Cost‐effectiveness of primary cytology and HPV DNA cervical screening

Abstract

Because cost-effectiveness of different cervical cytology screening strategies with and without human papillomavirus (HPV) DNA testing is unclear, we used a Markov model to estimate life expectancy and health care cost per woman during the remaining lifetime for 4 screening strategies: (i) cervical cytology screening at age 32, 35, 38, 41, 44, 47, 50, 55 and 60, (ii) same strategy with addition of testing for HPV DNA persistence at age 32, (iii) screening with combined cytology and testing for HPV DNA persistence at age 32, 41 and 50, iv) no screening. Input data were derived from population-based screening registries, health-service costs and from a population-based HPV screening trial. Impact of parameter uncertainty was addressed using probabilistic multivariate sensitivity analysis. Cytology screening between 32 and 60 years of age in 3-5 year intervals increased life expectancy and life-time costs were reduced from 533 to 248 US Dollars per woman compared to no screening. Addition of HPV DNA testing, at age 32 increased costs from 248 to 284 US Dollars without benefit on life expectancy. Screening with both cytology and HPV DNA testing, at ages 32, 41 and 50 reduced costs from 248 to 210 US Dollars with slightly increased life expectancy. In conclusion, population-based, organized cervical cytology screening between ages 32 to 60 is highly cost-efficient for cervical cancer prevention. If screening intervals are increased to at least 9 years, combined cytology and HPV DNA screening appeared to be still more effective and less costly. ' 2007 Wiley-Liss, Inc.Key words: Markov model; health economics; cervical cancer; organized screening Human Papillomavirus (HPV) DNA testing has been accepted as an adjunct to cytology for primary cervical screening in women over 30 years of age. 1,2 The combination of HPV testing and cervical cytology is more sensitive in detecting cervical intraepithelial neoplasia (CIN) lesions with risk for progression to invasive cancer than either method alone, with extremely high negative predictive values. [3][4][5] Several studies have evaluated the economic impact of cervical screening with and without HPV testing, but have reported variable results. [6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22] Possible reasons for discrepancies include different modeling methodologies, use of surrogate endpoints and use of input data based on clinical studies that may not have been representative of the population as a whole. However, most modeling studies have consistently found similar reductions of the cumulative lifetime risk of invasive cervical cancer as a result of cytology and HPV DNA screening. 6,11,12,19,[23][24][25] State transition models are used in more than 85% of all costeffectiveness analyses and several cervical cancer state transition models have been reported previously. 26,27 The long-term effects and cost of cytology and HPV screening cannot be captured in clinical trials, where all studies have used surrogate endpoints, such as CIN grade 2 or 3 (CIN2-3). ...

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.…”

“…In another project conducted in five less developed countries including; Kenya, Peru, South Africa and Thailand in 2005, Goldie suggested that applying HPV DNA testing just two times per lifetime i.e., at age 35 and 45 years was the most cost-effective, moreover, this strategy was dominated in India . In Sweden, Bisoleti et al showed that combined HPV DNA testing and cervical cytology three times per life time starting at age 32 was the most cost effective method (Bistoletti et al, 2008). Levin suggested rapid HPV DNA testing three times in a lifetime and starting at age 35 was the most cost-effective strategy at the national, township and county level in China (Levin 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).…”

“…One article modeled screening strategies and concluded that HPV DNA triage with three-and five-year intervals and co-screening every three years were the most costeffective strategies in Italy, the United Kingdom, France and the Netherlands (Kim et al, 2005). Bistoletti studied the cost-effectiveness of screening methods in Sweden and concluded that co-screening strategy at nine-year intervals was the most effective strategy (Bistoletti et al, 2008). Two articles indicated that 10-year intervals with HPV DNA testing was the most cost-effective strategy for five less developed countries and a co-screening strategy for South Africa (Vijayaraghavan et al, 2009).…”

“…Six articles proposed 3-5 years interval (Brown and Garber, 1999;Maxwell et al, 2002;Kim et al, 2005;Chuck, 2010;Vijayaraghavan et al, 2010b;Burger et al, 2012) and three articles showed that 5 years interval between screenings was cost effective (Kulasingam et al, 2009;Berkhof et al, 2010;de Kok et al, 2012). We just found one article in Sweden indicating that 9 years interval was cost effective (Bistoletti et al, 2008)…”