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Lobin C, Orang'o EO, Were E, Muthoka K, Singh K, De Allegri M, Obermann K, von Knebel Doeberitz M, Bussmann H. Cost-effectiveness analysis of alternative screening strategies for the detection of cervical cancer among women in rural areas of Western Kenya. Int J Cancer 2024. [PMID: 38801325 DOI: 10.1002/ijc.35036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Revised: 03/21/2024] [Accepted: 04/18/2024] [Indexed: 05/29/2024]
Abstract
While the incidence of cervical cancer has dropped in high-income countries due to organized cytology-based screening programs, it remains the leading cause of cancer death among women in Eastern Africa. Therefore, the World Health Organization (WHO) now urges providers to transition from widely prevalent but low-performance visual inspection with acetic acid (VIA) screening to primary human papillomavirus (HPV) DNA testing. Due to high HPV prevalence, effective triage tests are needed to identify those lesions likely to progress and so avoid over-treatment. To identify the optimal cost-effective strategy, we compared the VIA screen-and-treat approach to primary HPV DNA testing with p16/Ki67 dual-stain cytology or VIA as triage. We used a Markov model to calculate the budget impact of each strategy with incremental quality-adjusted life years and incremental cost-effectiveness ratios (ICER) as the main outcome. Deterministic cost-effectiveness analyses show that the screen-and-treat approach is highly cost-effective (ICER 2469 Int$), while screen, triage, and treat with dual staining is the most effective with favorable ICER than triage with VIA (ICER 9943 Int$ compared with 13,177 Int$). One-way sensitivity analyses show that the results are most sensitive to discounting, VIA performance, and test prices. In the probabilistic sensitivity analyses, the triage option using dual stain is the optimal choice above a willingness to pay threshold of 7115 Int$ being cost-effective as per WHO standards. The result of our analysis favors the use of dual staining over VIA as triage in HPV-positive women and portends future opportunities and necessary research to improve the coverage and acceptability of cervical cancer screening programs.
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Affiliation(s)
- Christopher Lobin
- Applied Tumor Biology, Institute of Pathology, Heidelberg University Hospital, Heidelberg, Germany
| | - Elkanah Omenge Orang'o
- Department of Reproductive Health, School of Medicine, College of Health Sciences, Moi University, Eldoret, Kenya
- Department of Obstetrics and Gynaecology, Aga Khan University, Nairobi, Kenya
| | - Edwin Were
- Department of Reproductive Health, School of Medicine, College of Health Sciences, Moi University, Eldoret, Kenya
| | - Kapten Muthoka
- Department of Reproductive Health, School of Medicine, College of Health Sciences, Moi University, Eldoret, Kenya
| | - Kavita Singh
- Heidelberg Institute of Global Health, Heidelberg University Hospital, Heidelberg, Germany
- Public Health Foundation of India, New Delhi, India
| | - Manuela De Allegri
- Heidelberg Institute of Global Health, Heidelberg University Hospital, Heidelberg, Germany
| | - Konrad Obermann
- CPD Center for Preventive Medicine and Digital Health, Ruprecht-Karls University Heidelberg, Germany
| | | | - Hermann Bussmann
- Applied Tumor Biology, Institute of Pathology, Heidelberg University Hospital, Heidelberg, Germany
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Simms KT, Keane A, Nguyen DTN, Caruana M, Hall MT, Lui G, Gauvreau C, Demke O, Arbyn M, Basu P, Wentzensen N, Lauby-Secretan B, Ilbawi A, Hutubessy R, Almonte M, De Sanjosé S, Kelly H, Dalal S, Eckert LO, Santesso N, Broutet N, Canfell K. Benefits, harms and cost-effectiveness of cervical screening, triage and treatment strategies for women in the general population. Nat Med 2023; 29:3050-3058. [PMID: 38087115 PMCID: PMC10719104 DOI: 10.1038/s41591-023-02600-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 09/19/2023] [Indexed: 12/17/2023]
Abstract
In 2020, the World Health Organization (WHO) launched a strategy to eliminate cervical cancer as a public health problem. To support the strategy, the WHO published updated cervical screening guidelines in 2021. To inform this update, we used an established modeling platform, Policy1-Cervix, to evaluate the impact of seven primary screening scenarios across 78 low- and lower-middle-income countries (LMICs) for the general population of women. Assuming 70% coverage, we found that primary human papillomavirus (HPV) screening approaches were the most effective and cost-effective, reducing cervical cancer age-standardized mortality rates by 63-67% when offered every 5 years. Strategies involving triaging women before treatment (with 16/18 genotyping, cytology, visual inspection with acetic acid (VIA) or colposcopy) had close-to-similar effectiveness to HPV screening without triage and fewer pre-cancer treatments. Screening with VIA or cytology every 3 years was less effective and less cost-effective than HPV screening every 5 years. Furthermore, VIA generated more than double the number of pre-cancer treatments compared to HPV. In conclusion, primary HPV screening is the most effective, cost-effective and efficient cervical screening option in LMICs. These findings have directly informed WHO's updated cervical screening guidelines for the general population of women, which recommend primary HPV screening in a screen-and-treat or screen-triage-and-treat approach, starting from age 30 years with screening every 5 years or 10 years.
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Affiliation(s)
- Kate T Simms
- The Daffodil Centre, University of Sydney, a joint venture with Cancer Council NSW, Sydney, NSW, Australia.
| | - Adam Keane
- The Daffodil Centre, University of Sydney, a joint venture with Cancer Council NSW, Sydney, NSW, Australia
| | - Diep Thi Ngoc Nguyen
- The Daffodil Centre, University of Sydney, a joint venture with Cancer Council NSW, Sydney, NSW, Australia
| | - Michael Caruana
- The Daffodil Centre, University of Sydney, a joint venture with Cancer Council NSW, Sydney, NSW, Australia
| | - Michaela T Hall
- The Daffodil Centre, University of Sydney, a joint venture with Cancer Council NSW, Sydney, NSW, Australia
| | - Gigi Lui
- The Daffodil Centre, University of Sydney, a joint venture with Cancer Council NSW, Sydney, NSW, Australia
| | - Cindy Gauvreau
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, ON, Canada
- SUCCESS Project, Expertise France, Paris, France
| | - Owen Demke
- Global Diagnostics, Clinton Health Access Initiative, Kigali, Rwanda
| | - Marc Arbyn
- Unit of Cancer Epidemiology, Belgian Cancer Centre, Sciensano, Brussels, Belgium
- Department of Human Structure and Repair, Faculty of Medicine and Health Sciences, University Ghent, Ghent, Belgium
| | - Partha Basu
- Early Detection, Prevention and Infections Branch, International Agency for Research on Cancer, Lyon, France
| | - Nicolas Wentzensen
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Rockville, MD, USA
| | - Beatrice Lauby-Secretan
- Evidence Synthesis and Classification Branch, International Agency for Research on Cancer (IARC), Lyon, France
| | - Andre Ilbawi
- Department for the Management of Noncommunicable Diseases, Disability, Violence and Injury Prevention, World Health Organization, Geneva, Switzerland
| | - Raymond Hutubessy
- Department of Immunization, Vaccines and Biologicals, World Health Organization, Geneva, Switzerland
| | - Maribel Almonte
- Early Detection, Prevention and Infections Branch, International Agency for Research on Cancer, Lyon, France
- Department of Sexual and Reproductive Health, World Health Organization, Geneva, Switzerland
| | - Silvia De Sanjosé
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Rockville, MD, USA
- ISGlobal, Barcelona, Spain
| | - Helen Kelly
- London School of Hygiene & Tropical Medicine, London, UK
| | - Shona Dalal
- Department of Global HIV, Hepatitis and Sexually Transmitted Infections Programmes, World Health Organization, Geneva, Switzerland
| | - Linda O Eckert
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Obstetrics and Gynecology, University of Washington, Seattle, WA, USA
| | - Nancy Santesso
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Nathalie Broutet
- Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Karen Canfell
- The Daffodil Centre, University of Sydney, a joint venture with Cancer Council NSW, Sydney, NSW, Australia
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3
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Zhao XL, Zhao S, Xia CF, Hu SY, Duan XZ, Liu ZH, Wang YY, You TT, Gao M, Qiao YL, Basu P, Zhao FH. Cost-effectiveness of the screen-and-treat strategies using HPV test linked to thermal ablation for cervical cancer prevention in China: a modeling study. BMC Med 2023; 21:149. [PMID: 37069602 PMCID: PMC10111823 DOI: 10.1186/s12916-023-02840-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Accepted: 03/20/2023] [Indexed: 04/19/2023] Open
Abstract
BACKGROUND Self-sampling HPV test and thermal ablation are effective tools to increase screening coverage and treatment compliance for accelerating cervical cancer elimination. We assessed the cost-effectiveness of their combined strategies to inform accessible, affordable, and acceptable cervical cancer prevention strategies. METHODS We developed a hybrid model to evaluate costs, health outcomes, and incremental cost-effectiveness ratios (ICER) of six screen-and-treat strategies combining HPV testing (self-sampling or physician-sampling), triage modalities (HPV genotyping, colposcopy or none) and thermal ablation, from a societal perspective. A designated initial cohort of 100,000 females born in 2015 was considered. Strategies with an ICER less than the Chinese gross domestic product (GDP) per capita ($10,350) were considered highly cost-effective. RESULTS Compared with current strategies in China (physician-HPV with genotype or cytology triage), all screen-and-treat strategies are cost-effective and self-HPV without triage is optimal with the most incremental quality-adjusted life-years (QALYs) gained (220 to 440) in rural and urban China. Each screen-and-treat strategy based on self-collected samples is cost-saving compared with current strategies (-$818,430 to -$3540) whereas more costs are incurred using physician-collected samples compared with current physician-HPV with genotype triage (+$20,840 to +$182,840). For screen-and-treat strategies without triage, more costs (+$9404 to +$380,217) would be invested in the screening and treatment of precancerous lesions rather than the cancer treatment compared with the current screening strategies. Notably, however, more than 81.6% of HPV-positive women would be overtreated. If triaged with HPV 7 types or HPV16/18 genotypes, 79.1% or 67.2% (respectively) of HPV-positive women would be overtreated with fewer cancer cases avoided (19 cases or 69 cases). CONCLUSIONS Screen-and-treat strategy using self-sampling HPV test linked to thermal ablation could be the most cost-effective for cervical cancer prevention in China. Additional triage with quality-assured performance could reduce overtreatment and remains highly cost-effective compared with current strategies.
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Affiliation(s)
- Xue-Lian Zhao
- Department of Epidemiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shuang Zhao
- Department of Clinical Trial Research Center, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Chang-Fa Xia
- Office of Cancer Screening, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shang-Ying Hu
- Department of Epidemiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xian-Zhi Duan
- Department of Obstetrics and Gynecology, Beijing Tongren Hospital, Beijing, China
| | - Zhi-Hua Liu
- Affiliated Shenzhen Maternity and Child Healthcare Hospital, Southern Medical University, Shenzhen, China
| | - Yue-Yun Wang
- Affiliated Shenzhen Maternity and Child Healthcare Hospital, Southern Medical University, Shenzhen, China
| | - Ting-Ting You
- Department of Epidemiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Meng Gao
- Department of Epidemiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- School of Population Medicine and Public Health, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - You-Lin Qiao
- School of Population Medicine and Public Health, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Partha Basu
- Early Detection, Prevention & Infections Branch, International Agency for Research on Cancer, Lyon, France
| | - Fang-Hui Zhao
- Department of Epidemiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
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Choi S, Ismail A, Pappas-Gogos G, Boussios S. HPV and Cervical Cancer: A Review of Epidemiology and Screening Uptake in the UK. Pathogens 2023; 12:pathogens12020298. [PMID: 36839570 PMCID: PMC9960303 DOI: 10.3390/pathogens12020298] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 01/31/2023] [Accepted: 02/09/2023] [Indexed: 02/15/2023] Open
Abstract
Cervical cancer is the fourth most common malignancy in females worldwide, and a leading cause of death in the United Kingdom (UK). The human papillomavirus (HPV) is the strongest risk factor for developing cervical intraepithelial neoplasia and cancer. Across the UK, the national HPV immunisation programme, introduced in 2008, has been successful in protecting against HPV-related infections. Furthermore, the National Health Service (NHS) implemented the cytology-based cervical cancer screening service to all females aged 25 to 64, which has observed a decline in cervical cancer incidence. In the UK, there has been an overall decline in age-appropriate coverage since April 2010. In 2019, the COVID-19 pandemic disrupted NHS cancer screening and immunisation programmes, leading to a 6.8% decreased uptake of cervical cancer screening from the previous year. Engagement with screening has also been associated with social deprivation. In England, incidence rates of cervical cancer were reported to be 65% higher in the most deprived areas compared to the least, with lifestyle factors such as cigarette consumption contributing to 21% of cervical cancer cases. In this article, we provide an update on the epidemiology of cervical cancer, and HPV pathogenesis and transmission, along with the current prevention programmes within the NHS.
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Affiliation(s)
- Sunyoung Choi
- GKT School of Medicine, King’s College London, London SE1 9RT, UK
| | - Ayden Ismail
- GKT School of Medicine, King’s College London, London SE1 9RT, UK
| | - George Pappas-Gogos
- Department of General Surgery, University Hospital of Alexandroupolis, School of Medicine, Democritus University of Thrace, 6th Kilometer, 68100 Alexandroupolis, Greece
| | - Stergios Boussios
- Department of Medical Oncology, Medway NHS Foundation Trust, Windmill Road, Kent, Gillingham ME7 5NY, UK
- Faculty of Life Sciences & Medicine, School of Cancer & Pharmaceutical Sciences, King’s College London, London SE1 9RT, UK
- Kent Medway Medical School, University of Kent, Kent, Canterbury CT2 7LX, UK
- AELIA Organization, 9th Km Thessaloniki—Thermi, 57001 Thessaloniki, Greece
- Correspondence: or or or
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Nygård M, Nygård S. The Future of Cervical Cancer Prevention: From "One-Size-Fits-All" to Personalized Screening. J Pers Med 2023; 13:jpm13020161. [PMID: 36836396 PMCID: PMC9966965 DOI: 10.3390/jpm13020161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 01/03/2023] [Indexed: 01/18/2023] Open
Abstract
Cervical cancer screening represents an excellent model system for the development of personalized cancer-prevention strategies [...].
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Catarino R, Vassilakos P, Petignat P, Combescure C. Harms and benefits of cervical cancer screening among non-attenders in Switzerland: The transition towards HPV-based screening. Prev Med Rep 2022; 29:101929. [PMID: 35959498 PMCID: PMC9357843 DOI: 10.1016/j.pmedr.2022.101929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Accepted: 07/26/2022] [Indexed: 11/16/2022] Open
Abstract
We evaluate the expected benefits and harms of cervical cancer screening strategies. Primary self-sampling with HPV was associated with a lower cancer incidence and mortality compared to cytology. Primary self-sampling with HPV resulted in a reduction of screening and follow-up visits. Primary self-sampling with HPV has a reasonable balance of harms and benefits when performed every 5 years.
Human papillomavirus (HPV) testing is replacing cytological screening for cervical cancer. Our aim was to assess the expected benefits and harms of different cervical screening strategies. This study is sub-analysis of a previous cost-effectiveness study with a target population of unscreened women without cervical cancer aged ≥ 25 years. A recursive decision-tree with one-year cycles was used to model the life-long natural HPV history. Markov cohort simulations were used to assess the expected outcomes from the model. The outcomes of three strategies were compared with the absence of screening: HPV-testing on self-collected vaginal samples (Self-HPV) followed by colposcopy (Self-HPV/colpo), Self-HPV and triage with cytology (Self-HPV/PAP), cytology and triage with HPV (PAP/HPV). All screening strategies resulted in reductions in cancer cases and deaths. Self-HPV strategies were associated with a lower cancer incidence and mortality life-long, not only when performed every 3 years but also when Self-HPV was performed every 5 years vs cytology every 3 years. The gain in life expectancy obtained was 82 days with Self-HPV/colpo, 81 days with Self-HPV/PAP and 75 days with PAP/HPV compared to no screening. The number of lifetime total visits was greater with PAP/HPV compared with the Self-HPV strategies (13.13 vs < 3). The number of conizations remained relatively stable with the change of screening frequency and strategy. Self-HPV may represent a reasonable balance of harms and benefits when performed every 5 years compared to cytology every 3 years. Self-HPV/PAP yielded the most efficient harm to benefit ratio when using colposcopy as a proxy for harms.
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Affiliation(s)
- Rosa Catarino
- Department of Paediatrics, Gynaecology and Obstetrics, Geneva University Hospitals, Boulevard de la Cluse 30, 1205 Geneva, Switzerland
- Corresponding author at: Division of Gynaecology, Geneva University Hospitals, Boulevard de la Cluse 30, 1205 Geneva, Switzerland.
| | - Pierre Vassilakos
- Department of Paediatrics, Gynaecology and Obstetrics, Geneva University Hospitals, Boulevard de la Cluse 30, 1205 Geneva, Switzerland
- Geneva Foundation for Medical Education and Research, Route de Ferney 150, 1211 Geneva, Switzerland
| | - Patrick Petignat
- Department of Paediatrics, Gynaecology and Obstetrics, Geneva University Hospitals, Boulevard de la Cluse 30, 1205 Geneva, Switzerland
| | - Christophe Combescure
- Division of Clinical Epidemiology, Geneva University Hospitals, Rue Gabrielle-Perret-Gentil 4, 1205 Geneva, Switzerland
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Raman Spectroscopy: A Personalized Decision-Making Tool on Clinicians' Hands for In Situ Cancer Diagnosis and Surgery Guidance. Cancers (Basel) 2022; 14:cancers14051144. [PMID: 35267451 PMCID: PMC8909093 DOI: 10.3390/cancers14051144] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 02/04/2022] [Accepted: 02/07/2022] [Indexed: 12/23/2022] Open
Abstract
Simple Summary Cancer still constitutes one of the main global health challenges. Novel approaches towards understanding the molecular composition of the disease can be employed as adjuvant tools to current oncological applications. Raman spectroscopy has been contemplated and pursued to serve as a noninvasive, real time, in vivo tool which may uncover the molecular basis of cancer and simultaneously offer high specificity, sensitivity, and multiplexing capacity, as well as high spatial and temporal resolution. In this review, the potential impact of Spontaneous Raman spectroscopy in clinical applications related to cancer diagnosis and surgical removal is analyzed. Moreover, the coupling of Raman systems with modern instrumentation and machine learning methods has been explored as a prominent enhancement factor towards a personalized approach promoting objectivity and accuracy in surgical oncology. Abstract Accurate in situ diagnosis and optimal surgical removal of a malignancy constitute key elements in reducing cancer-related morbidity and mortality. In surgical oncology, the accurate discrimination between healthy and cancerous tissues is critical for the postoperative care of the patient. Conventional imaging techniques have attempted to serve as adjuvant tools for in situ biopsy and surgery guidance. However, no single imaging modality has been proven sufficient in terms of specificity, sensitivity, multiplexing capacity, spatial and temporal resolution. Moreover, most techniques are unable to provide information regarding the molecular tissue composition. In this review, we highlight the potential of Raman spectroscopy as a spectroscopic technique with high detection sensitivity and spatial resolution for distinguishing healthy from malignant margins in microscopic scale and in real time. A Raman spectrum constitutes an intrinsic “molecular finger-print” of the tissue and any biochemical alteration related to inflammatory or cancerous tissue state is reflected on its Raman spectral fingerprint. Nowadays, advanced Raman systems coupled with modern instrumentation devices and machine learning methods are entering the clinical arena as adjunct tools towards personalized and optimized efficacy in surgical oncology.
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Burger EA, de Kok IMCM, Groene E, Killen J, Canfell K, Kulasingam S, Kuntz KM, Matthijsse S, Regan C, Simms KT, Smith MA, Sy S, Alarid-Escudero F, Vaidyanathan V, van Ballegooijen M, Kim JJ. Estimating the Natural History of Cervical Carcinogenesis Using Simulation Models: A CISNET Comparative Analysis. J Natl Cancer Inst 2021; 112:955-963. [PMID: 31821501 DOI: 10.1093/jnci/djz227] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND The natural history of human papillomavirus (HPV)-induced cervical cancer (CC) is not directly observable, yet the age of HPV acquisition and duration of preclinical disease (dwell time) influences the effectiveness of alternative preventive policies. We performed a Cancer Intervention and Surveillance Modeling Network (CISNET) comparative modeling analysis to characterize the age of acquisition of cancer-causing HPV infections and implied dwell times for distinct phases of cervical carcinogenesis. METHODS Using four CISNET-cervical models with varying underlying structures but fit to common US epidemiological data, we estimated the age of acquisition of causal HPV infections and dwell times associated with three phases of cancer development: HPV, high-grade precancer, and cancer sojourn time. We stratified these estimates by HPV genotype under both natural history and CC screening scenarios, because screening prevents cancer development that affects the mix of detected cancers. RESULTS The median time from HPV acquisition to cancer detection ranged from 17.5 to 26.0 years across the four models. Three models projected that 50% of unscreened women acquired their causal HPV infection between ages 19 and 23 years, whereas one model projected these infections occurred later (age 34 years). In the context of imperfect compliance with US screening guidelines, the median age of causal infection was 4.4-15.9 years later compared with model projections in the absence of screening. CONCLUSIONS These validated CISNET-CC models, which reflect some uncertainty in the development of CC, elucidate important drivers of HPV vaccination and CC screening policies and emphasize the value of comparative modeling when evaluating public health policies.
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Affiliation(s)
- Emily A Burger
- Harvard T.H. Chan School of Public Health, Boston, MA.,University of Oslo, Oslo, Norway
| | | | | | - James Killen
- Cancer Research Division, Cancer Council NSW, Sydney, Australia
| | - Karen Canfell
- Cancer Research Division, Cancer Council NSW, Sydney, Australia.,School of Public Health, University of Sydney, Sydney, Australia
| | | | | | | | | | - Kate T Simms
- Cancer Research Division, Cancer Council NSW, Sydney, Australia.,School of Public Health, University of Sydney, Sydney, Australia
| | - Megan A Smith
- Cancer Research Division, Cancer Council NSW, Sydney, Australia.,School of Public Health, University of Sydney, Sydney, Australia
| | - Stephen Sy
- Harvard T.H. Chan School of Public Health, Boston, MA
| | - Fernando Alarid-Escudero
- Drug Policy Program, Center for Research and Teaching in Economics (CIDE)-CONACyT, Aguascalientes, Mexico
| | | | | | - Jane J Kim
- Harvard T.H. Chan School of Public Health, Boston, MA
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9
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Xia C, Xu X, Zhao X, Hu S, Qiao Y, Zhang Y, Hutubessy R, Basu P, Broutet N, Jit M, Zhao F. Effectiveness and cost-effectiveness of eliminating cervical cancer through a tailored optimal pathway: a modeling study. BMC Med 2021; 19:62. [PMID: 33653331 PMCID: PMC7927373 DOI: 10.1186/s12916-021-01930-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 01/27/2021] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND The World Health Assembly has adopted a global strategy to eliminate cervical cancer. However, neither the optimal pathway nor the corresponding economic and health benefits have been evaluated. We take China as an example to assess the optimal pathway towards elimination and the cost-effectiveness of tailored actions. METHODS A validated hybrid model was used to assess the costs and benefits of alternative strategies combining human papillomavirus vaccination, cervical screening, and treatment of pre-invasive lesions and invasive cancer for females with different immunization history. All Chinese females living or projected to be born during 2015-2100, under projected trends in aging, urbanization, and sexual activity, were considered. Optimal strategies were determined by cost-effectiveness efficiency frontiers. Primary outcomes were cervical cancer cases and deaths averted and incremental cost-effectiveness ratios (ICERs). We employed a lifetime horizon from a societal perspective. One-way and probabilistic sensitivity analyses evaluate model uncertainty. RESULTS The optimal pathway represents an integration of multiple tailored strategies from females with different immunization history. If China adopts the optimal pathway, the age-standardized incidence of cervical cancer is predicted to decrease to fewer than four new cases per 100,000 women (i.e., elimination) by 2047 (95% confidence interval 2043 to 2050). Compared to the status quo, the optimal pathway would avert a total of 7,509,192 (6,922,744 to 8,359,074) cervical cancer cases and 2,529,873 (2,366,826 to 2,802,604) cervical cancer deaths in 2021-2100, with the discounted ICER being $- 339 (- 687 to - 79) per quality-adjusted life-year. CONCLUSIONS By adopting an optimal pathway from 2021 (namely, the year of the first Chinese Centennial Goals) onwards, cervical cancer could be eliminated by the late 2040s (namely, ahead of the second Chinese Centennial Goals) while saving net economic costs in China.
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Affiliation(s)
- Changfa Xia
- National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No.17 Pan-jia-yuan South Lane, Chaoyang District, Beijing, 100021, China
| | - Xiaoqian Xu
- National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No.17 Pan-jia-yuan South Lane, Chaoyang District, Beijing, 100021, China
| | - Xuelian Zhao
- National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No.17 Pan-jia-yuan South Lane, Chaoyang District, Beijing, 100021, China
| | - Shangying Hu
- National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No.17 Pan-jia-yuan South Lane, Chaoyang District, Beijing, 100021, China
| | - Youlin Qiao
- National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No.17 Pan-jia-yuan South Lane, Chaoyang District, Beijing, 100021, China
| | - Yong Zhang
- National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No.17 Pan-jia-yuan South Lane, Chaoyang District, Beijing, 100021, China
| | - Raymond Hutubessy
- Department of Immunization, Vaccines and Biologicals (IVB), World Health Organization, Geneva, Switzerland
| | - Partha Basu
- Screening Group, Early Detection and Prevention Section, International Agency for Research on Cancer, Lyon, France
| | - Nathalie Broutet
- Department of Reproductive Health and Research - WHO Special Research Programme on Human Reproduction (HRP), World Health Organization, Geneva, Switzerland
| | - Mark Jit
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
- School of Public Health, University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Fanghui Zhao
- National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No.17 Pan-jia-yuan South Lane, Chaoyang District, Beijing, 100021, China.
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Chesson HW, Meites E, Ekwueme DU, Saraiya M, Markowitz LE. Cost-effectiveness of HPV vaccination for adults through age 45 years in the United States: Estimates from a simplified transmission model. Vaccine 2020; 38:8032-8039. [PMID: 33121846 PMCID: PMC10395540 DOI: 10.1016/j.vaccine.2020.10.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 09/30/2020] [Accepted: 10/07/2020] [Indexed: 01/28/2023]
Abstract
INTRODUCTION The objective of this study was to assess incremental costs and benefits of a human papillomavirus (HPV) vaccination program expanded to include "mid-adults" (adults aged 27 through 45 years) in the United States. METHODS We adapted a previously published, dynamic mathematical model of HPV transmission and HPV-associated disease to estimate the incremental costs and benefits of a 9-valent HPV vaccine (9vHPV) program for people aged 12 through 45 years compared to a 9vHPV program for females aged 12 through 26 years and males aged 12 through 21 years. RESULTS A 9vHPV program for females aged 12 through 26 years and males aged 12 through 21 years was estimated to cost < $10,000 quality-adjusted life year (QALY) gained, compared to no vaccination. Expanding the 9vHPV program to include mid-adults was estimated to cost $587,600 per additional QALY gained when including adults through age 30 years, and $653,300 per additional QALY gained when including adults through age 45 years. Results were most sensitive to assumptions about HPV incidence among mid-adults, current and historical vaccination coverage, vaccine price, and the impact of HPV diseases on quality of life. CONCLUSIONS Mid-adult vaccination is much less cost-effective than the comparison strategy of routine vaccination for all adolescents at ages 11 to 12 years and catch-up vaccination for women through age 26 years and men through age 21 years.
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11
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Moriña D, Martí JI, Puig P, Diaz M. Online Cost-Effectiveness ANalysis (OCEAN): a user-friendly interface to conduct cost-effectiveness analyses for cervical cancer. BMC Med Inform Decis Mak 2020; 20:211. [PMID: 32887589 PMCID: PMC7487926 DOI: 10.1186/s12911-020-01232-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 08/26/2020] [Indexed: 11/29/2022] Open
Abstract
Background Most cost-effectiveness analyses in the context of cervical cancer prevention involve the use of mathematical models to simulate HPV infection, cervical disease and prevention strategies. However, it is common for professionals who would need to perform these analyses to not be familiar with the models. This work introduces the Online Cost-Effectiveness ANalysis tool, featuring an easy-to-use web interface providing health professionals, researchers and decision makers involved in cervical cancer prevention programmes with a useful instrument to conduct complex cost-effectiveness analyses, which are becoming an essential tool as an approach for supporting decision-making that involves important trade-offs. Results The users can run cost-effectiveness evaluations of cervical cancer prevention strategies without deep knowledge of the underlying mathematical model or any programming language, obtaining the most relevant costs and health outcomes in a user-friendly format. The results provided by the tool are consistent with the existing literature. Conclusions Having such a tool will be an asset to the cervical cancer prevention community, providing researchers with an easy-to-use instrument to conduct cost-effectiveness analyses.
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Affiliation(s)
- David Moriña
- Barcelona Graduate School of Mathematics (BGSMath), Barcelona, Spain. .,Departament de Matemàtiques, Universitat Autònoma de Barcelona (UAB), Cerdanyola del Vallès, 08193, Barcelona, Spain. .,Department of Econometrics, Statistics and Applied Economics, Riskcenter-IREA, Universitat de Barcelona (UB), Barcelona, Spain.
| | - José Ignacio Martí
- Unit of Infections and Cancer - Information and Interventions (UNIC-I&I), Cancer Epidemiology Research Program (CERP), Catalan Institute of Oncology (ICO)-IDIBELL, Barcelona, Spain
| | - Pedro Puig
- Barcelona Graduate School of Mathematics (BGSMath), Barcelona, Spain.,Departament de Matemàtiques, Universitat Autònoma de Barcelona (UAB), Cerdanyola del Vallès, 08193, Barcelona, Spain
| | - Mireia Diaz
- Unit of Infections and Cancer - Information and Interventions (UNIC-I&I), Cancer Epidemiology Research Program (CERP), Catalan Institute of Oncology (ICO)-IDIBELL, Barcelona, Spain.,Centro de Investigación Biomédica en Red (CIBERONC), Barcelona, Spain
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12
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Hall MT, Smith MA, Lew JB, O'Hallahan J, Fentiman G, Neal H, Sage M, Canfell K. The combined impact of implementing HPV immunisation and primary HPV screening in New Zealand: Transitional and long-term benefits, costs and resource utilisation implications. Gynecol Oncol 2019; 152:472-479. [PMID: 30876491 DOI: 10.1016/j.ygyno.2018.10.045] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Revised: 10/16/2018] [Accepted: 10/30/2018] [Indexed: 11/27/2022]
Abstract
BACKGROUND In response to emergent evidence, many countries are transitioning from cytology-based to HPV screening. We evaluated the impact of an upcoming transition on health outcomes and resource utilisation in New Zealand. METHODS An extensively validated model of HPV transmission, vaccination, natural history and cervical screening ('Policy1-Cervix') was utilised to simulate a transition from three-yearly cytology for women 20-69 years to five-yearly HPV screening with 16/18 genotyping for women 25-69 years, accounting for population growth and the impact of HPV immunisation. Cervical cancer rates, resources use (test volumes), costs, and test positivity rates from 2015 to 2035 were estimated. FINDINGS By 2035, the transition to HPV screening will result in declines in cervical cancer incidence and mortality rates by 32% and 25%, respectively, compared to 2018. A potentially detectable 5% increase in cervical cancer incidence due to earlier detection is predicted for the year of transition. Annual numbers of women screened will fluctuate with the five-year screening interval. Cytology volumes will reduce by over 80% but colposcopy volumes will be similar to pre-transition rates, and program costs will be reduced by 16%. A 9% HPV test positivity rate is expected in the first round of HPV screening (2019-2023), with 2.7% of women referred for colposcopy. Transitioning from cytology to primary HPV cervical screening could avert 149 cancer cases and 45 deaths by 2035. CONCLUSION Primary HPV screening and vaccination will reduce cervical cancer and resources use. A small transient apparent increase of invasive cancer rates due to earlier detection may be detectable at the population level, reflecting the introduction of a more sensitive screening test. These findings can be used to inform health services planning and public communications surrounding program implementation.
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Affiliation(s)
- Michaela T Hall
- Cancer Research Division, Cancer Council NSW, Sydney, Australia; School of Mathematics and Statistics, University of New South Wales, Sydney, Australia.
| | - Megan A Smith
- Cancer Research Division, Cancer Council NSW, Sydney, Australia; School of Public Health, University of Sydney, Sydney, Australia
| | - Jie-Bin Lew
- Cancer Research Division, Cancer Council NSW, Sydney, Australia
| | | | | | | | | | - Karen Canfell
- Cancer Research Division, Cancer Council NSW, Sydney, Australia; School of Public Health, University of Sydney, Sydney, Australia.
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13
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Vassilakos P, Poncet A, Catarino R, Viviano M, Petignat P, Combescure C. Cost-effectiveness evaluation of HPV self-testing offered to non-attendees in cervical cancer screening in Switzerland. Gynecol Oncol 2019; 153:92-99. [PMID: 30718124 DOI: 10.1016/j.ygyno.2019.01.021] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 01/17/2019] [Accepted: 01/22/2019] [Indexed: 01/10/2023]
Abstract
OBJECTIVE About 30% of women who are eligible for cervical cancer (CC) screening remain un-screened or under-screened in Switzerland. HPV testing on self-collected vaginal samples (Self-HPV) has shown to be more sensitive than cytology while also reaching non-attendees. The objective of this study was to explore the cost-effectiveness of offering Self-HPV to non-attendees in Switzerland. METHODS A recursive decision-tree with one-year cycles was used to model the life-long natural HPV history. Markov cohort simulations were used to assess the expected outcomes from the model. The outcomes of three strategies were compared with the absence of screening: Self-HPV and triage with colposcopy (Self-HPV/colpo), Self-HPV and triage with Pap cytology (Self-HPV/PAP), cytological screening and triage with HPV (PAP/HPV). Sensitivity analyses for the key parameters of the model were conducted to check the robustness of findings. RESULTS Offering a Self-HPV screening to non-attendees could prevent 90% of CC and 94% of CC-related deaths in the study population. The current cytology-based program could reduce by 83% the number of CC cases and by 88% the number of CC-related deaths over the population's lifetime. Compared to the absence of screening, incremental cost-effectiveness ratios (ICER) were estimated to be, per saved Quality Adjusted Life Year (QALY), 12413US$ for the strategy Self-HPV/colpo, 11138US$ for the strategy Self-HPV/Pap and 22488US$ for the strategy PAP/HPV. CONCLUSIONS Offering Self-HPV as a CC screening strategy to non-attendees in Switzerland is a cost-effective solution that is associated with a reduction of CC cases and related deaths. Self-HPV is more cost-effective than the currently used cytology-based screening.
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Affiliation(s)
- Pierre Vassilakos
- Geneva Foundation for Medical Education and Research, route de Ferney 150, 1211 Geneva, Switzerland; Department of Gynaecology and Obstetrics, Geneva University Hospitals, Boulevard de la Cluse 30, 1205 Geneva, Switzerland
| | - Antoine Poncet
- Division of Clinical Epidemiology, Geneva University Hospitals, Rue Gabrielle-Perret-Gentil 4, 1205 Geneva, Switzerland
| | - Rosa Catarino
- Department of Gynaecology and Obstetrics, Geneva University Hospitals, Boulevard de la Cluse 30, 1205 Geneva, Switzerland.
| | - Manuela Viviano
- Department of Gynaecology and Obstetrics, Geneva University Hospitals, Boulevard de la Cluse 30, 1205 Geneva, Switzerland
| | - Patrick Petignat
- Department of Gynaecology and Obstetrics, Geneva University Hospitals, Boulevard de la Cluse 30, 1205 Geneva, Switzerland
| | - Christophe Combescure
- Division of Clinical Epidemiology, Geneva University Hospitals, Rue Gabrielle-Perret-Gentil 4, 1205 Geneva, Switzerland
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Projected future impact of HPV vaccination and primary HPV screening on cervical cancer rates from 2017-2035: Example from Australia. PLoS One 2018; 13:e0185332. [PMID: 29444073 PMCID: PMC5812553 DOI: 10.1371/journal.pone.0185332] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Accepted: 09/11/2017] [Indexed: 11/22/2022] Open
Abstract
Background Many countries are transitioning from cytology-based to longer-interval HPV screening. Trials comparing HPV-based screening to cytology report an increase in CIN2/3 detection at the first screen, and longer-term reductions in CIN3+; however, population level year-to-year transitional impacts are poorly understood. We undertook a comprehensive evaluation of switching to longer-interval primary HPV screening in the context of HPV vaccination. We used Australia as an example setting, since Australia will make this transition in December 2017. Methods Using a model of HPV vaccination, transmission, natural history and cervical screening, Policy1-Cervix, we simulated the planned transition from recommending cytology every two years for sexually-active women aged 18–20 to 69, to recommending HPV screening every five years for women aged 25–74 years. We estimated rates of CIN2/3, cervical cancer incidence, and mortality for each year from 2005 to 2035, considering ranges for HPV test accuracy and screening compliance in the context of HPV vaccination (current coverage ~82% in females; ~76% in males). Findings Transient increases are predicted to occur in rates of CIN2/3 detection and invasive cervical cancer in the first two to three years following the screening transition (of 16–24% and 11–14% in respectively, compared to 2017 rates). However, by 2035, CIN2/3 and invasive cervical cancer rates are predicted to fall by 40–44% and 42–51%, respectively, compared to 2017 rates. Cervical cancer mortality rates are predicted to remain unchanged until ~2020, then decline by 34–45% by 2035. Over the period 2018–2035, switching to primary HPV screening in Australia is expected to avert 2,006 cases of invasive cervical cancer and save 587 lives. Conclusions Transient increases in detected CIN2/3 and invasive cancer, which may be detectable at the population level, are predicted following a change to primary HPV screening. This is due to improved test sensitivity bringing forward diagnoses, resulting in longer term reductions in both cervical cancer incidence and mortality. Fluctuations in health outcomes due to the transition to a longer screening interval are predicted to occur for 10–15 years, but cervical cancer rates will be significantly reduced thereafter due to the impact of HPV vaccination and HPV screening. In order to maintain confidence in primary HPV screening through the transitional phase, it is important to widely communicate that an initial increase in CIN2/3 and perhaps even invasive cervical cancer is expected after a national transition to primary HPV screening, that this phenomenon is due to increased prevalent disease detection, and that this effect represents a marker of screening success.
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15
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Present and future of cervical cancer prevention in Spain: a cost-effectiveness analysis. Eur J Cancer Prev 2018; 25:430-9. [PMID: 26375246 DOI: 10.1097/cej.0000000000000202] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Human papillomavirus (HPV) vaccination within a nonorganized setting creates a poor cost-effectiveness scenario. However, framed within an organized screening including primary HPV DNA testing with lengthening intervals may provide the best health value for invested money. To compare the effectiveness and cost-effectiveness of different cervical cancer (CC) prevention strategies, including current status and new proposed screening practices, to inform health decision-makers in Spain, a Markov model was developed to simulate the natural history of HPV and CC. Outcomes included cases averted, life expectancy, reduction in the lifetime risk of CC, life years saved, quality-adjusted life years (QALYs), net health benefits, lifetime costs, and incremental cost-effectiveness ratios. The willingness-to-pay threshold is defined at 20 000&OV0556;/QALY. Both costs and health outcomes were discounted at an annual rate of 3%. A strategy of 5-year organized HPV testing has similar effectiveness, but higher efficiency than 3-year cytology. Screening alone and vaccination combined with cytology are dominated by vaccination followed by 5-year HPV testing with cytology triage (12 214&OV0556;/QALY). The optimal age for both ending screening and switching age from cytology to HPV testing in older women is 5 years later for unvaccinated than for vaccinated women. Net health benefits decrease faster with diminishing vaccination coverage than screening coverage. Primary HPV DNA testing is more effective and cost-effective than current cytological screening. Vaccination uptake improvements and a gradual change toward an organized screening practice are critical components for achieving higher effectiveness and efficiency in the prevention of CC in Spain.
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16
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Moriña D, de Sanjosé S, Diaz M. Impact of model calibration on cost-effectiveness analysis of cervical cancer prevention. Sci Rep 2017; 7:17208. [PMID: 29222509 PMCID: PMC5722890 DOI: 10.1038/s41598-017-17215-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Accepted: 11/21/2017] [Indexed: 12/02/2022] Open
Abstract
Markov chain models are commonly used to simulate the natural history of human papillomavirus infection and subsequent cervical lesions with the aim of predicting future benefits of health interventions. Developing and calibrating these models entails making a number of critical decisions that will influence the ability of the model to reflect real conditions and predict future situations. Accuracy of selected inputs and calibration procedures are two of the crucial aspects for model performance and understanding their influence is essential, especially when involves policy decisions. The aim of this work is to assess the health and economic impact on cervical cancer prevention strategies currently under discussion according to the most common methods of model calibration combined with different accuracy degree of initial inputs. Model results show large differences on the goodness of fit and cost-effectiveness outcomes depending on the calibration approach used, and these variations may affect health policy decisions. Our findings strengthen the importance of obtaining good calibrated probability matrices to get reliable health and cost outcomes, and are directly generalizable to any cost-effectiveness analysis based on Markov chain models.
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Affiliation(s)
- David Moriña
- Unit of Infections and Cancer - Information and Interventions (UNIC - I&I), Cancer Epidemiology Research Program (CERP), Catalan Institute of Oncology (ICO)-IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain.
| | - Silvia de Sanjosé
- Cancer Epidemiology Research Program (CERP), Catalan Institute of Oncology (ICO)-IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain
- Centro de Investigación Biomédica en Red (CIBERESP), Barcelona, Spain
| | - Mireia Diaz
- Unit of Infections and Cancer - Information and Interventions (UNIC - I&I), Cancer Epidemiology Research Program (CERP), Catalan Institute of Oncology (ICO)-IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain.
- Centro de Investigación Biomédica en Red (CIBERONC), Barcelona, Spain.
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17
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Marcellusi A. Impact of HPV vaccination: health gains in the Italian female population. Popul Health Metr 2017; 15:36. [PMID: 28962572 PMCID: PMC5622511 DOI: 10.1186/s12963-017-0154-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Accepted: 09/21/2017] [Indexed: 01/05/2023] Open
Abstract
Background Human papillomavirus (HPV) is the leading cause of cervical cancer and other malignant and benign neoplastic lesions. HPV vaccination has three potential goals: to prevent transmission, infection, and disease. At present, there are no available data about health consequences of HPV immunization in Italy. The aim of this study is to evaluate the effect of current HPV vaccination strategy in Italy. Methods A multistate morbidity-mortality model was developed to estimate the infection process in a theoretical cohort of Italian women. The Markov process considered nine health states (health, anogenital warts, grade 1 and grade 2/3 cervical intraepithelial neoplasia, cervical cancer, anal cancer, death due to cervical cancer, anal cancer and other causes), and 26 transition probabilities for each age group. The model was informed with the available data in national and international literature. Effectiveness of immunization was assumed considering a literature review pertaining to models and vaccination coverage rates observed in Italy. Life expectancy (ex), Quality-Adjusted Life Years (QALYs), Disability-Adjusted Life Years (DALYs), and attributable risk (AR) were estimated for no intervention (cervical cancer screening) and vaccination strategies scenarios. Results The model showed that in a cohort of 100,000 Italian women the e0 is equal to 83.1 years. With current HPV vaccination strategy the e0 achieves 83.2 (+0.1) years. When HPV-related diseases are considered altogether, the QALYs increase from 82.7 to 82.9 (+0.2 QALYs) with no intervention and vaccination strategies respectively. DALYs decrease by 0.6 due to vaccination. Finally, AR is equal to 93 and 265 cases per 100,000 women in population and not vaccinated, respectively. Conclusion When mortality due to cervical cancer is considered, HPV vaccination seems to have a low impact on health unit gains in the Italian female population. Conversely, when several HPV-related and cancer morbidity conditions are included, the effect of vaccination becomes quite remarkable. Electronic supplementary material The online version of this article (10.1186/s12963-017-0154-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Andrea Marcellusi
- National Research Council (CNR), Institute for Research on Population and Social Policies (IRPPS), Via Palestro 32, 00185, Rome, Italy. .,Department Accounting, Finance and Informatics, Kingston Business School Kingston University, London, UK. .,Economic Evaluation and HTA (EEHTA), CEIS, Faculty of Economics, University of Rome "Tor Vergata", Rome, Italy.
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18
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Damm O, Horn J, Mikolajczyk RT, Kretzschmar MEE, Kaufmann AM, Deleré Y, Ultsch B, Wichmann O, Krämer A, Greiner W. Cost-effectiveness of human papillomavirus vaccination in Germany. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2017; 15:18. [PMID: 28878573 PMCID: PMC5583986 DOI: 10.1186/s12962-017-0080-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Accepted: 08/23/2017] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND The aim of this study was to assess the cost-effectiveness of human papillomavirus (HPV) vaccination in addition to the current cervical cancer screening programme in Germany using a dynamic transmission model. METHODS Based on a mathematical model simulating the transmission dynamics and the natural history of HPV infection and associated diseases (cervical intraepithelial neoplasia, cervical cancer, and genital warts), we estimated the epidemiological and economic consequences of HPV vaccination with both the quadrivalent and bivalent vaccines. In our base case analysis, we assessed the cost-effectiveness of vaccinating 12-year-old girls with a 3-dose schedule. In sensitivity analysis, we also evaluated the use of a 2-dose schedule and assessed the impact of vaccinating boys. RESULTS From a health care payer perspective, incremental cost-effectiveness ratios (ICERs) of a 3-dose schedule were €34,249 per quality-adjusted life year (QALY) for the bivalent and €14,711 per QALY for the quadrivalent vaccine. Inclusion of indirect costs decreased ICERs by up to 40%. When adopting a health care payer perspective, ICERs of a 2-dose approach decreased to €19,450 per QALY for the bivalent and to €3645 per QALY for the quadrivalent vaccine. From a societal perspective, a 2-dose approach using the quadrivalent vaccine was a cost-saving strategy while using the bivalent vaccine resulted in an ICER of €13,248 per QALY. Irrespective of the perspective adopted, additional vaccination of boys resulted in ICERs exceeding €50,000 per QALY, except for scenarios with low coverage (20%) in girls. CONCLUSIONS Our model results suggest that routine HPV vaccination of 12-year-old girls with three doses is likely to be cost-effective in Germany. Due to the additional impact on genital warts, the quadrivalent vaccine appeared to be more cost-effective than the bivalent vaccine. A 2-dose schedule of the quadrivalent vaccine might even lead to cost savings when adopting a societal perspective. The cost-effectiveness of additional vaccination of boys was highly dependent on the coverage in girls.
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Affiliation(s)
- Oliver Damm
- Department of Health Economics and Health Care Management, School of Public Health, Bielefeld University, Universitätsstraße 25, 33615 Bielefeld, Germany
| | - Johannes Horn
- Epidemiological and Statistical Methods Research Group, Helmholtz Centre for Infection Research, Braunschweig, Germany
| | - Rafael T. Mikolajczyk
- Epidemiological and Statistical Methods Research Group, Helmholtz Centre for Infection Research, Braunschweig, Germany
- Hannover Medical School, Hannover, Germany
- German Centre for Infection Research, Site Hannover-Braunschweig, Hannover/Braunschweig, Germany
| | - Mirjam E. E. Kretzschmar
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
- Centre for Infectious Disease Control, RIVM, Bilthoven, The Netherlands
| | - Andreas M. Kaufmann
- Gynecologic Tumor Immunology, Clinic for Gynecology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | | | | | - Ole Wichmann
- Immunisation Unit, Robert Koch Institute, Berlin, Germany
| | - Alexander Krämer
- Department of Public Health Medicine, School of Public Health, Bielefeld University, Bielefeld, Germany
| | - Wolfgang Greiner
- Department of Health Economics and Health Care Management, School of Public Health, Bielefeld University, Universitätsstraße 25, 33615 Bielefeld, Germany
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Egger M, Johnson L, Althaus C, Schöni A, Salanti G, Low N, Norris SL. Developing WHO guidelines: Time to formally include evidence from mathematical modelling studies. F1000Res 2017; 6:1584. [PMID: 29552335 PMCID: PMC5829466 DOI: 10.12688/f1000research.12367.2] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/19/2018] [Indexed: 12/15/2022] Open
Abstract
In recent years, the number of mathematical modelling studies has increased steeply. Many of the questions addressed in these studies are relevant to the development of World Health Organization (WHO) guidelines, but modelling studies are rarely formally included as part of the body of evidence. An expert consultation hosted by WHO, a survey of modellers and users of modelling studies, and literature reviews informed the development of recommendations on when and how to incorporate the results of modelling studies into WHO guidelines. In this article, we argue that modelling studies should routinely be considered in the process of developing WHO guidelines, but particularly in the evaluation of public health programmes, long-term effectiveness or comparative effectiveness. There should be a systematic and transparent approach to identifying relevant published models, and to commissioning new models. We believe that the inclusion of evidence from modelling studies into the Grading of Recommendations Assessment, Development and Evaluation (GRADE) process is possible and desirable, with relatively few adaptations. No single "one-size-fits-all" approach is appropriate to assess the quality of modelling studies. The concept of the 'credibility' of the model, which takes the conceptualization of the problem, model structure, input data, different dimensions of uncertainty, as well as transparency and validation into account, is more appropriate than 'risk of bias'.
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Affiliation(s)
- Matthias Egger
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, 3012, Switzerland.,Centre for Infectious Disease Epidemiology and Research (CIDER), University of Cape Town, Cape Town, 7925, South Africa
| | - Leigh Johnson
- Centre for Infectious Disease Epidemiology and Research (CIDER), University of Cape Town, Cape Town, 7925, South Africa
| | - Christian Althaus
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, 3012, Switzerland
| | - Anna Schöni
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, 3012, Switzerland
| | - Georgia Salanti
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, 3012, Switzerland
| | - Nicola Low
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, 3012, Switzerland
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20
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Egger M, Johnson L, Althaus C, Schöni A, Salanti G, Low N, Norris SL. Developing WHO guidelines: Time to formally include evidence from mathematical modelling studies. F1000Res 2017; 6:1584. [PMID: 29552335 DOI: 10.12688/f1000research.12367.1] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/11/2017] [Indexed: 12/15/2022] Open
Abstract
In recent years, the number of mathematical modelling studies has increased steeply. Many of the questions addressed in these studies are relevant to the development of World Health Organization (WHO) guidelines, but modelling studies are rarely formally included as part of the body of evidence. An expert consultation hosted by WHO, a survey of modellers and users of modelling studies, and literature reviews informed the development of recommendations on when and how to incorporate the results of modelling studies into WHO guidelines. In this article, we argue that modelling studies should routinely be considered in the process of developing WHO guidelines, but particularly in the evaluation of public health programmes, long-term effectiveness or comparative effectiveness. There should be a systematic and transparent approach to identifying relevant published models, and to commissioning new models. We believe that the inclusion of evidence from modelling studies into the Grading of Recommendations Assessment, Development and Evaluation (GRADE) process is possible and desirable, with relatively few adaptations. No single "one-size-fits-all" approach is appropriate to assess the quality of modelling studies. The concept of the 'credibility' of the model, which takes the conceptualization of the problem, model structure, input data, different dimensions of uncertainty, as well as transparency and validation into account, is more appropriate than 'risk of bias'.
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Affiliation(s)
- Matthias Egger
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, 3012, Switzerland.,Centre for Infectious Disease Epidemiology and Research (CIDER), University of Cape Town, Cape Town, 7925, South Africa
| | - Leigh Johnson
- Centre for Infectious Disease Epidemiology and Research (CIDER), University of Cape Town, Cape Town, 7925, South Africa
| | - Christian Althaus
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, 3012, Switzerland
| | - Anna Schöni
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, 3012, Switzerland
| | - Georgia Salanti
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, 3012, Switzerland
| | - Nicola Low
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, 3012, Switzerland
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21
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Simms KT, Hall M, Smith MA, Lew JB, Hughes S, Yuill S, Hammond I, Saville M, Canfell K. Optimal Management Strategies for Primary HPV Testing for Cervical Screening: Cost-Effectiveness Evaluation for the National Cervical Screening Program in Australia. PLoS One 2017; 12:e0163509. [PMID: 28095411 PMCID: PMC5240951 DOI: 10.1371/journal.pone.0163509] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Accepted: 09/10/2016] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Several countries are implementing a transition to HPV testing for cervical screening in response to the introduction of HPV vaccination and evidence indicating that HPV screening is more effective than cytology. In Australia, a 2017 transition from 2-yearly conventional cytology in 18-20 to 69 years to 5-yearly primary HPV screening in 25 to 74 years will involve partial genotyping for HPV 16/18 with direct referral to colposcopy for this higher risk group. The objective of this study was to determine the optimal management of women positive for other high-risk HPV types (not 16/18) ('OHR HPV'). METHODS We used a dynamic model of HPV transmission, vaccination, natural history and cervical screening to determine the optimal management of women positive for OHR HPV. We assumed cytology triage testing was used to inform management in this group and that those with high-grade cytology would be referred to colposcopy and those with negative cytology would receive 12-month surveillance. For those with OHR HPV and low-grade cytology (considered to be a single low-grade category in Australia incorporating ASC-US and LSIL), we evaluated (1) the 20-year risk of invasive cervical cancer assuming this group are referred for 12-month follow-up vs. colposcopy, and compared this to the risk in women with low-grade cytology under the current program (i.e. an accepted benchmark risk for 12-month follow-up in Australia); (2) the population-level impact of the whole program, assuming this group are referred to 12-month surveillance vs. colposcopy; and (3) the cost-effectiveness of immediate colposcopy compared to 12-month follow-up. Evaluation was performed both for HPV-unvaccinated cohorts and cohorts offered vaccination (coverage ~72%). FINDINGS The estimated 20-year risk of cervical cancer is ≤1.0% at all ages if this group are referred to colposcopy vs. ≤1.2% if followed-up in 12 months, both of which are lower than the ≤2.6% benchmark risk in women with low-grade cytology in the current program (who are returned for 12-month follow-up). At the population level, immediate colposcopy referral provides an incremental 1-3% reduction in cervical cancer incidence and mortality compared with 12-month follow-up, but this is in the context of a predicted 24-36% reduction associated with the new HPV screening program compared to the current cytology-based program. Furthermore, immediate colposcopy substantially increases the predicted number of colposcopies, with >650 additional colposcopies required to avert each additional case of cervical cancer compared to 12-month follow-up. Compared to 12-month follow-up, immediate colposcopy has an incremental cost-effectiveness ratio (ICER) of A$104,600/LYS (95%CrI:A$100,100-109,100) in unvaccinated women and A$117,100/LYS (95%CrI:A$112,300-122,000) in cohorts offered vaccination [Indicative willingness-to-pay threshold: A$50,000/LYS]. CONCLUSIONS In primary HPV screening programs, partial genotyping for HPV16/18 or high-grade triage cytology in OHR HPV positive women can be used to refer the highest risk group to colposcopy, but 12-month follow-up for women with OHR HPV and low-grade cytology is associated with a low risk of developing cervical cancer. Direct referral to colposcopy for this group would be associated with a substantial increase in colposcopy referrals and the associated harms, and is also cost-ineffective; thus, 12-month surveillance for women with OHR HPV and low-grade cytology provides the best balance between benefits, harms and cost-effectiveness.
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Affiliation(s)
- Kate T. Simms
- Cancer Research Division, Cancer Council NSW, Sydney, New South Wales, Australia
- Prince of Wales Clinical School, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Michaela Hall
- Cancer Research Division, Cancer Council NSW, Sydney, New South Wales, Australia
- Prince of Wales Clinical School, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Megan A. Smith
- Cancer Research Division, Cancer Council NSW, Sydney, New South Wales, Australia
- Prince of Wales Clinical School, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
- School of Public Health, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Jie-Bin Lew
- Cancer Research Division, Cancer Council NSW, Sydney, New South Wales, Australia
- Prince of Wales Clinical School, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Suzanne Hughes
- Cancer Research Division, Cancer Council NSW, Sydney, New South Wales, Australia
| | - Susan Yuill
- Cancer Research Division, Cancer Council NSW, Sydney, New South Wales, Australia
| | - Ian Hammond
- Steering Committee for the Renewal Implementation Project, National Cervical Screening Program, Department of Health, Canberra, Australian Capital Territory, Australia
- School of Women's and Infants' Health, University of Western Australia, Perth, Western Australia, Australia
| | - Marion Saville
- Victorian Cytology Service, Victoria, Australia
- Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Victoria, Australia
| | - Karen Canfell
- Cancer Research Division, Cancer Council NSW, Sydney, New South Wales, Australia
- Prince of Wales Clinical School, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
- School of Public Health, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
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22
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Simms KT, Smith MA, Lew JB, Kitchener HC, Castle PE, Canfell K. Will cervical screening remain cost-effective in women offered the next generation nonavalent HPV vaccine? Results for four developed countries. Int J Cancer 2016; 139:2771-2780. [DOI: 10.1002/ijc.30392] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Revised: 06/27/2016] [Accepted: 07/14/2016] [Indexed: 12/26/2022]
Affiliation(s)
- Kate T. Simms
- Cancer Research Division; Cancer Council NSW; Woolloomooloo Sydney NSW Australia
- Prince of Wales Clinical School; The University of New South Wales; Australia
| | - Megan A. Smith
- Cancer Research Division; Cancer Council NSW; Woolloomooloo Sydney NSW Australia
- Prince of Wales Clinical School; The University of New South Wales; Australia
- School of Public Health; University of Sydney; Australia
| | - Jie-Bin Lew
- Cancer Research Division; Cancer Council NSW; Woolloomooloo Sydney NSW Australia
- Prince of Wales Clinical School; The University of New South Wales; Australia
| | | | - Philip E. Castle
- Department of Epidemiology and Population Health; Albert Einstein College of Medicine; Bronx NY
- Global Coalition against Cervical Cancer; Arlington VA
| | - Karen Canfell
- Cancer Research Division; Cancer Council NSW; Woolloomooloo Sydney NSW Australia
- Prince of Wales Clinical School; The University of New South Wales; Australia
- School of Public Health; University of Sydney; Australia
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Lew JB, Simms K, Smith M, Lewis H, Neal H, Canfell K. Effectiveness Modelling and Economic Evaluation of Primary HPV Screening for Cervical Cancer Prevention in New Zealand. PLoS One 2016; 11:e0151619. [PMID: 27187495 PMCID: PMC4871332 DOI: 10.1371/journal.pone.0151619] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2015] [Accepted: 05/05/2016] [Indexed: 11/18/2022] Open
Abstract
Background New Zealand (NZ) is considering transitioning from 3-yearly cervical cytology screening in women 20–69 years (current practice) to primary HPV screening. We evaluated HPV-based screening in both HPV-unvaccinated women and cohorts offered HPV vaccination in New Zealand (vaccination coverage ~50%). Methods A complex model of HPV transmission, vaccination, cervical screening, and invasive cervical cancer was extensively validated against national population-based datasets. Sixteen potential strategies for HPV screening were considered. Results Most primary HPV strategies were more effective than current practice, for both unvaccinated women and cohorts offered vaccination. The optimal strategy for both groups was 5-yearly HPV screening in women aged 25–69 years with partial genotyping for HPV 16/18 and referral to colposcopy, and cytological triage of other oncogenic types. This is predicted to reduce cervical cancer incidence and mortality by a further 12–16% and to save 4–13% annually in program costs (excluding overheads). The findings are sensitive to assumptions about future adherence to initiating screening at 25 years. Conclusion Primary HPV screening with partial genotyping would be more effective and less costly than the current cytology-based screening program, in both unvaccinated women and cohorts offered vaccination. These findings have been considered in a review of cervical screening in NZ.
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Affiliation(s)
- Jie-Bin Lew
- Cancer Research Division, Cancer Council New South Wales, New South Wales, Australia
- * E-mail:
| | - Kate Simms
- Cancer Research Division, Cancer Council New South Wales, New South Wales, Australia
| | - Megan Smith
- Cancer Research Division, Cancer Council New South Wales, New South Wales, Australia
| | - Hazel Lewis
- Public Health Physician, Wellington, New Zealand
| | - Harold Neal
- National Screening Unit, Ministry of Health, Wellington, New Zealand
| | - Karen Canfell
- Cancer Research Division, Cancer Council New South Wales, New South Wales, Australia
- School of Public Health, Sydney Medical School, University of Sydney, Sydney, Australia
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24
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Koeneman MM, Kruse AJ, Kooreman LFS, Zur Hausen A, Hopman AHN, Sep SJS, Van Gorp T, Slangen BFM, van Beekhuizen HJ, van de Sande M, Gerestein CG, Nijman HW, Kruitwagen RFPM. TOPical Imiquimod treatment of high-grade Cervical intraepithelial neoplasia (TOPIC trial): study protocol for a randomized controlled trial. BMC Cancer 2016; 16:132. [PMID: 26897518 PMCID: PMC4761416 DOI: 10.1186/s12885-016-2187-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2014] [Accepted: 02/16/2016] [Indexed: 11/10/2022] Open
Abstract
Background Cervical intraepithelial neoplasia (CIN) is the premalignant condition of cervical cancer. Whereas not all high grade CIN lesions progress to cervical cancer, the natural history and risk of progression of individual lesions remain unpredictable. Therefore, high-grade CIN is currently treated by surgical excision: large loop excision of the transformation zone (LLETZ). This procedure has potential complications, such as acute haemorrhage, prolonged bleeding, infection and preterm birth in subsequent pregnancies. These complications could be prevented by development of a non-invasive treatment modality, such as topical imiquimod treatment. The primary study objective is to investigate the efficacy of topical imiquimod 5 % cream for the treatment of high-grade CIN and to develop a biomarker profile to predict clinical response to imiquimod treatment. Secondary study objectives are to assess treatment side-effects, disease recurrence and quality of life during and after different treatment modalities. Methods/design The study design is a randomized controlled trial. One hundred forty women with a histological diagnosis of high-grade CIN (CIN 2–3) will be randomized into two arms: imiquimod treatment during 16 weeks (experimental arm) or immediate LLETZ (standard care arm). Treatment efficacy will be evaluated by colposcopy with diagnostic biopsies at 20 weeks for the experimental arm. Successful imiquimod treatment is defined as regression to CIN 1 or less, successful LLETZ treatment is defined as PAP 1 after 6 months. Disease recurrence will be evaluated by cytology at 6, 12 and 24 months after treatment. Side-effects will be evaluated using a standardized report form. Quality of life will be evaluated using validated questionnaires at baseline, 20 weeks and 1 year after treatment. Biomarkers, reflecting both host and viral factors in the pathophysiology of CIN, will be tested at baseline with the aim of developing a predictive biomarker profile for the clinical response to imiquimod treatment. Discussion Treatment of high-grade CIN lesions with imiquimod in a selected patient population may diminish complications as a result of surgical intervention. More knowledge on treatment efficacy, side effects and long-term recurrence rates after treatment is necessary. Trial registration EU Clinical Trials Register EU-CTR2013-001260-34. Registered 18 March 2013. Medical Ethical Committee approval number: NL44336.068.13 (Medical Ethical Committee Maastricht University Hospital, University of Maastricht). Affiliation: Maastricht University Hospital. Registration number ClinicalTrials.gov: NCT02329171.
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Affiliation(s)
- M M Koeneman
- Department of Obstetrics and Gynaecology, Maastricht University Medical Center, Post box 5800, 6202 AZ, Maastricht, The Netherlands. .,GROW, School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands.
| | - A J Kruse
- Department of Obstetrics and Gynaecology, Maastricht University Medical Center, Post box 5800, 6202 AZ, Maastricht, The Netherlands.,GROW, School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - L F S Kooreman
- Department of Pathology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - A Zur Hausen
- Department of Pathology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - A H N Hopman
- GROW, School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands.,Department of Molecular Cell Biology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - S J S Sep
- Department of Internal Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - T Van Gorp
- Department of Obstetrics and Gynaecology, Maastricht University Medical Center, Post box 5800, 6202 AZ, Maastricht, The Netherlands.,GROW, School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - B F M Slangen
- Department of Obstetrics and Gynaecology, Maastricht University Medical Center, Post box 5800, 6202 AZ, Maastricht, The Netherlands.,GROW, School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - H J van Beekhuizen
- Department of Obstetrics and Gynaecology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - M van de Sande
- Department of Obstetrics and Gynaecology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - C G Gerestein
- Department of Obstetrics and Gynaecology, Meander Medical Center, Amersfoort, The Netherlands
| | - H W Nijman
- Department of Obstetrics and Gynaecology, University Medical Center Groningen, Groningen, The Netherlands
| | - R F P M Kruitwagen
- Department of Obstetrics and Gynaecology, Maastricht University Medical Center, Post box 5800, 6202 AZ, Maastricht, The Netherlands.,GROW, School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands
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25
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Haeussler K, Marcellusi A, Mennini FS, Favato G, Picardo M, Garganese G, Bononi M, Costa S, Scambia G, Zweifel P, Capone A, Baio G. Cost-Effectiveness Analysis of Universal Human Papillomavirus Vaccination Using a Dynamic Bayesian Methodology: The BEST II Study. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2015; 18:956-68. [PMID: 26686779 DOI: 10.1016/j.jval.2015.08.010] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/12/2015] [Revised: 08/05/2015] [Accepted: 08/08/2015] [Indexed: 05/23/2023]
Abstract
BACKGROUND Human papillomavirus (HPV) plays a role in the development of benign and malign neoplasms in both sexes. The Italian recommendations for HPV vaccines consider only females. The BEST II study (Bayesian modelling to assess the Effectiveness of a vaccination Strategy to prevent HPV-related diseases) evaluates 1) the cost-effectiveness of immunization strategies targeting universal vaccination compared with cervical cancer screening and female-only vaccination and 2) the economic impact of immunization on various HPV-induced diseases. OBJECTIVE The objective of this study was to evaluate whether female-only vaccination or universal vaccination is the most cost-effective intervention against HPV. METHODS We present a dynamic Bayesian Markov model to investigate transmission dynamics in cohorts of females and males in a follow-up period of 55 years. We assumed that quadrivalent vaccination (against HPV 16, 18, 6, and 11) is available for 12-year-old individuals. The model accounts for the progression of subjects across HPV-induced health states (cervical, vaginal, vulvar, anal, penile, and head/neck cancer as well as anogenital warts). The sexual mixing is modeled on the basis of age-, sex-, and sexual behavioral-specific matrices to obtain the dynamic force of infection. RESULTS In comparison to cervical cancer screening, universal vaccination results in an incremental cost-effectiveness ratio of €1,500. When universal immunization is compared with female-only vaccination, it is cost-effective with an incremental cost-effectiveness ratio of €11,600. Probabilistic sensitivity analysis shows a relatively large amount of parameter uncertainty, which interestingly has, however, no substantial impact on the decision-making process. The intervention being assessed seems to be associated with an attractive cost-effectiveness profile. CONCLUSIONS Universal HPV vaccination is found to be a cost-effective choice when compared with either cervical cancer screening or female-only vaccination within the Italian context.
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Affiliation(s)
- Katrin Haeussler
- Department of Statistical Science, University College London, London, UK.
| | - Andrea Marcellusi
- Economic Evaluation and HTA, Faculty of Economics, University of Rome "Tor Vergata," Rome, Italy; Department of Demography, University of Rome "La Sapienza," Rome, Italy
| | - Francesco Saverio Mennini
- Economic Evaluation and HTA, Faculty of Economics, University of Rome "Tor Vergata," Rome, Italy; Institute of Leadership and Management in Health, Kingston University London, London, UK
| | - Giampiero Favato
- Institute of Leadership and Management in Health, Kingston University London, London, UK
| | - Mauro Picardo
- Laboratory of Cutaneous Pathophysiology, San Gallicano Dermatological Institute (IRCCS), Rome, Italy
| | - Giorgia Garganese
- Department of Obstetrics and Gynecology, Catholic University of the Sacred Heart, Rome, Italy
| | - Marco Bononi
- Department of Surgery Pietro Valdoni, University of Rome "La Sapienza," Rome, Italy
| | - Silvano Costa
- Department of Gynecology and Obstetrics, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Giovanni Scambia
- Department of Obstetrics and Gynecology, Catholic University of the Sacred Heart, Rome, Italy
| | - Peter Zweifel
- Socioeconomic Institute, University of Zurich, Zurich, Switzerland
| | - Alessandro Capone
- Institute of Leadership and Management in Health, Kingston University London, London, UK
| | - Gianluca Baio
- Department of Statistical Science, University College London, London, UK
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26
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The estimated lifetime probability of acquiring human papillomavirus in the United States. Sex Transm Dis 2015; 41:660-4. [PMID: 25299412 DOI: 10.1097/olq.0000000000000193] [Citation(s) in RCA: 311] [Impact Index Per Article: 34.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND Estimates of the lifetime probability of acquiring human papillomavirus (HPV) can help to quantify HPV incidence, illustrate how common HPV infection is, and highlight the importance of HPV vaccination. METHODS We developed a simple model, based primarily on the distribution of lifetime numbers of sex partners across the population and the per-partnership probability of acquiring HPV, to estimate the lifetime probability of acquiring HPV in the United States in the time frame before HPV vaccine availability. RESULTS We estimated the average lifetime probability of acquiring HPV among those with at least 1 opposite sex partner to be 84.6% (range, 53.6%-95.0%) for women and 91.3% (range, 69.5%-97.7%) for men. Under base case assumptions, more than 80% of women and men acquire HPV by age 45 years. CONCLUSIONS Our results are consistent with estimates in the existing literature suggesting a high lifetime probability of HPV acquisition and are supported by cohort studies showing high cumulative HPV incidence over a relatively short period, such as 3 to 5 years.
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27
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Butsashvili M, Abzianidze T, Kajaia M, Agladze D, Kldiashvili E, Bednarczyk R, McNutt LA, Kamkamidze G. Seroprevalence and awareness of human papillomavirus infection and cervical cancer screening results among reproductive-aged Georgian women. THE JOURNAL OF FAMILY PLANNING AND REPRODUCTIVE HEALTH CARE 2015; 41:265-71. [PMID: 25900523 DOI: 10.1136/jfprhc-2013-100833] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/13/2013] [Accepted: 03/06/2015] [Indexed: 11/04/2022]
Abstract
INTRODUCTION As is the case in many developing countries, more than half of the new cervical cancer cases in Georgia are late-stage diagnoses, thus reducing the opportunity for effective treatment. A state cancer screening programme was launched in Tbilisi in 2006; 5 years later the programme had expanded to other regions in Georgia. METHODS This study was designed to estimate awareness about human papillomavirus (HPV), cervical cancer screening, the HPV vaccine, and the seroprevalence of HPV infection among reproductive-aged Georgian women. Study participants were recruited from four women's consultation centres in different regions of Georgia. Data were collected through interviewer-administered questionnaires and HPV seroprevalence was assessed for HPV types 6/11/16/18. RESULTS Of the 500 study participants, 52.0% were aware of HPV and 36.4% stated that the main cause of cervical cancer is HPV. Of those aware of HPV, 78% reported attending for cervical cancer screening at least once during their lifetime. Half (50.8%) of all respondents were unaware of the HPV vaccine. Of the women who agreed to be tested for anti-HPV antibodies (n=317), 21.1% were positive. Women reporting no condom use were more likely to have HPV antibodies (prevalence ratio 2.77; 95% confidence interval 1.79-4.27). Awareness of cervical cancer screening was significantly associated with HPV seropositivity. With multivariate analysis, both absence of condom use and lack of knowledge about cervical cancer screening were independently associated with HPV seropositivity. CONCLUSION More comprehensive public awareness campaigns should be developed to raise awareness about HPV screening and prevention.
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Affiliation(s)
| | | | - Maia Kajaia
- Head of Epidemiologic Department, Health Research Union (HRU), Tbilisi, Georgia
| | - Dodo Agladze
- Laboratory Scientist, Health Research Union (HRU), Tbilisi, Georgia
| | | | - Robert Bednarczyk
- Associate Professor, Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Louise-Anne McNutt
- Associate Professor of Epidemiology and Biostatistics, School of Public Health, University at Albany, State University of New York, Albany, NY, USA
| | - George Kamkamidze
- Head of Laboratory Department, Health Research Union (HRU), Tbilisi, Georgia
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Huh WK, Williams E, Huang J, Bramley T, Poulios N. Cost effectiveness of human papillomavirus-16/18 genotyping in cervical cancer screening. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2015; 13:95-107. [PMID: 25385310 PMCID: PMC5031721 DOI: 10.1007/s40258-014-0135-4] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
BACKGROUND There is limited understanding of the health economic implications of cervical screening with human papillomavirus (HPV)-16/18 genotyping. OBJECTIVE The aim of this study was to evaluate the cost effectiveness of cervical cancer primary screening with a HPV-16/18 genotyping test which simultaneously detects 12 other high-risk HPV types. METHODS A Markov cohort model compared four strategies: (1) cytology with reflex HPV testing for atypical squamous cells of undetermined significance (ASC-US); (2) co-testing with cytology and HPV testing; (3) HPV with reflex to cytology; and (4) HPV with 16/18 genotyping and reflex cytology (ASC-US threshold). Screening began at age 30 and was performed triennially over 40 years. Screening sensitivity and specificity values for cervical intraepithelial neoplasia (CIN) 3 were obtained from the Addressing THE Need for Advanced HPV Diagnostics (ATHENA) trial. Outcomes for a 1-year follow-up scenario wherein persistent disease was detected were estimated. Screening and cancer treatment costs were calculated from a US payer's perspective in 2013. Costs and quality-adjusted life-years (QALYs) were discounted at 3 % annually. RESULTS Applying a US$50,000/QALY threshold, strategy (4) dominated strategies (2) and (3) by reducing costs and cancer incidence and improving QALYs, and was cost effective versus strategy (1). Accounting for persistent ≥CIN 3 at 1 year, strategy (4) was cost effective versus all other strategies. Detecting HPV-16/18 resulted in earlier diagnosis of clinically relevant ≥CIN 3 at initial screening and efficient use of follow-up resources. Outcomes were most influenced by strategy performance. CONCLUSIONS Incorporating HPV-16/18 genotyping is cost effective and may improve detection of CIN, thereby preventing cervical cancer.
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Affiliation(s)
- Warner K Huh
- University of Alabama at Birmingham, 1700 6th Avenue South, WIC Room 10250, Birmingham, 35233, AL, USA,
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Connelly LB, Le HND. Cost-effectiveness of a bivalent human papillomavirus vaccination program in Japan. Sex Health 2015; 12:520-31. [DOI: 10.1071/sh14241] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2014] [Accepted: 06/17/2015] [Indexed: 11/23/2022]
Abstract
Background
Human papillomavirus (HPV) vaccines and their widespread adoption have the potential to relieve a large part of the burden of cervical cancer morbidity and mortality, particularly in countries that have low screening rates or, like Japan, lack a cohesive universal screening program. An economic evaluation was conducted to assess the cost-effectiveness of introducing a bivalent HPV vaccination program in Japan from a healthcare perspective. Methods: A Markov model of the natural history of HPV infection that incorporates both vaccination and screening was developed for Japan. The modelled intervention, a bivalent HPV vaccine with a 100% lifetime vaccine efficacy and 80% vaccine coverage, given to a cohort of 12-year-old Japanese girls in conjunction with the current screening program, was compared with screening alone in terms of costs and effectiveness. A discount rate of 5% was applied to both costs and utilities where relevant. Results: Vaccination alongside screening compared with screening alone is associated with an incremental cost-effectiveness ratio (ICER) of US$20 315 per quality-adjusted-life-year gained if 80% coverage is assumed. The ICER at 5% coverage with the vaccine plus screening, compared with screening alone, is US$1158. Conclusion: The cost-effectiveness results suggest that the addition of a HPV vaccination program to Japan’s cervical cancer screening program is highly likely to prove a cost-effective way to reduce the burden of cervical cancer, precancerous lesions and HPV16/18-related diseases.
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30
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Zhang SK, Kang LN, Chang IJ, Zhao FH, Hu SY, Chen W, Shi JF, Zhang X, Pan QJ, Li SM, Qiao YL. The natural history of cervical cancer in chinese women: results from an 11-year follow-up study in china using a multistate model. Cancer Epidemiol Biomarkers Prev 2014; 23:1298-305. [PMID: 24789847 DOI: 10.1158/1055-9965.epi-13-0846] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND It is important to understand the natural history of cervical cancer, which has implications for cancer prevention and management. However, a dearth of studies on the long-term development of cervical cancer exists in China. METHODS We investigated the natural history of cervical cancer in Chinese women by creating a multistate model using 11 years of follow-up data from the Shanxi Province Cervical Cancer Screening Study I conducted from 1999 to 2010. In 1999, a total of 1,997 eligible women, ages 35 to 45 years, were enrolled in Xiangyuan County, Shanxi Province. Participants were followed up in 2005 and 2010, respectively. RESULTS The average time a subject spent in CIN1 before transiting into another state was 1.4693 years [95% confidence interval (CI): 1.1215-1.9251] and the average time a subject spent in CIN2 was 2.9822 years (95% CI: 1.9790-4.4938). A subject's transition probability from CIN1 to normal increased with time. However, the transition probability from CIN1 to CIN2 was relatively lower, with 3-, 5-, and 10-year transition probabilities of 0.1415, 0.1066, and 0.0437. Comparison of 5-year transition probabilities between CIN2 to normal/CIN1 and CIN2 to CIN3(+) yielded a ratio of 2.74. CONCLUSIONS Women with CIN1 had a substantial tendency for regression. Similarly, women with CIN2 had a higher probability of regression to normal/CIN1 than progression to CIN3(+). Findings in this study may have significant implications for the development and evaluation of formal cervical cancer preventive strategies in China. IMPACT This study may serve as a valuable reference to future research on other multistate cancer processes.
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Affiliation(s)
- Shao-Kai Zhang
- Authors' Affiliations: Departments of Cancer Epidemiology
| | - Le-Ni Kang
- Authors' Affiliations: Departments of Cancer Epidemiology
| | - Irene J Chang
- Authors' Affiliations: Departments of Cancer Epidemiology, Miller School of Medicine, University of Miami, Miami, Florida
| | - Fang-Hui Zhao
- Authors' Affiliations: Departments of Cancer Epidemiology
| | - Shang-Ying Hu
- Authors' Affiliations: Departments of Cancer Epidemiology
| | - Wen Chen
- Authors' Affiliations: Departments of Cancer Epidemiology
| | - Ju-Fang Shi
- Authors' Affiliations: Departments of Cancer Epidemiology
| | | | | | - Shu-Min Li
- Gynecology, Cancer Institute/Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China; and
| | - You-Lin Qiao
- Authors' Affiliations: Departments of Cancer Epidemiology,
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Rásky É, Regitnig P, Schenouda M, Burkert N, Freidl W. Quality of screening with conventional Pap smear in Austria - a longitudinal evaluation. BMC Public Health 2013; 13:998. [PMID: 24152300 PMCID: PMC4015555 DOI: 10.1186/1471-2458-13-998] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2012] [Accepted: 10/14/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In recent decades, the incidence of cervical cancer and cervical cancer mortality in Austria has declined by varying degrees. The Pap smear is to be considered a causal factor for this decline. METHODS This longitudinal analysis is based on a data set of Pap smear assessments collected by the Committee for Quality Assurance of the Austrian Society of Cytology. Data from 15 laboratories participating in a voluntary self-monitoring program was analyzed for the time span 2004-2008. The data was analyzed in terms of smear quality and assessment quality.A rank-correlation-test for a monotonic trend analysis in the proportion of the three parameters Pap 0, "satisfactory, but limited/SBL", and Pap IIID/IV for the timespan 2004 to 2008 was carried out. RESULTS For this study, we analyzed an average number of 730,000 smears per year over a five-year period. Specimens from all but two laboratories, i.e. < 2% of all smears, met the quality criterion for Pap 0 (Bethesda 2001 equivalent: Specimen processed and examined, but unsatisfactory for evaluation of epithelial abnormality), whilst only four laboratories, i.e. < 10% of all smears, reached the national requirement for smears classified as "satisfactory, but limited/SBL".When using the Pap IIID/IV ratio (LSIL: HSIL/AIS ratio) of 3:1 to 8:1 as a surrogate quality marker for the interpretation of smears, only five laboratories met this criterion during the survey period.The trend analysis indicated only that an increasing number of samples per year is correlated with an increased proportion of Pap 0 and "satisfactory, but limited/SBL" smears. CONCLUSIONS Although participants get regular feedback about their results, no general improvements in smear taking or assessment were observed over the years, so mandatory quality management, including the possibility of sanctions, is suggested in order to reduce adverse health effects for women.
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Affiliation(s)
- Éva Rásky
- Institute of Social Medicine and Epidemiology, Medical University Graz, Universitaetsstrasse 6/I, 8010 Graz, Austria
| | - Peter Regitnig
- Institute of Pathology, Medical University Graz, Auenbruggerplatz 25, 8036 Graz, Austria
- Austrian Society of Cytology, Auenbruggerplatz 25, 8036 Graz, Austria
| | - Michél Schenouda
- Institute of Social Medicine and Epidemiology, Medical University Graz, Universitaetsstrasse 6/I, 8010 Graz, Austria
| | - Nathalie Burkert
- Institute of Social Medicine and Epidemiology, Medical University Graz, Universitaetsstrasse 6/I, 8010 Graz, Austria
| | - Wolfgang Freidl
- Institute of Social Medicine and Epidemiology, Medical University Graz, Universitaetsstrasse 6/I, 8010 Graz, Austria
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Sexually transmitted infections among US women and men: prevalence and incidence estimates, 2008. Sex Transm Dis 2013; 40:187-93. [PMID: 23403598 DOI: 10.1097/olq.0b013e318286bb53] [Citation(s) in RCA: 928] [Impact Index Per Article: 84.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Most sexually active people will be infected with a sexually transmitted infection (STI) at some point in their lives. The number of STIs in the United States was previously estimated in 2000. We updated previous estimates to reflect the number of STIs for calendar year 2008. METHODS We reviewed available data and literature and conservatively estimated incident and prevalent infections nationally for 8 common STIs: chlamydia, gonorrhea, syphilis, herpes, human papillomavirus, hepatitis B, HIV, and trichomoniasis. Where available, data from nationally representative surveys such as the National Health and Nutrition Examination Survey were used to provide national estimates of STI prevalence or incidence. The strength of each estimate was rated good, fair, or poor, according to the quality of the evidence. RESULTS In 2008, there were an estimated 110 million prevalent STIs among women and men in the United States. Of these, more than 20% of infections (22.1 million) were among women and men aged 15 to 24 years. Approximately 19.7 million incident infections occurred in the United States in 2008; nearly 50% (9.8 million) were acquired by young women and men aged 15 to 24 years. Human papillomavirus infections, many of which are asymptomatic and do not cause disease, accounted for most of both prevalent and incident infections. CONCLUSIONS Sexually transmitted infections are common in the United States, with a disproportionate burden among young adolescents and adults. Public health efforts to address STIs should focus on prevention among at-risk populations to reduce the number and impact of STIs.
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Brotherton JML, Gertig DM. Primary prophylactic human papillomavirus vaccination programs: future perspective on global impact. Expert Rev Anti Infect Ther 2013; 9:627-39. [PMID: 21819329 DOI: 10.1586/eri.11.78] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Of the 40 types of human papillomavirus that can infect the mucosal epithelium, four types can now be prevented using prophylactic vaccination. Two of these types (high-risk types 16 and 18) cause 70% of cervical cancers, a proportion of other genital cancers and a subset of head and neck cancers. The low-risk types 6 and 11 cause 90% of genital warts and the disease recurrent respiratory papillomatosis. Thus, if primary HPV vaccination programs can be implemented effectively, the potential for a reduction in global disease burden is great. This article considers the current issues and challenges in delivering primary HPV vaccination programs effectively and the likely impact of the vaccines in both the near and more distant future.
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Affiliation(s)
- Julia M L Brotherton
- National HPV Vaccination Program Register, Victorian Cytology Service Registries, Victorian Cytology Service, PO Box 310, East Melbourne, Victoria 8002, Australia.
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Novel health economic evaluation of a vaccination strategy to prevent HPV-related diseases: the BEST study. Med Care 2013; 50:1076-85. [PMID: 22922435 DOI: 10.1097/mlr.0b013e318269e06d] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The development of human papillomavirus (HPV)-related diseases is not understood perfectly and uncertainties associated with commonly utilized probabilistic models must be considered. The study assessed the cost-effectiveness of a quadrivalent-based multicohort HPV vaccination strategy within a Bayesian framework. METHODS A full Bayesian multicohort Markov model was used, in which all unknown quantities were associated with suitable probability distributions reflecting the state of currently available knowledge. These distributions were informed by observed data or expert opinion. The model cycle lasted 1 year, whereas the follow-up time horizon was 90 years. Precancerous cervical lesions, cervical cancers, and anogenital warts were considered as outcomes. RESULTS The base case scenario (2 cohorts of girls aged 12 and 15 y) and other multicohort vaccination strategies (additional cohorts aged 18 and 25 y) were cost-effective, with a discounted cost per quality-adjusted life-year gained that corresponded to €12,013, €13,232, and €15,890 for vaccination programs based on 2, 3, and 4 cohorts, respectively. With multicohort vaccination strategies, the reduction in the number of HPV-related events occurred earlier (range, 3.8-6.4 y) when compared with a single cohort. The analysis of the expected value of information showed that the results of the model were subject to limited uncertainty (cost per patient = €12.6). CONCLUSIONS This methodological approach is designed to incorporate the uncertainty associated with HPV vaccination. Modeling the cost-effectiveness of a multicohort vaccination program with Bayesian statistics confirmed the value for money of quadrivalent-based HPV vaccination. The expected value of information gave the most appropriate and feasible representation of the true value of this program.
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Lew JB, Howard K, Gertig D, Smith M, Clements M, Nickson C, Shi JF, Dyer S, Lord S, Creighton P, Kang YJ, Tan J, Canfell K. Expenditure and resource utilisation for cervical screening in Australia. BMC Health Serv Res 2012; 12:446. [PMID: 23216968 PMCID: PMC3548768 DOI: 10.1186/1472-6963-12-446] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2012] [Accepted: 11/21/2012] [Indexed: 11/13/2022] Open
Abstract
Background The National Cervical Screening Program in Australia currently recommends that women aged 18–69 years are screened with conventional cytology every 2 years. Publicly funded HPV vaccination was introduced in 2007, and partly as a consequence, a renewal of the screening program that includes a review of screening recommendations has recently been announced. This study aimed to provide a baseline for such a review by quantifying screening program resource utilisation and costs in 2010. Methods A detailed model of current cervical screening practice in Australia was constructed and we used data from the Victorian Cervical Cytology Registry to model age-specific compliance with screening and follow-up. We applied model-derived rate estimates to the 2010 Australian female population to calculate costs and numbers of colposcopies, biopsies, treatments for precancer and cervical cancers in that year, assuming that the numbers of these procedures were not yet substantially impacted by vaccination. Results The total cost of the screening program in 2010 (excluding administrative program overheads) was estimated to be A$194.8M. We estimated that a total of 1.7 million primary screening smears costing $96.7M were conducted, a further 188,900 smears costing $10.9M were conducted to follow-up low grade abnormalities, 70,900 colposcopy and 34,100 histological evaluations together costing $21.2M were conducted, and about 18,900 treatments for precancerous lesions were performed (including retreatments), associated with a cost of $45.5M for treatment and post-treatment follow-up. We also estimated that $20.5M was spent on work-up and treatment for approximately 761 women diagnosed with invasive cervical cancer. Overall, an estimated $23 was spent in 2010 for each adult woman in Australia on cervical screening program-related activities. Conclusions Approximately half of the total cost of the screening program is spent on delivery of primary screening tests; but the introduction of HPV vaccination, new technologies, increasing the interval and changing the age range of screening is expected to have a substantial impact on this expenditure, as well as having some impact on follow-up and management costs. These estimates provide a benchmark for future assessment of the impact of changes to screening program recommendations to the costs of cervical screening in Australia.
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Affiliation(s)
- Jie-Bin Lew
- Cancer Research Division, Cancer Council NSW, 153 Dowling Street, Woolloomooloo, Sydney, NSW 2011, Australia
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Waters EK. Aggregation and competitive exclusion: explaining the coexistence of human Papillomavirus types and the effectiveness of limited vaccine conferred cross-immunity. Acta Biotheor 2012; 60:333-56. [PMID: 22752424 DOI: 10.1007/s10441-012-9161-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2011] [Accepted: 06/15/2012] [Indexed: 11/26/2022]
Abstract
Human Papillomavirus (HPV) types are sexually transmitted infections that cause a number of human cancers. According to the competitive exclusion principle in ecology, HPV types that have lower transmission probabilities and shorter durations of infection should be outcompeted by more virulent types. This, however, is not the case, as numerous HPV types co-exist, some which are less transmissible and more easily cleared than others. This paper examines whether this exception to the competitive exclusion principle can be explained by the aggregation of infection with HPV types, which results in patchy spatial distributions of infection, and what implications this has for the effect of vaccination on multiple HPV types. A deterministic transmission model is presented that models the patchy distribution of infected individuals using Lloyd's mean crowding. It is first shown that higher aggregation can result in a reduced capacity for onward transmission and reduce the required efficacy of vaccination. It is shown that greater patchiness in the distribution of lower prevalence HPV types permits co-existence. This affirms the hypothesis that the aggregation of HPV types provides an explanation for the violation of the competitive exclusion principle. Greater aggregation of lower prevalence types has important implications where type-specific HPV vaccines also offer cross-protection against non-target types. It is demonstrated that the degree of cross-protection can be less than the degree of vaccine protection conferred against directly targeted types and still result in the elimination of non-target types when these non-target types are patchily distributed.
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Affiliation(s)
- E K Waters
- The University of Notre Dame Australia, PO Box 944, Broadway, NSW 2007, Australia.
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Legood R, Smith M, Lew JB, Walker R, Moss S, Kitchener H, Patnick J, Canfell K. Cost effectiveness of human papillomavirus test of cure after treatment for cervical intraepithelial neoplasia in England: economic analysis from NHS Sentinel Sites Study. BMJ 2012; 345:e7086. [PMID: 23117060 PMCID: PMC3487104 DOI: 10.1136/bmj.e7086] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVES To evaluate the cost effectiveness of human papillomavirus testing after treatment for cervical intraepithelial neoplasia (CIN). DESIGN 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. SETTING English NHS Cervical Cancer Screening Programme. INTERVENTIONS 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. MAIN OUTCOME MEASURES Cases of underlying CIN3+ averted at 10 years and costs per 1000 women treated. RESULTS 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. CONCLUSIONS 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.
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Affiliation(s)
- Rosa Legood
- Health Services Research and Policy Unit, London School of Hygiene and Tropical Medicine, London WC1 9HS, UK.
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Saslow D, Solomon D, Lawson HW, Killackey M, Kulasingam SL, Cain JM, Garcia FAR, Moriarty AT, Waxman AG, Wilbur DC, Wentzensen N, Downs LS, Spitzer M, Moscicki AB, Franco EL, Stoler MH, Schiffman M, Castle PE, Myers ER, Chelmow D, Herzig A, Kim JJ, Kinney W, Herschel WL, Waldman J. American Cancer Society, American Society for Colposcopy and Cervical Pathology, and American Society for Clinical Pathology screening guidelines for the prevention and early detection of cervical cancer. J Low Genit Tract Dis 2012; 16:175-204. [PMID: 22418039 PMCID: PMC3915715 DOI: 10.1097/lgt.0b013e31824ca9d5] [Citation(s) in RCA: 237] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
An update to the American Cancer Society (ACS) guideline regarding screening for the early detection of cervical precancerous lesions and cancer is presented. The guidelines are based on a systematic evidence review, contributions from six working groups, and a recent symposium co-sponsored by the ACS, American Society for Colposcopy and Cervical Pathology (ASCCP), and American Society for Clinical Pathology (ASCP), which was attended by 25 organizations. The new screening recommendations address age-appropriate screening strategies, including the use of cytology and high-risk human papillomavirus (HPV) testing, follow-up (e.g., management of screen positives and screening interval for screen negatives) of women after screening, age at which to exit screening, future considerations regarding HPV testing alone as a primary screening approach, and screening strategies for women vaccinated against HPV16/18 infections.
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Affiliation(s)
- Debbie Saslow
- Breast and Gynecologic Cancer, Cancer Control Science Department, American Cancer Society, Atlanta, GA 30303, USA.
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Economic modelling assessment of the HPV quadrivalent vaccine in Brazil: a dynamic individual-based approach. Vaccine 2012; 30:4866-71. [PMID: 22652405 DOI: 10.1016/j.vaccine.2012.04.087] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2012] [Revised: 04/14/2012] [Accepted: 04/24/2012] [Indexed: 01/04/2023]
Abstract
We examined the cost-effectiveness of the quadrivalent HPV vaccine for the pre-adolescent female population of Brazil. Using demographic, epidemiological and cancer data, we developed a dynamic individual-based model representing the natural history of HPV/cervical cancer as well as the impact of screening and vaccination programmes. Assuming the current screening strategies, we calculated the incremental cost-effectiveness ratio (ICER) for cohorts with and without vaccination taking into account different combinations of vaccination coverage (50%, 70%, 90%) and cost per vaccinated woman (US$25, US$55, US$125, US$556). The results varied from cost-saving (coverage 50% or 70% and cost per vaccinated woman US$25) to 5950 US$/QALY (coverage 90% and cost per vaccinated 556 US$). In a scenario in which a booster shot was needed after 10 years in order to secure lifelong protection, the ICER resulted in 13,576 US$/QALY. Considering the very cost-effective and cost-effective thresholds based on Brazil's GDP per capita, apart from the booster scenario which would be deemed cost-effective, all the other scenarios would be deemed very cost-effective. Both the cost per dose of vaccine and discount rate (5%) had an important impact on the results. Vaccination in addition to the current screening programme is likely to save years of life and, depending on the cost of vaccination, may even save resources. Price negotiations between governments and manufacturers will be paramount in determining that the vaccine not only represents good value for money, but is also affordable in middle-income countries like Brazil.
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Saslow D, Solomon D, Lawson HW, Killackey M, Kulasingam SL, Cain J, Garcia FAR, Moriarty AT, Waxman AG, Wilbur DC, Wentzensen N, Downs LS, Spitzer M, Moscicki AB, Franco EL, Stoler MH, Schiffman M, Castle PE, Myers ER. American Cancer Society, American Society for Colposcopy and Cervical Pathology, and American Society for Clinical Pathology screening guidelines for the prevention and early detection of cervical cancer. CA Cancer J Clin 2012; 62:147-72. [PMID: 22422631 PMCID: PMC3801360 DOI: 10.3322/caac.21139] [Citation(s) in RCA: 781] [Impact Index Per Article: 65.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
An update to the American Cancer Society (ACS) guideline regarding screening for the early detection of cervical precancerous lesions and cancer is presented. The guidelines are based on a systematic evidence review, contributions from 6 working groups, and a recent symposium cosponsored by the ACS, the American Society for Colposcopy and Cervical Pathology, and the American Society for Clinical Pathology, which was attended by 25 organizations. The new screening recommendations address age-appropriate screening strategies, including the use of cytology and high-risk human papillomavirus (HPV) testing, follow-up (eg, the management of screen positives and screening intervals for screen negatives) of women after screening, the age at which to exit screening, future considerations regarding HPV testing alone as a primary screening approach, and screening strategies for women vaccinated against HPV16 and HPV18 infections.
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Affiliation(s)
- Debbie Saslow
- Cancer Control Science Department, American Cancer Society, Atlanta, GA 30303, USA.
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Saslow D, Solomon D, Lawson HW, Killackey M, Kulasingam SL, Cain J, Garcia FAR, Moriarty AT, Waxman AG, Wilbur DC, Wentzensen N, Downs LS, Spitzer M, Moscicki AB, Franco EL, Stoler MH, Schiffman M, Castle PE, Myers ER. American Cancer Society, American Society for Colposcopy and Cervical Pathology, and American Society for Clinical Pathology screening guidelines for the prevention and early detection of cervical cancer. Am J Clin Pathol 2012; 137:516-42. [PMID: 22431528 DOI: 10.1309/ajcptgd94evrsjcg] [Citation(s) in RCA: 526] [Impact Index Per Article: 43.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
An update to the American Cancer Society (ACS) guideline regarding screening for the early detection of cervical precancerous lesions and cancer is presented. The guidelines are based on a systematic evidence review, contributions from 6 working groups, and a recent symposium cosponsored by the ACS, the American Society for Colposcopy and Cervical Pathology, and the American Society for Clinical Pathology, which was attended by 25 organizations. The new screening recommendations address age-appropriate screening strategies, including the use of cytology and high-risk human papillomavirus (HPV) testing, follow-up (eg, the management of screen positives and screening intervals for screen negatives) of women after screening, the age at which to exit screening, future considerations regarding HPV testing alone as a primary screening approach, and screening strategies for women vaccinated against HPV16 and HPV18 infections.
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Smith JHF. Cytology, liquid-based cytology and automation. Best Pract Res Clin Obstet Gynaecol 2011; 25:585-96. [PMID: 21632286 DOI: 10.1016/j.bpobgyn.2011.04.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2011] [Revised: 03/31/2011] [Accepted: 04/26/2011] [Indexed: 11/15/2022]
Affiliation(s)
- John H F Smith
- Department of Histopathology and Cytology, Royal Hallamshire Hospital, Sheffield, UK.
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Cost-effectiveness of a cervical screening program with human papillomavirus vaccine. Int J Technol Assess Health Care 2011; 27:290-7. [DOI: 10.1017/s0266462311000456] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Objectives: Recent introduction of a quadrivalent human papillomavirus (HPV) vaccine for girls in New Zealand is expected to decrease the incidence of HPV infection as well as resultant cytological abnormalities and cervical cancer. This may affect the cost-effectiveness of the national cervical screening program by reducing the incidence of lesions detected. This study investigates the cost-effectiveness of the current cervical screening policy with and without the HPV vaccine and compares these results with the cost-effectiveness of a range of other screening strategies.Methods: A Markov state-transition model was built based on the natural history of HPV and cervical carcinogenesis. The model followed a hypothetical cohort of girls from 12 years to 85 years of age or death, through screening and treatment pathways. The model compared a “no vaccine and current screening” strategy with a selection of screening strategies with different age ranges and frequency intervals.Results: The most cost-effective cervical screening strategy in the presence of the HPV vaccine would be screening women aged 30–60 every 5 years. Moving to this screening strategy from the base case of no vaccine and the current New Zealand strategy of screening women aged 20–69 every 3 years is predicted to have an incremental cost per quality-adjusted life-year gained of NZ$9,841 (€4,428).Conclusions: Reducing screening intensity from 3 to 5 years as well as narrowing the screening age range for the vaccinated cohort once they reach mid-twenties is recommended. The importance of achieving a high vaccine uptake in New Zealand remains high.
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Cost-effectiveness of primary HPV screening for cervical cancer in Germany – a decision analysis. Eur J Cancer 2011; 47:1633-46. [DOI: 10.1016/j.ejca.2011.03.006] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2010] [Revised: 03/03/2011] [Accepted: 03/04/2011] [Indexed: 11/21/2022]
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Biomarker expression in cervical intraepithelial neoplasia: potential progression predictive factors for low-grade lesions. Hum Pathol 2011; 42:1007-12. [DOI: 10.1016/j.humpath.2010.10.021] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2010] [Revised: 10/18/2010] [Accepted: 10/20/2010] [Indexed: 12/28/2022]
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Shi JF, Canfell K, Lew JB, Zhao FH, Legood R, Ning Y, Simonella L, Ma L, Kang YJ, Zhang YZ, Smith MA, Chen JF, Feng XX, Qiao YL. Evaluation of primary HPV-DNA testing in relation to visual inspection methods for cervical cancer screening in rural China: an epidemiologic and cost-effectiveness modelling study. BMC Cancer 2011; 11:239. [PMID: 21668946 PMCID: PMC3141766 DOI: 10.1186/1471-2407-11-239] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2010] [Accepted: 06/13/2011] [Indexed: 12/11/2022] Open
Abstract
Background A new lower-cost rapid-throughput human papillomavirus (HPV) test (careHPV, Qiagen, Gaithersburg, USA) has been shown to have high sensitivity for the detection of high grade cervical intraepithelial neoplasia. Methods We assessed the outcomes and cost-effectiveness of careHPV screening in rural China, compared to visual inspection with acetic acid, when used alone (VIA) or in combination with Lugol's iodine (VIA/VILI). Using data on sexual behaviour, test accuracy, diagnostic practices and costs from studies performed in rural China, we estimated the cost-effectiveness ratio (CER) and associated lifetime outcomes for once-lifetime and twice-lifetime screening strategies, and for routine screening at 5-yearly, 10-yearly and IARC-recommended intervals. The optimal age range for once-lifetime screening was also assessed. Results For all strategies, the relative ordering of test technologies in reducing cervical cancer incidence and mortality was VIA (least effective); VIA/VILI; careHPV@1.0 pg/ml and careHPV@0.5 pg/ml (most effective). For once-lifetime strategies, maximum effectiveness was achieved if screening occurred between 35-50 years. Assuming a participation rate of ~70%, once-lifetime screening at age 35 years would reduce cancer mortality by 8% (for VIA) to 12% (for careHPV@0.5) over the long term, with a CER of US$557 (for VIA) to $959 (for careHPV@1.0) per life year saved (LYS) compared to no intervention; referenced to a 2008 GDP per capita in Shanxi Province of $2,975. Correspondingly, regular screening with an age-standardised participation rate of 62% (which has been shown to be achievable in this setting) would reduce cervical cancer mortality by 19-28% (for 10-yearly screening) to 43-54% (using IARC-recommended intervals), with corresponding CERs ranging from $665 (for 10-yearly VIA) to $2,269 (for IARC-recommended intervals using careHPV@1.0) per LYS. Conclusions This modelled analysis suggests that primary careHPV screening compares favourably to visual inspection screening methodologies in rural China, particularly if used as part of a regular screening program.
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Affiliation(s)
- Ju-Fang Shi
- Department of Cancer Epidemiology, Cancer Institute, Chinese Academy of Medical Sciences, Peking Union Medical College, 17, South Panjiayuan LN, PO Box 2258, Beijing 100021, China
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Cervical cancer screening in Australia: modelled evaluation of the impact of changing the recommended interval from two to three years. BMC Public Health 2010; 10:734. [PMID: 21110881 PMCID: PMC3001736 DOI: 10.1186/1471-2458-10-734] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2010] [Accepted: 11/26/2010] [Indexed: 11/16/2022] Open
Abstract
Background The National Cervical Screening Program in Australia currently recommends that sexually active women between the ages of 18-70 years attend routine screening every 2 years. The publically funded National HPV Vaccination Program commenced in 2007, with catch-up in females aged 12-26 years conducted until 2009; and this may prompt consideration of whether the screening interval and other aspects of the organized screening program could be reviewed. The aim of the current evaluation was to assess the epidemiologic outcomes and cost implications of changing the recommended screening interval in Australia to 3 years. Methods We used a modelling approach to evaluate the effects of moving to a 3-yearly recommended screening interval. We used data from the Victorian Cervical Cytology Registry over the period 1997-2007 to model compliance with routine screening under current practice, and registry data from other countries with 3-yearly recommendations to inform assumptions about future screening behaviour under two alternative systems for screening organisation - retention of a reminder-based system (as in New Zealand), or a move to a call-and-recall system (as in England). Results A 3-yearly recommendation is predicted to be of similar effectiveness to the current 2-yearly recommendation, resulting in no substantial change to the total number of incident cervical cancer cases or cancer deaths, or to the estimated 0.68% average cumulative lifetime risk of cervical cancer in unvaccinated Australian women. However, a 3-yearly screening policy would be associated with decreases in the annual number of colposcopy and biopsy procedures performed (by 4-10%) and decreases in the number of treatments for pre-invasive lesions (by 2-4%). The magnitude of the decrease in the number of diagnostic procedures and treatments would depend on the method of screening organization, with call-and-recall screening associated with the highest reductions. The cost savings are predicted to be of the order of A$10-18 M annually, equivalent to 6-11% of the total cost of the current program (excluding overheads), with call-and-recall being associated with the greatest savings. Conclusions Lengthening the recommended screening interval to 3 years in Australia is not predicted to result in increases in rates of cervical cancer and is predicted to decrease the number of women undergoing diagnostic and treatment procedures. These findings are consistent with a large body of international evidence showing that screening more frequently than every three years with cervical cytology does not result in substantial gains in screening effectiveness.
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Melnikow J, Kulasingam S, Slee C, Helms LJ, Kuppermann M, Birch S, McGahan CE, Coldman A, Chan BKS, Sawaya GF. Surveillance after treatment for cervical intraepithelial neoplasia: outcomes, costs, and cost-effectiveness. Obstet Gynecol 2010; 116:1158-70. [PMID: 20966702 DOI: 10.1097/aog.0b013e3181f88e72] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To estimate outcomes and costs of surveillance strategies after treatment for high-grade cervical intraepithelial neoplasia (CIN). METHODS 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. RESULTS 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. CONCLUSION 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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Affiliation(s)
- Joy Melnikow
- Department of Economics, Center for Healthcare Policy and Research, University of California, Davis, California 95817, USA.
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Obradovic M, Mrhar A, Kos M. Cost-effectiveness analysis of HPV vaccination alongside cervical cancer screening programme in Slovenia. Eur J Public Health 2010; 20:415-21. [DOI: 10.1093/eurpub/ckp208] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Van de Velde N, Brisson M, Boily MC. Understanding differences in predictions of HPV vaccine effectiveness: A comparative model-based analysis. Vaccine 2010; 28:5473-84. [PMID: 20573580 DOI: 10.1016/j.vaccine.2010.05.056] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2010] [Accepted: 05/24/2010] [Indexed: 01/03/2023]
Abstract
Mathematical models of HPV vaccine effectiveness and cost-effectiveness have produced conflicting results. The aim of this study was to use mathematical models to compare and isolate the impact of the assumptions most commonly made when modeling the effectiveness of HPV vaccines. Our results clearly show that differences in how we model natural immunity, herd immunity, partnership duration, HPV types, and waning of vaccine protection lead to important differences in the predicted effectiveness of HPV vaccines. These results are important and useful to assist modelers/health economists in choosing the appropriate level of complexity to include in their models, provide epidemiologists with insight on key data necessary to increase the robustness of model predictions, and help decision makers better understand the reasons underlying conflicting results from HPV models.
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Affiliation(s)
- Nicolas Van de Velde
- Département de Médecine Sociale et Préventive, Université Laval, Québec, QC, Canada
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