Current cervical cancer screening practices remain less cost-effective and are linked to less health benefit then they would be if current guideline recommendations were followed, according to a model-based cost-effectiveness study published online September 29 in the Annals of Internal Medicine.
Overscreening, underscreening, losing track of women in follow-up, and poor management of care for women with abnormal test results have all contributed to approximately 12,000 new cases and 4000 deaths from cervical cancer annually, report Jane J. Kim, PhD, from the Center for Health Decision Science at the Harvard T.H. Chan School of Public Health, Boston, Massachusetts, and colleagues.
"In terms of cost-effectiveness, current screening practice remained inefficient in all simulations conducted, implying that although guidelines-based strategies are more costly, the gains in health are also relatively greater," the authors write.
If screening and referral practices adhered to recommended guidelines perfectly, including cytologic testing every 3 years, patients would experience greater quality of life, with a total lifetime incremental net monetary benefit of $1645 per person in 2012 dollars. Considered costs included direct medical costs resulting from screening, diagnosis, and treatment of precancerous lesions and invasive cancer. The authors explain that incremental net monetary benefit "translates the incremental benefit (additional [quality-adjusted life-years (QALYs)] gained) into monetary terms for a given willingness-to-pay...threshold (by multiplying the QALYs gained by the [willingness-to-pay]) and then subtracting the incremental cost."
The researchers analyzed screening, diagnostic, and treatment data from the New Mexico HPV Pap Registry, which is the only existing population-based US cervical cancer screening registry. It included laboratory reports on all women screened from 2007 to 2011 or 2012 in New Mexico. The authors limited their model to cytologic testing only because less than 20% of women aged 30 to 65 years underwent cytologic and HPV cotesting as a screening strategy.
Current guidelines of cytologic screenings every 3 years would lead to an 80.9% drop in cervical cancer incidence and an 86.7% drop in mortality compared with no screening, the researchers calculate. That reduction came with an incremental cost-effectiveness ratio (ICER) of $15,260 per QALY, with ICER defined as "the additional cost divided by the additional health benefit of a specific strategy compared with the next less-costly strategy."
Yet current screening practice reduces lifetime cervical cancer incidence by only 48.5% and mortality by 58.4% compared with no screening, with an ICER of $19,530 per QALY gained.
In contrast, cotesting every 5 years would lead to a greater reduction than 3-year cytologic testing, with a 91.1% reduction in incidence and 93.5% reduction in mortality, but at a higher ICER of $59,440 per QALY. Annual cytologic screenings were nearly identical to the reduction in disease burden from 5-year cotesting, but with an ICER of more than $1 million per QALY gained.
"Perfect compliance with HPV triage testing had very little effect on outcomes compared with current screening practice," the authors write. "[I]n contrast, scenarios with perfect follow-up for excisional treatment referrals, perfect adherence to screening every 3 years with routine cytologic testing, and perfect follow-up for diagnostic colposcopy/biopsy referrals were associated with increasingly higher QALYs with only small changes in costs."
The authors note the potentially limited generalizability of the study, as the population includes only women from New Mexico, but notes that the New Mexico population is demographically and socially similar to the US population. The analysis also did not take into account effects of HPV vaccination.
"Despite these limitations, our findings robustly support the notion that there is room for improvement in the current practice of cervical cancer screening," the authors write. "Our analysis indicates that we stand to gain the most health benefit by equalizing the screening rate for all eligible women and ensuring complete diagnostic follow-up and that we can make sizable investments toward these improvements."
The research was funded by the National Cancer Institute. The authors have disclosed no relevant financial relationships.
Ann Intern Med. Published online September 29, 2015. Abstract
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