Choosing wisely: a model-based analysis evaluating the trade-offs in cancer benefit and diagnostic referrals among alternative HPV testing strategies in Norway

Burger, Emily A.; Pedersen, Kine; Sy, Stephen; Kristiansen, Ivar Sønbø; Kim, Jane J.

doi:10.1038/bjc.2017.248

Cited by 15 publications

(15 citation statements)

References 27 publications

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“…Evidence of deterioration in the predictive value of cytology as a primary screen in immunized women has been documented, although this does not translate into poor performance as a triage of HR‐HPV‐positive samples . It is also worth noting that the extent of triage in immunized populations will reduce given evidence from modeling studies that indicate 10‐year screening starting aged 30 is optimal . Conclusions from modeling endeavors, while extremely helpful, clearly incorporate various assumptions and differing levels of vaccine‐uptake, type of vaccine and dimensions of program (including the detail of catch‐up immunization) will exert influence.…”

Section: ±P16 ± Ki67mentioning

confidence: 99%

“…83 It is also worth noting that the extent of triage in immunized populations will reduce given evidence from modeling studies that indicate 10-year screening starting aged 30 is optimal. 84,85 Conclusions from modeling endeavors, while extremely helpful, clearly incorporate various assumptions and differing levels of vaccine-uptake, type of vaccine and dimensions of program (including the detail of catch-up immunization) will exert influence. This makes a comprehensive, "one size fits all" solution difficult.…”

Section: Triage For Immunized Womenmentioning

confidence: 99%

See 1 more Smart Citation

Eurogin roadmap 2017: Triage strategies for the management of HPV‐positive women in cervical screening programs

Cuschieri

Ronco²,

Lörincz

et al. 2018

Intl Journal of Cancer

142

150

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Cervical cancer screening will rely, increasingly, on HPV testing as a primary screen. The requirement for triage tests which can delineate clinically significant infection is thus prescient. In this EUROGIN 2017 roadmap, justification behind the most evidenced triages is outlined, as are challenges for implementation. Cytology is the triage with the most follow-up data; the existence of an HR-HPV-positive, cytology-negative group presents a challenge and retesting intervals for this group (and choice of retest) require careful consideration. Furthermore, cytology relies on subjective skills and while adjunctive dual-staining with p16/Ki67 can mitigate inter-operator/-site disparities, clinician-taken samples are required. Comparatively, genotyping and methylation markers are objective and are applicable to self-taken samples, offering logistical advantages including in low and middle income settings. However, genotyping may have diminishing returns in immunised populations and type(s) included must balance absolute risk for disease to avoid low specificity. While viral and cellular methylation markers show promise, more prospective data are needed in addition to refinements in automation. Looking forward, systems that detect multiple targets concurrently such as next generation sequencing platforms will inform the development of triage tools. Additionally, multistep triage strategies may be beneficial provided they do not create complex, unmanageable pathways. Inevitably, the balance of risk to cost(s) will be key in decision making, although defining an acceptable risk will likely differ between settings. Finally, given the significant changes to cervical screening and the variety of triage strategies, appropriate education of both health care providers and the public is essential.

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Section: ±P16 ± Ki67mentioning

confidence: 99%

Section: Triage For Immunized Womenmentioning

confidence: 99%

Eurogin roadmap 2017: Triage strategies for the management of HPV‐positive women in cervical screening programs

Cuschieri

Ronco²,

Lörincz

et al. 2018

Intl Journal of Cancer

142

150

View full text Add to dashboard Cite

show abstract

“…For unvaccinated populations, primary HPV testing for these women may be considered resource intensive, potentially resulting in more colposcopies due to the higher prevalence of HPV in younger women [ 26 ]. However, a recent model-based analysis evaluating the health benefit and resource use trade-offs associated with primary HPV testing strategies for HPV-unvaccinated women concluded that primary HPV testing could start at an earlier age, e.g., at age 25 years, using a more conservative cytology-based triage algorithm for HPV-positive women to control colposcopy use [ 27 ]. An Australian study also suggested that primary HPV testing was preferred for unvaccinated women under 30 years of age, as well as for women in vaccinated cohorts [ 28 ].…”

Section: Introductionmentioning

confidence: 99%

Cost-effectiveness of cervical cancer screening with primary HPV testing for unvaccinated women in Sweden

et al. 2020

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Background Sweden revised their cervical cancer screening program in 2017 to include cytology-based screening for women aged 23-29 years and primary human papillomavirus (HPV) testing for women aged 30-64 years; however, alternative strategies may be preferred. To inform cervical cancer prevention policies for unvaccinated women, we evaluated the cost-effectiveness of alternative screening strategies, including the current Swedish guidelines. Methods We adapted a mathematical simulation model of HPV and cervical cancer to the Swedish context using primary epidemiologic data. We compared the cost-effectiveness of alternative screening strategies that varied by the age to start screening, the age to switch from cytology to HPV testing, HPV strategies not preceded by cytology, screening frequency, and management of HPV-positive/cytology-negative women. Results We found that the current Swedish guidelines were more costly and less effective than alternative primary HPV-based strategies. All cost-efficient strategies involved primary HPV testing not preceded by cytology for younger women. Given a cost-effectiveness threshold of €85,619 per quality-adjusted life year gained, the optimal strategy involved 5-yearly primary HPV-based screening for women aged 23-50 years and 10-yearly HPV-based screening for women older than age 50 years. Conclusions Primary screening based on HPV alone may be considered for unvaccinated women for those countries with similar HPV burdens.

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“…Primary outcomes were re-test attendance, and re-test attendance within recommended timeframe, both recorded as dichotomous variables. Re-test was considered within the recommended time frame when was performed between month 12 and 18 after primary screening [17]. Women who returned up to 30 days off the range were also included.…”

Section: Methodsmentioning

confidence: 99%

Factors associated with low adherence to cervical cancer follow-up retest among HPV+/ cytology negative women: a study in programmatic context in a low-income population in Argentina

2019

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Background Cervical Cancer is still a major public health challenge in low and middle-income countries. HPV testing has been an innovative approach, which was introduced in Argentina for women aged 30+ through the Jujuy Demonstration Project (JDP) carried out between 2012 and 2014. After a positive HPV-test, cytology is used as triage method. Under this protocol, the group of women with HPV+ and normal cytology are recommended to repeat the test within 12–18 months. Studies have shown that this group has increased risk of CIN2+, however, assuring high levels of repeating test among these women is difficult to achieve. We analyze those factors associated with lower re-test attendance among HPV+/ cytology negative women at a programmatic level in low-middle income settings. Methods We used data of women aged 30+ HPV-tested in the JDP and followed until 2018 ( n = 49,565). We performed a set of different adjusted logistic regression models. Primary outcomes were re-test attendance and re-test attendance within recommended timeframe. We assessed as covariates age, health insurance status, year of HPV-testing, Pap testing in the past 3 years, HPV-testing modality (clinician-collected (CC) tests/self-collected (SC) tests), and span between HPV-test collection and report of results. Results Forty nine thousand five hundred sixty five women were HPV-tested and 6742 had a positive HPV-test. Among HPV+ women, a total of 4522 were HPV+/Cytology negative (67.1%). In total, 3172 HPV+/Cytology negative women (70.1%) had a record of a second HPV test as of March 2018. Only 1196 women (26%) completed the second test within the timeframe. Women with no record of a previous Pap (OR: 0.46, 95% CI: 0.4–0.53, p < 0.001), aged 64+ (OR: 0.46, 95% CI: 0.31-0.68, p < 0.001) were less likely to be retested; while women with clinician-collected samples had higher odds of being re-tested (OR: 1.42, 95% CI: 1.06–1.91, p < 0.001). Conclusions Low re-test rates were found in HPV +/ normal cytology women. Tailored interventions are needed to increase the effectiveness of the screening in this group, especially for those women with characteristics associated to lower attendance.

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Choosing wisely: a model-based analysis evaluating the trade-offs in cancer benefit and diagnostic referrals among alternative HPV testing strategies in Norway

Cited by 15 publications

References 27 publications

Eurogin roadmap 2017: Triage strategies for the management of HPV‐positive women in cervical screening programs

Eurogin roadmap 2017: Triage strategies for the management of HPV‐positive women in cervical screening programs

Cost-effectiveness of cervical cancer screening with primary HPV testing for unvaccinated women in Sweden

Factors associated with low adherence to cervical cancer follow-up retest among HPV+/ cytology negative women: a study in programmatic context in a low-income population in Argentina

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