When and how often to screen for cervical cancer in three low- and middle-income countries: A cost-effectiveness analysis

Abstract

World Health Organization guidelines recommend that cervical cancer screening programs should prioritize screening coverage in women aged 30 to 49 years. Decisions about target ages and screening frequency depend upon local burden of disease, costs, and capacity. We used cost and test performance data from the START-UP demonstration projects in India, Nicaragua, and Uganda to evaluate the cost-effectiveness of screening at various start ages, intervals, and frequencies. We calibrated a mathematical simulation model of cervical carcinogenesis to each country and compared screening with careHPV (cervical and vaginal sampling), visual inspection with acetic acid (VIA), and cytology between the ages of 25 and 50 years, at frequencies of once to three times in a lifetime, at 5- and 10-year intervals. Screening with careHPV (cervical sampling) was the most effective and cost-effective strategy in all settings; careHPV (vaginal sampling) was only slightly less effective. The most critical ages for screening are between ages 30 and 45 years. Within this age range, screening at certain ages may be relatively more cost-effective, but cancer risk reductions are similar for a given screening test and interval. Screening three times between 30 and 45 years was very cost-effective and reduced cancer risk by ~50%.

To expand coverage, or increase frequency: Quantifying the tradeoffs between equity and efficiency facing cervical cancer screening programs in low-resource settings

“…Because we did not have costing data to reflect expansion of screening coverage with self‐collection in a community setting, our estimates of the cost‐effectiveness of expanding coverage are based on provider‐collection at the clinic. However, a previous analysis suggests that differences in test performance and effectiveness between collection methods are small . Thus, if the costs of a screening program relying on HPV self‐collection in a community‐based setting are similar to or less than the costs of a program relying on provider‐collection, the impact on the cost‐effectiveness profile of expanding coverage will likely be small as well.…”

“…We compared screening two or three times in a lifetime at baseline screening coverage — which we defined as existing coverage with once in a lifetime screening, ranging from 30% to 80%— against screening once in a woman's lifetime as screening coverage varied from baseline to 90%. The model was calibrated to epidemiologic data from Uganda . Test performance and cost data were obtained from the START‐UP demonstration project in Kampala, Uganda .…”

“…The natural history model of cervical carcinogenesis and a description of the model parameterization process have been previously published …”

“…For natural history transitions, we estimated baseline “prior” input parameter values and set plausible ranges using epidemiologic data . We conducted repeated model simulations in the absence of any intervention, in which a single random value for each uncertain parameter was selected from the plausible range, creating a unique natural history input parameter set.…”

“…Cost data have been published elsewhere and are summarized in Table . Direct medical costs of screening, diagnosis, and treatment of precancerous lesions were drawn from the START‐UP study, and included staff time, clinical supplies, drugs, clinical equipment, laboratory staff time, laboratory supplies and laboratory equipment.…”