the Canadian physician population).

RESULTS

Of 504 potentially eligible practitioners, 311 (62%) responded, of whom 246 indicated that they administered chemotherapy and were thus included in final analyses. Respondents tended to underestimate the risk of HBV reactivation, and recognition of the major risk factor for HBV carriage (ie, birth in an endemic area) was low. Forty percent of respondents reported rarely or never testing for HBV before chemotherapy, and 36% reported screening only those patients with HBV risk factors. In multivariate analysis, having a predominantly hematologic practice, practitioner experience with HBV reactivation, ability to correctly estimate the risk of HBV reactivation, fewer years in practice, and female sex were independently associated with an increased likelihood of screening for HBV.

CONCLUSION

Canadian oncologists and hematologists tend to underestimate the risk of HBV reactivation and report relatively low HBV screening rates. Among those practitioners who do screen, the favored strategy is selective screening of patients with HBV risk factors. However, oncologists'/hematologists' knowledge regarding risk factors for HBV carriage seems to be low, potentially undermining the success of a selective screening strategy.

Hepatitis B Virus Screening Before Chemotherapy for Lymphoma: A Cost-Effectiveness Analysis

Purpose

Hepatitis B virus (HBV) reactivation is a potentially fatal complication of chemotherapy that can be largely prevented with antiviral prophylaxis. It remains unclear whether HBV screening is cost effective.

Methods

A decision model was developed to compare the clinical outcomes, costs, and cost effectiveness of three HBV screening strategies for patients with lymphoma before R-CHOP (rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone) chemotherapy: screen all patients for hepatitis B surface antigen (HBsAg; Screen-All), screen patients identified as being at high risk for HBV infection (Screen-HR), and screen no one (Screen-None). Patients testing positive were administered antiviral therapy until 6 months after completion of chemotherapy. Those not screened were initiated on antiviral therapy only if HBV hepatitis occurred. Probabilities of HBV and lymphoma outcomes were derived from systematic literature review. A third-party payer perspective was adopted, costs were expressed in 2011 Canadian dollars, and a 1-year time horizon was used.

Results

Screen-All was the dominant strategy. It was least costly at $32,589, compared with $32,598 for Screen-HR and $32,657 for Screen-None. It was also associated with the highest 1-year survival rate at 84.99%, compared with 84.96% for Screen-HR and 84.86% for Screen-None. The analysis was sensitive to the prevalence of HBsAg positivity in the low-risk population, with Screen-HR becoming least costly when this value was ≤ 0.20%.

Conclusion

In patients receiving R-CHOP for lymphoma, screening all patients for HBV reduces the rate of HBV reactivation (10-fold) and is less costly than screening only high-risk patients or screening no patients.

Paying more than lip service to an oral lesion: a case of plasmablastic lymphoma

Plasmablastic lymphoma (PBL) is a variant of lymphoma originally described in the oral cavity of patients with advanced HIV. Our patient developed PBL despite well-controlled HIV and a CD4 count greater than 800 cells/µl. A drug interaction with an inhaled corticosteroid and ritonavir likely contributed to the development of this malignancy through increased immune suppression.

Screening for hepatitis B surface antigen before chemotherapy: current practice and opportunities for improvement

INTRODUCTION

Hepatitis B virus (hbv) reactivation is a recognized complication of chemotherapy. The U.S. Centers for Disease Control and Prevention recommend that all patients be screened for the hbv surface antigen (hbsag) before chemotherapy. We sought to determine the frequency of hbsag testing before chemotherapy at our hospital and to increase the frequency of testing to more than 90% of patients starting chemotherapy.

METHODS

Using a retrospective electronic chart review, we identified the frequency of hbsag testing for patients initiated on intravenous chemotherapy at out institution between March 2006 and March 2007. The frequency of left ventricular function testing in the subgroup of patients receiving potentially cardiotoxic chemotherapy was identified as a comparator. An educational intervention was developed and delivered to the multidisciplinary oncology team. The frequency of hbsag testing was determined post intervention. Qualitative interviews were conducted with the members of the oncology team to identify risk perception and barriers to testing.

RESULTS

Of 208 patients started on intravenous chemotherapy between March 2006 and March 2007, only 28 (14%) were tested for hbsag. All 138 patients scheduled for cardiotoxic chemotherapy (100%) underwent left ventricular function testing. In the post-intervention phase, of 74 patients started on intravenous chemotherapy, 24 (31%) underwent hbsag testing, with 1 patient testing positive.

CONCLUSIONS

The frequency of testing for hbsag before chemotherapy was very low at our institution. An educational intervention resulted in only a modest improvement. Potential barriers to routine screening include lack of awareness about existing guidelines, controversy about the evidence that supports hbsag testing guidelines, and a perception by physicians that hbv reactivation does not occur with solid tumours.