Cost-effectiveness analysis of human papillomavirus DNA testing and Pap smear for cervical cancer screening in a publicly financed health-care system

Abstract

Objective:To evaluate the long-term cost-effectiveness of different strategies for human papillomavirus (HPV) DNA testing combined with Pap smear for cervical cancer screening in Taiwan.Methods:This study adopts a perspective of Department of Health in cost-effectiveness analysis to compare a no-screening strategy with nine different screening strategies. These strategies comprise three screening tools (Pap smear alone, HPV DNA testing followed by Pap smear triage, and HPV DNA testing combined with Pap smear), and three screening intervals (annually, every 3 years, and every 5 years). Outcomes are life expectancy, quality-adjusted life years (QALYs), lifetime costs, and incremental cost-effectiveness ratios (ICERs). Probabilistic sensitivity analyses (PSAs) were conducted to assess parameter uncertainty.Results:When three times gross domestic product per capita is used as the decision threshold, all nine screening strategies were cost-effective compared with the no-screening strategy. Compared with the current screening strategy (an annual Pap smear), HPV DNA testing followed by Pap smear triage every 5 years and every 3 years were cost-effective. Results of PSA also indicated that a HPV DNA testing followed by Pap smear triage every 5 or every 3 years achieved the highest expected net benefits.Conclusions:Possible economic advantages are associated with extending the cervical cancer screening interval from one Pap smear annually to HPV DNA testing followed by Pap smear triage every 5 years with an ICER $1 247 000 per QALY gained, especially in a country with a publicly financed health-care system.

A Systematic Review of Economic Aspects of Cervical Cancer Screening Strategies Worldwide: Discrepancy between Economic Analysis and Policymaking

“…Methods for calculating the ICER in six articles were; cost/ QALY (Mandelblatt et al, 2002b, Berkhof et al, 2010Chuck, 2010;Chow et al, 2010;Vijayaraghavan et al, 2009;2010a), in 13 studies the ICER were estimated by cost/LYG (Brown and Garber, 1999;Maxwell et al, 2002;Mandelblatt et al, 2002a;Goldie et al, 2001;2004;Kim et al, 2005;Bidus et al, 2006;Andres-Gamboa et al, 2008;Kulasingam et al, 2009;Levin et al, 2010;Sroczynski et al, 2011;Burger et al, 2012). Two studies did not report their ICER (Bistoletti et al, 2008;de Kok et al, 2012).…”

“…The converted ICER of each country was compared with GDP per capita; in the USA, the ratio of ICER based on GDP per capita was approximately five fold (Goldie et al, 2004), and in other countries it was up to three times higher. We could not estimate ICER for one study in European countries due to a lack of data such as a separate ICER for each country (de Kok et al, 2012), and one article did not report the index year (Chow et al, 2010) .…”

“…Four articles in four high income countries (Goldie et al, 2001;2004;Mandelblatt et al, 2002a;Bistoletti et al, 2008;Burger et al, 2012;de Kok et al, 2012), nine middle income countries from seven articles Andres-Gamboa et al, 2008;Vijayaraghavan et al, 2009;Chow et al, 2010;Levin et al, 2010) and 1 article in low income countries suggested starting age after age 30 (Table 1).…”

“…Burger in Norway, suggested screening with cytology for younger women and HPV DNA testing strategy every four years after the age of 34 years (Burger et al, 2012). Seven papers suggested a five-year interval with various strategies such as HPV DNA testing (Andres-Gamboa et al, 2008;Kulasingam et al, 2009;Levin et al, 2010), HPV DNA triage (Berkhof et al, 2010;Chow et al, 2010), and primary HPV DNA in both types of co-screening or triage (de Kok et al, 2012). Mandelblatt suggested VIA with immediate treatment every five years as the most costeffective method in Thailand (Mandelblatt et al, 2002b).…”

“…In four articles 5 years interval was recommended (Mandelblatt et al, 2002a;Andres-Gamboa et al, 2008;Chow et al, 2010;Levin et al, 2010)and six countries in 2 articles indicated that 10 years interval was cost effective Vijayaraghavan et al, 2009)…”