Cost-effectiveness of Extending Cervical Cancer Screening Intervals Among Women With Prior Normal Pap Tests

Duke University, Durham, North Carolina, United States
Obstetrics and Gynecology (Impact Factor: 5.18). 03/2006; 107(2 Pt 1):321-8. DOI: 10.1097/01.AOG.0000196500.50044.ce
Source: PubMed


Annual cervical cancer screening in women with many prior normal Pap tests is common despite limited evidence on the cost-effectiveness of this strategy. We estimated the cost-effectiveness of screening women with 3 or more prior normal tests compared with screening those with no prior tests.
We used a validated cost-effectiveness model in conjunction with data on the prevalence of biopsy-proven cervical neoplasia in women enrolled in the Centers for Disease Control and Prevention National Breast and Cervical Cancer Early Detection Program. Women were grouped according to age at the final Program Pap test (aged < 30, 30-44, 45-59, and 60-65 years) and by screening history (0, 1, 2, and 3+ consecutive prior normal Program tests) to estimate cost per life-year and quality-adjusted life-year associated with annual, biennial, and triennial screening.
For women aged 30-44 years with no prior tests, incremental cost-effectiveness ratios ranged from 20,533 US dollars for screening triennially (compared with no further screening) to 331,837 US dollars for screening annually (compared with biennially) per life-year saved. Among same-aged women with 3 or more prior normal Program tests, incremental cost-effectiveness ratios for the same measures ranged from 60,029 US dollars to 709,067 US dollars per life-year saved. Inclusion of the most conservative utility estimates resulted in incremental cost-effectiveness ratios in excess of 100,000 US dollars per quality-adjusted life-year saved associated with annual screening of same-aged women with 3 or more prior normal tests compared with biennial screening.
As the number of prior normal Pap tests increases, the costs per life-year saved increase substantially. Resources should be prioritized for screening those never or rarely screened women.

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    • "Another advantage of this study is fewer assumptions were needed than more complex Markov and hybrid models did. Since the base-case is established by the incidence rate of different diseases, there is no need to have the following domestic information for modeling: the possible progression from HPV infection to CIN I, CIN II, CIN III, cervical cancer, the probability of HPV infection, the probability of HPV transmission, cervical cancer screening and sexually transmitted disease prevention activities, but the potential benefits of preventing vaginal, anal, vulvar, and oropharyngeal cancers in our estimated cost-effectiveness of HPV vaccine were not considered and the QALY loss related to the initial distress of receiving an abnormal Pap smear result (50) was not considered in this study. Thus, the benefits of HPV vaccination may be underestimated because of reducing the number of abnormal Pap smear results (51, 52). "
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    ABSTRACT: Human Papilloma Virus (HPV) vaccine has been added recently to the Iran Drug List. So, decision makers need information beyond that available from RCTs to recommend funding for this vaccination program to add it to the National Immunization program in Iran. Modeling and economic studies have addressed some of those information needs in foreign countries. In order to determine the long term benefit of this vaccine and impact of vaccine program on the future rate of cervical cancer in Iran, we described a model, based on the available economic and health effects of human papilloma virus (HPV), to estimate the cost-effectiveness of HPV vaccination of 15-year-old girls in Iran. Our objective is to estimate the cost-effectiveness of HPV vaccination in Iran against cervical cancer based on available data; incremental cost-effectiveness ratio (ICER) calculations were based on a model comparing a cohort of 15-year-old girls with and without vaccination. We developed a static model based on available data in Iran on the epidemiology of HPV related health outcome. The model compared the cohort of all 15-year old girls alive in the year 2013 with and without vaccination. The cost per QALY, which was found based on our assumption for the vaccination of 15-years old girl to current situation was 439,000,000 Iranian Rial rate (IRR). By considering the key parameters in our sensitivity analysis, value varied from 251,000,000 IRR to 842,000,000 IRR. In conclusion, quadrivalent HPV vaccine (Gardasil) is not cost-effective in Iran based on the base-case parameters value.
    Full-text · Article · Mar 2014 · Iranian journal of pharmaceutical research (IJPR)
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    • "To our knowledge, this is the first analysis to evaluate the costeffectiveness of alternate screening strategies to prevent cervical cancer in Norway. We expand upon previous modelling studies, which look at primary HPV DNA testing in developed countries (Goldie et al, 2004, 2006; Sherlaw-Johnson and Philips, 2004; Kim et al, 2005; Bidus et al, 2006; Kulasingam et al, 2006; Goldhaber- Fiebert et al, 2008) to include new alternative triage strategies for older women who are HPV-positive, but cytology-negative. There is no consensus regarding how to optimally manage HPV-positive results to avoid over referral and unwarranted stress for women (Cuzick et al, 2006a) and the choice of management strategy for HPV þ /CytÀ women may depend on other factors such as colposcopy resource constraints and preference to minimise false-positive results. "
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    ABSTRACT: New screening technologies and vaccination against human papillomavirus (HPV), the necessary cause of cervical cancer, may impact optimal approaches to prevent cervical cancer. We evaluated the cost-effectiveness of alternative screening strategies to inform cervical cancer prevention guidelines in Norway. We leveraged the primary epidemiologic and economic data from Norway to contextualise a simulation model of HPV-induced cervical cancer. The current cytology-only screening was compared with strategies involving cytology at younger ages and primary HPV-based screening at older ages (31/34+ years), an option being actively deliberated by the Norwegian government. We varied the switch-age, screening interval, and triage strategies for women with HPV-positive results. Uncertainty was evaluated in sensitivity analysis. Current cytology-only screening was less effective and more costly than strategies that involve switching to primary HPV testing in older ages. For unvaccinated women, switching at age 34 years to primary HPV testing every 4 years was optimal given the Norwegian cost-effectiveness threshold ($83,000 per year of life saved). For vaccinated women, a 6-year screening interval was cost-effective. When we considered a wider range of strategies, we found that an earlier switch to HPV testing (at age 31 years) may be preferred. Strategies involving a switch to HPV testing for primary screening in older women is expected to be cost-effective compared with current recommendations in Norway.
    Full-text · Article · Mar 2012 · British Journal of Cancer
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    • "For women with regular access to health care, cervical cancer mortality can be greatly reduced by regular Pap tests (Sanders & Taira, 2003). Still, this disease exacts substantial health and economic costs, suggesting that widespread HPV vaccination could prove cost effective (Elbasha, Dasback, & Insinga, 2007; Kulasingam et al., 2006), particularly among preadolescent girls (Kim & Goldie, 2008). HPV vaccination may be especially beneficial to Hispanic and African American women, who are less likely to get regular Pap tests (Huerta, 2003; O'Brien et al., 2003). "
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    ABSTRACT: To determine the most effective ways to present human papillomavirus (HPV) vaccine risk and benefit information to mothers in Hispanic, African American, and White communities, to increase mothers' intentions to vaccinate their daughters against HPV. The study used a 3 x 2 between-subjects factorial design, involving 3 different risk presentation formats (graphical HPV statistics, nongraphical HPV statistics, or no-statistics control) and the presence or absence of rhetorical questions (RQ). Data were collected from a national sample of 471 mothers of girls ages 11-16. The primary outcome variable was mothers' intention to vaccinate their daughters against HPV. Secondary outcomes included mothers' self-reported message comprehension and perceptions of daughters' vulnerability to HPV infection, infection severity, vaccine efficacy, and obstacles to immunization. Results showed that both risk presentation format and RQs had an overall positive effect on mothers' intention to vaccinate their daughters. However, the interventions appear to be more effective when used separately than when used in combination. Each of these interventions is brief and could easily be implemented by health care providers as well as in patient health communication literature.
    Full-text · Article · Jan 2010 · Health Psychology
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