Journal of the National Cancer Institute Advance Access originally published online on February 26, 2008
JNCI Journal of the National Cancer Institute 2008 100(5):308-320; doi:10.1093/jnci/djn019
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© The Author 2008. Published by Oxford University Press.
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ARTICLES |
Cost-Effectiveness of Cervical Cancer Screening With Human Papillomavirus DNA Testing and HPV-16,18 Vaccination
Affiliations of authors: Doctoral Program in Health Policy, Decision Science Concentration, Harvard University, Cambridge, MA (JDGF); Program in Health Decision Science (JDGF, NKS, SJG) and Departments of Health Policy and Management (JDGF, NKS, SJG, KMK), Population and International Health (JAS), and Biostatistics (KMK), Harvard School of Public Health, Boston, MA; Harvard University Initiative for Global Health, Cambridge, MA (JAS); Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, MN (KMK)
Correspondence to: Sue J. Goldie, MD, MPH, Department of Health Policy and Management, Harvard School of Public Health, 718 Huntington Ave, 2nd Floor, Boston, MA 02115 (e-mail: sue_goldie{at}harvard.edu).
Background: The availability of human papillomavirus (HPV) DNA testing and vaccination against HPV types 16 and 18 (HPV-16,18) motivates questions about the cost-effectiveness of cervical cancer prevention in the United States for unvaccinated older women and for girls eligible for vaccination.
Methods: An empirically calibrated model was used to assess the quality-adjusted life years (QALYs), lifetime costs, and incremental cost-effectiveness ratios (2004 US dollars per QALY) of screening, vaccination of preadolescent girls, and vaccination combined with screening. Screening varied by initiation age (18, 21, or 25 years), interval (every 1, 2, 3, or 5 years), and test (HPV DNA testing of cervical specimens or cytologic evaluation of cervical cells with a Pap test). Testing strategies included: 1) cytology followed by HPV DNA testing for equivocal cytologic results (cytology with HPV test triage); 2) HPV DNA testing followed by cytology for positive HPV DNA results (HPV test with cytology triage); and 3) combined HPV DNA testing and cytology. Strategies were permitted to switch once at age 25, 30, or 35 years.
Results: For unvaccinated women, triennial cytology with HPV test triage, beginning by age 21 years and switching to HPV testing with cytology triage at age 30 years, cost $78000 per QALY compared with the next best strategy. For girls vaccinated before age 12 years, this same strategy, beginning at age 25 years and switching at age 35 years, cost $41000 per QALY with screening every 5 years and $188000 per QALY screening triennially, each compared with the next best strategy. These strategies were more effective and cost-effective than screening women of all ages with cytology alone or cytology with HPV triage annually or biennially.
Conclusions: For both vaccinated and unvaccinated women, age-based screening by use of HPV DNA testing as a triage test for equivocal results in younger women and as a primary screening test in older women is expected to be more cost-effective than current screening recommendations.
| CONTEXT AND CAVEATS Prior knowledge Cervical cancer screening by cytology has reduced mortality from invasive cancer, although disparities exist in access to screening and outcomes. Human papillomavirus (HPV) DNA testing and vaccination against HPV-16,18 have recently become available. Study design A simulation model was used to assess quality-adjusted life years, lifetime costs, and incremental cost-effectiveness ratios of screening, vaccination of preadolescent girls (girls younger than 12 years), and vaccination combined with screening. Screening was varied by start age (18, 21, or 25 years), interval between screenings (1, 2, 3, or 5 years), test (HPV DNA testing or cytologic testing with a Pap test, or both combined), and age at which tests switched (25, 30, or 35, or no switch). Contribution For both vaccinated and unvaccinated women, age-based screening with HPV DNA testing as a triage test for equivocal results in younger women and as a primary screening test in older women is expected to be more cost-effective than current screening recommendations. Implications Achieving this potential will likely depend on high vaccine coverage in preadolescent girls, communication of clear messages to both vaccinated and unvaccinated women about continuing screening and following appropriate age-based guidelines, and targeted efforts to recruit and screen women with historically poor access to cervical cancer prevention. Limitations Vaccine uptake, vaccine effectiveness, duration of HPV-type–specific immunity, screening compliance, and behavior of subgroups of women defined by vaccination status, race, access to preventive care, and other factors are uncertain.
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Manuscript received May 31, 2007; revised December 16, 2007; accepted January 15, 2008.
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