Surveillance After Treatment for Cervical Intraepithelial Neoplasia Outcomes, Costs, and Cost-Effectiveness
ABSTRACT To estimate outcomes and costs of surveillance strategies after treatment for high-grade cervical intraepithelial neoplasia (CIN).
A hypothetical cohort of women was evaluated after treatment for CIN 2 or 3 using a Markov model incorporating data from a large study of women treated for CIN, systematic reviews of test accuracy, and individual preferences. Surveillance strategies included initial conventional or liquid-based cytology, human papillomavirus testing, or colposcopy 6 months after treatment, followed by annual or triennial cytology. Estimated outcomes included CIN, cervical cancer, cervical cancer deaths, life expectancy, costs, cost per life-year, and cost per quality-adjusted life-year.
Conventional cytology at 6 and 12 months, followed by triennial cytology, was least costly. Compared with triennial cytology, annual cytology follow-up reduced expected cervical cancer deaths by 73% to 77% and had an average incremental cost per life-year gained of $69,000 to $81,000. For colposcopy followed by annual cytology, the incremental cost per life-year gained ranged from $70,000 to more than $1 million, depending on risk. Between-strategy differences in mean additional life expectancy per woman were less than 4 days; differences in mean incremental costs per woman were as high as $822. In the cost-utility analysis, colposcopy at 6 months followed by annual cytology had an incremental cost per quality-adjusted life-year of less than $5,500. Human papillomavirus testing or liquid-based cytology added little to no improvement to life-expectancy with higher costs.
Annual conventional cytology surveillance reduced cervical cancers and cancer deaths compared with triennial cytology. For high risk of recurrence, a strategy of colposcopy at 6 months increased life expectancy and quality-adjusted life expectancy. Human papillomavirus testing and liquid-based cytology increased costs, but not effectiveness, compared with traditional approaches.
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ABSTRACT: Major advances in screening have lowered the death rate from cervical cancer in the United States. One of the first major advances in cervical cancer screening was the Papanicolaou (Pap) test. The second major advance was liquid-based cytology (LBC). This review presents a wide range of data, discusses the strengths and weaknesses of the available information regarding Pap technologies, and reviews the meta-analyses, which have examined the differences in clinical performance. The review concludes with information on new and future developments to further decrease cervical cancer deaths.Reviews in obstetrics and gynecology 01/2011; 4(Suppl 1):S2-S11.
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ABSTRACT: To evaluate the cost effectiveness of human papillomavirus testing after treatment for cervical intraepithelial neoplasia (CIN). Economic analysis using a Markov modelling approach to combine cost and epidemiological data from the NHS Sentinel Sites Study with data from previous studies of post-treatment recurrence rates. English NHS Cervical Cancer Screening Programme. Management guidelines after treatment of CIN involving annual cytology follow-up for 10 years, compared with alternative protocols using the human papillomavirus test to reduce the amount of post-treatment surveillance. Cases of underlying CIN3+ averted at 10 years and costs per 1000 women treated. Model predictions indicated that, at observed levels of compliance with post-treatment recommendations, management with only cytological follow-up would result in 29 residual cases of recurrent CIN3+ by 10 years and would cost £358 222 (€440 426; $574 910) (discounted) per 1000 women treated. Implementation of human papillomavirus test of cure in cytologically negative women according to the sentinel sites protocol would avert an additional 8.4 cases of CIN 3+ and reduce costs by £9388 per 1000 women treated. Human papillomavirus test of cure would be more effective and would be cost saving compared with cytology only follow-up. The results of this evaluation support the full scale implementation of human papillomavirus test of cure after treatment of CIN within the NHS Cervical Screening Programme.BMJ (online) 11/2012; 345(oct31 4):e7086. DOI:10.1136/bmj.e7086 · 16.38 Impact Factor
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ABSTRACT: To evaluate the feasibility and utility of intraoperative post-conisation human papillomavirus (IOP-HPV) testing and cytology to detect treatment failure in patients with cervical intraepithelial neoplasia grades 2–3 (CIN2–3). Prospective observational pilot study. Barcelona, Spain. A cohort of 132 women treated for CIN2–3 by loop electrosurgical conisation. An endocervical sample was obtained intraoperatively with a cytobrush from the cervix remaining after the conisation. The material was kept in PreservCyt medium and processed for Hybrid Capture 2 and cytology. Patients were followed-up for 24 months. The performance of IOP-HPV testing and IOP cytology was compared with conventional indicators of recurrence (cone margin, endocervical curettage, and HPV testing and cytology at 6 months). Treatment failure (i.e. recurrent CIN2–3 during follow-up). Treatment failure was identified in 12 women (9.1%). IOP-HPV testing for sensitivity, specificity, and positive and negative predictive values for treatment failure were 91.7, 78.3, 62.2, and 96.0%, respectively, which are similar to the figures for conventional HPV testing at 6 months (91.7, 76.0, 64.0, and 95.1%, respectively), and are better than the values of other conventional predictive factors (cone margin, endocervical curettage, and cytology intraoperative at 6 months). IOP-HPV was strongly associated with treatment failure in the multivariate analysis (OR 15.40, 95% CI 1.58–150.42). IOP-HPV testing is feasible, and accurately predicts treatment failure in patients with CIN2–3. This new approach may allow an early identification of patients with treatment failure, thereby facilitating the scheduling of an attenuated follow-up for negative patients who are at very low risk of persistent disease.BJOG An International Journal of Obstetrics & Gynaecology 11/2012; 120(4). DOI:10.1111/1471-0528.12072 · 3.86 Impact Factor