Treatment methods for cervical intraepithelial neoplasia in England: A cost-effectiveness analysis

OBJECTIVE

To compare the cost-effectiveness of different treatments for cervical intraepithelial neoplasia (CIN).

DESIGN

A cost-effectiveness analysis based on data available in the literature and expert opinion.

SETTING

England.

POPULATION

Women treated for CIN.

METHODS

We developed a decision-analytic model to simulate the clinical course of 1000 women who received local treatment for CIN and were followed up for 10 years after treatment. In the model we considered surgical complications as well as oncological and reproductive outcomes over the 10-year period. The costs calculated were those incurred by the National Health Service (NHS) of England.

MAIN OUTCOME MEASURES

Cost per one CIN2+ recurrence averted (oncological outcome); cost per one preterm birth averted (reproductive outcome); overall cost per one adverse oncological or reproductive outcome averted.

RESULTS

For young women of reproductive age, large loop excision of the transformation zone (LLETZ) was the most cost-effective treatment overall at all willingness-to-pay thresholds. For postmenopausal women, LLETZ remained the most cost-effective treatment up to a threshold of £31,500, but laser conisation became the most cost-effective treatment above that threshold.

CONCLUSIONS

LLETZ is the most cost-effective treatment for both younger and older women. However, for older women, more radical excision with laser conisation could also be considered if the NHS is willing to spend more than £31,500 to avert one CIN2+ recurrence.

Cervical cancer screening and treatment costing in Senegal

Introduction

in Senegal, cervical cancer is the leading cause of cancers among women. This study estimated the costs associated with cervical cancer screening and treatment for precancerous lesions from the health system perspective.

Methods

we estimated costs for screening, diagnostics, and treatment. We conducted a cross-sectional study in seven regions with primary data collected from 50 health facilities. Data collection included structured questionnaires, with secondary data from the Ministry of Health and other sources. A mixed-methods approach combined ingredients-based costing and financial expenditures to estimate direct medical and non-medical costs. All costs are reported in 2019 USD.

Results

average costs were $3.71 for visual inspection with acetic acid, $16.49 for Pap smear, and $46.65 for human papillomavirus deoxyribonucleic acid (HPV DNA) testing. Screening cost drivers were clinical exam supplies and clinical equipment for visual inspection with acetic acid, offsite processing of specimens for Pap smear, and lab equipment costs for HPV DNA procedure. The average cost of diagnosis via colposcopy alone was $25.73, and colposcopy with biopsy/endocervical curettage was $74.96. The average cost of treatment followed by one visit for pre-cancerous lesions was $195.24 for loop electrosurgical excision, $47.35 for cryotherapy, and $32.35 for thermal ablation. Clinical equipment and lab costs were the largest contributors to colposcopy and endocervical curettage/biopsy expenses. Clinical equipment made up the largest portion of cryotherapy, loop electrosurgical excision, and thermoablation costs.

Conclusion

this study is the first to estimate the costs of HPV screening and treatment in Senegal, which can be used to inform decision-making on cervical cancer investments.

Cost-effectiveness analysis of primary human papillomavirus testing in cervical cancer screening: Results from the HPV FOCAL Trial

The Human Papillomavirus FOr CervicAL cancer (HPV FOCAL) trial is a large randomized controlled trial comparing the efficacy of primary HPV testing to cytology among women in the population-based Cervix Screening Program in British Columbia, Canada. We conducted a cost-effectiveness analysis based on the HPV FOCAL trial to estimate the incremental cost per detected high-grade cervical intraepithelial neoplasia of grade 2 or worse lesions (CIN2+). A total of 19,009 women aged 25 to 65 were randomized to one of two study groups. Women in the intervention group received primary HPV testing with reflex liquid-based cytology (LBC) upon a positive finding with a screening interval of 48 months. Women in the control group received primary LBC testing, and those negative returned at 24 months for LBC and again at 48 months for exit screening. Both groups received HPV and LBC co-testing at the 48-month exit. Incremental costs during the course of the trial were comparable between the intervention and control groups. The intervention group had lower overall costs and detected a larger number of CIN2+ lesions, resulting in a lower mean cost per CIN2+ detected ($7551) than the control group ($8325), a difference of -$773 [all costs in 2018 USD]. Cost per detected lesion was sensitive to the costs of sample collection, HPV testing, and LBC testing. The HPV FOCAL Trial results suggest that primary HPV testing every 4 years produces similar outcomes to LBC-based testing every 2 years for cervical cancer screening at a lower cost.

Cervical cancer screening coverage, management of squamous intraepithelial lesions and related costs in France

Until 2018, cervical cancer screening in France was an unorganized individual screening, with the exception of some pilot programs in some territories. We aimed to assess, before the implementation of organized cervical cancer screening and human papillomavirus (HPV) nonavalent vaccine introduction in the vaccination schedule in 2018, (i) the individual cervical cancer screening coverage, (ii) the management of squamous intraepithelial lesions (SIL) and (iii) the related costs. We used the Système National des Données de Santé (SNDS) (Echantillon Généraliste de Bénéficiaires [EGB] and Programme de Médicalisation des systèmes d'information [PMSI]) to assess the cervical screening coverage rate in France between January 1st, 2012 and December 31st, 2014, and to describe diagnostic investigations and therapeutic management of SIL in 2013. After extrapolation to the general population, a total of 10,847,814 women underwent at least one smear test over the 3-year study period, corresponding to a coverage rate of 52.4% of the women aged 25 to 64 included. In 2013, 126,095 women underwent HPV test, 327,444 women underwent colposcopy, and 9,653 underwent endocervical curettage; 31,863 had conization and 12,162 had laser ablation. Besides, 34,067 women experienced hospital stays related to management of SIL; 25,368 (74.5%) had high-grade lesions (HSIL) and 7,388 (21.7%) low-grade lesions (LSIL). Conization was the most frequent in-hospital therapeutic procedure: 89.5% (22,704) of women with an in-hospital procedure for HSIL and 64.7% (4,781) for LSIL. Mean cost of smear test, colposcopy and HPV tests were around 50€. Total cost for hospital stays in 2013 was estimated at M41€, or a mean cost of 1,211€ per woman; 76% were due to stays with HSIL. This study highlights the low coverage rate of individual cervical cancer screening and a high burden related to SIL management.

Prospective cohort study examining cervical cancer screening methods in HIV-positive and HIV-negative Cambodian Women: a comparison of human papilloma virus testing, visualization with acetic acid and digital colposcopy

OBJECTIVES

Logistical and economic issues make traditional cytology-based cervical cancer screening challenging in developing countries. Alternative, cost-effective, screening strategies must be developed to screen millions of women in resource-poor countries such as Cambodia.

DESIGN

A prospective cohort study during which all women underwent four cervical cancer screening methods: (1) self-sampled human papilloma virus (HPV) testing (careHPV system), (2) clinician-collected HPV testing, (3) visualization with acetic acid (VIA) and (4) digital colposcopy (DC) with the Enhanced Visual Assessment System (EVA).

SETTING

A referral hospital in Phnom Penh, Cambodia.

PARTICIPANTS

Two hundred and fifty Cambodian women (129 HIV+, 121 HIV-). Subjects were recruited from the National Center for HIV/AIDS Dermatology and sexually transmitted disease (STD) cohort, the Sihanouk Hospital Center of Hope's Rural Outreach Teams and the Pochentong Medical Center.

RESULTS

Fifty six of the 250 (22.4%) patients tested positive for high-risk HPV (hrHPV+). Thirty seven of the 129 HIV+ women were hrHPV+ (28.6%) whereas 19/121 HIV- women were hrHPV+ (15.7%) p=0.0154. Self-sampling HPV specimens identified 50/56 (89%) whereas physician-collected specimens identified 45/56 (80%) p=0.174. 95.2% of the patients felt comfortable obtaining HPV self-samples. Thirty seven of 250 women were VIA+. Thirty of 37 VIA+ women underwent confirmatory biopsies for cervical intraepithelial neoplasia (CIN) (26 CIN1, 4 CIN2+). The rate of confirmed dysplasia in the HIV+ group was 20/129 (15.5%) compared with 10/121 (8.26%) in HIV- women p=0.0291. The contemporaneous physician impressions of the DC images accurately differentiated between CIN1 and CIN2+ lesions in all 30 women having confirmatory biopsies.

CONCLUSIONS

The results of this study suggest potential modifications of the current cervical screening strategy that is currently being employed in Cambodia. The first step in this new strategy would be self-swabbing for hrHPV. Subsequently, hrHPV+ patients would have DC and immediate treatment based on colposcopic findings: cryotherapy for suspected CIN1 and loop electrosurgical excision procedure (LEEP) for suspected CIN2+.

Community-based HPV self-collection versus visual inspection with acetic acid in Uganda: a cost-effectiveness analysis of the ASPIRE trial

BACKGROUND

Cervical cancer is the leading cause of cancer death for women in Uganda, despite the potential for prevention through organised screening. Community-based self-collected human papillomavirus (HPV) testing has been proposed to reduce barriers to screening.

OBJECTIVE

Our objective was to evaluate the cost-effectiveness of the Advances in Screening and Prevention of Reproductive Cancers (ASPIRE) trial, conducted in Kisenyi, Uganda in April 2014 (n=500). The trial compared screening uptake and compliance with follow-up in two arms: (1) community-based (ie, home or workplace) self-collected HPV testing (facilitated by community health workers) with clinic-based visual inspection with acetic acid (VIA) triage of HPV-positive women ('HPV-VIA') and (2) clinic-based VIA ('VIA'). In both arms, VIA was performed at the local health unit by midwives with VIA-positive women receiving immediate treatment with cryotherapy.

DESIGN

We informed a Monte Carlo simulation model of HPV infection and cervical cancer with screening uptake, compliance and retrospective cost data from the ASPIRE trial; additional cost, test performance and treatment effectiveness data were drawn from observational studies. The model was used to assess the cost-effectiveness of each arm of ASPIRE, as well as an HPV screen-and-treat strategy ('HPV-ST') involving community-based self-collected HPV testing followed by treatment for all HPV-positive women at the clinic.

OUTCOME MEASURES

The primary outcomes were reductions in cervical cancer risk and incremental cost-effectiveness ratios (ICERs), expressed in dollars per year of life saved (YLS).

RESULTS

HPV-ST was the most effective and cost-effective screening strategy, reducing the lifetime absolute risk of cervical cancer from 4.2% (range: 3.8%-4.7%) to 3.5% (range: 3.2%-4%), 2.8% (range: 2.4%-3.1%) and 2.4% (range: 2.1%-2.7%) with ICERs of US$130 (US$110-US$150) per YLS, US$240 (US$210-US$280) per YLS, and US$470 (US$410-US$550) per YLS when performed one, three and five times per lifetime, respectively. Findings were robust across sensitivity analyses, unless HPV costs were more than quadrupled.

CONCLUSIONS

Community-based self-collected HPV testing followed by treatment for HPV-positive women has the potential to be an effective and cost-effective screening strategy.

Patients with newly diagnosed cervical cancer should be screened for anal human papilloma virus and anal dysplasia: Results of a pilot study using a STELLA computer simulation and economic model

BACKGROUND

Women with cervical cancer often have anal human papillomavirus (HPV) infection and anal dysplasia. However, effectiveness of anal HPV screening is unknown.

METHODS

A dynamic model was constructed using STELLA. Populations are represented as "stocks" that change according to model rates. Initial anal cytology in new cervical cancer patients, dysplasia progression and regression, cost of treating high-grade squamous intraepithelial lesions (HSIL), and lifetime costs for anal cancer care were extrapolated from the literature. Local costs of anal HPV testing and cytology were obtained. Outcomes included anal cancer rates, anal cancer deaths, screening costs and cancer care.

RESULTS

Benefits in the screened group included reduction in anal cancers after three years and anal cancer deaths after four years. After 10 years, predicted costs per anal cancer prevented and anal cancer deaths were $168,796 and $210,057 and were $98,631 and $210,057 at 20 years. Predicted costs per quality of life year saved at 10 and 20 years were $9785 and $1687. Sensitivity analysis demonstrated cost-effectiveness of screening for a variety of cure rates HSIL with electrocautery.

CONCLUSION

Screening for anal HPV and treatment of anal HSIL in patients with cervical cancer is cost-effective, prevents anal cancer and reduces anal cancer deaths.

Comparing two Modalities of Management of Women with Cytologic Evidence of Squamous Or Glandular Atypia: Early Repeat Cytology or Colposcopy

Early repeat cytology is recommended in most screening programs for cervical cancer in subjects with squamous or glandular abnormalities not amounting to neoplasia (atypical squamous cells of undetermined significance, ASCUS), but immediate colposcopy is also recommended in some countries, especially those where there is easy access to colposcopic facilities. We evaluated the cost-effectiveness of the two procedures in a prospective study of women with cytologic ASCUS, invited to cytocolposcopic assessment after 6 months. Colposcopy-directed biopsy was assumed as the gold standard, and the accuracy of colposcopy at 6 months was assumed to be equal to that of immediate colposcopy. Out of 874 compilers, punch biopsy was performed in 303 cases (34.7%), and 19 CIN2+ lesions were detected (CIN2 = 12, CIN3 = 6, microinvasive carcinoma = 1). Detecting 13 CIN2+ lesions at colposcopy required 874 colposcopies and 303 directed biopsies: the cost per CIN2+ lesion detected with the procedure was 2,749 US$. Detecting 15 CIN2+ lesions at repeat cytology required 874 cytologic examinations, 137 colposcopies, 64 directed biopsies, and 6 diagnostic large-loop resections, the latter being performed in subjects with high-grade squamous intraepithelial lesion and less severe lesions at punch biopsy: the cost per CIN2+ lesion detected with the procedure was 1,961 US$. The policy of repeat smear was more cost-effective than immediate colposcopy. According to such results, the protocol of the Florence screening program has been modified since October 1996.

Colposcopy as a Primary Screening test for Cervical Cancer

Aim and background

To evaluate the cost effectiveness of screening by colposcopy compared to conventional cytology.

Methods

A prospective study was performed in the Florence District screening center on 3,000 consecutive women, self referring, who were examined by cytology and colposcopy in a blind fashion. Further assessment was based on cytologic report or on colposcopy-directed punch biopsy. Actual costs of the whole screening process were known. The cost effectiveness of different possible simulated screening scenarios was then determined.

Results

Overall, 18 high-grade lesions (CIN3 = 9, CIN2 = 9) were detected. Four different screening scenarios were compared, namely a) cytology alone, b) cytology + repeat smear for ASCUS (atypical squamous cells of undeterminate significance) cases, c) colposcopy + cytology for cases of condyloma at punch biopsy, and d) colposcopy alone. Although they had a higher cost per examined woman (a) = 17.98, b) = 19.40, c) = 23.86, d)= 22.10 US$), scenarios c) and d) had a higher relative sensitivity (a = 44.4, b = 61.1, c = 100, d = 88.8%) and a lower cost per high-grade lesion detected (a = 6,743, b = 5,291, c = 3,977, d = 4,144 US$).

Conclusions

Screening by colposcopy is a feasible procedure which is more sensitive and more cost effective than conventional cytologic screening. At least in those settings where access to cytopathology may be difficult, screening by colposcopy should be considered as a possible alternative.

Cost-effectiveness of HPV-based cervical cancer screening in the public health system in Nicaragua

OBJECTIVES

To evaluate the cost-effectiveness of human papillomavirus (HPV) DNA testing (versus Papanicolaou (Pap)-based screening) for cervical cancer screening in Nicaragua.

DESIGN

A previously developed Monte Carlo simulation model of the natural history of HPV infection and cervical cancer was calibrated to epidemiological data from Nicaragua. Cost data inputs were derived using a micro-costing approach in Carazo, Chontales and Chinandega departments; test performance data were from a demonstration project in Masaya department.

SETTING

Nicaragua's public health sector facilities.

PARTICIPANTS

Women aged 30-59 years.

INTERVENTIONS

Screening strategies included (1) Pap testing every 3 years, with referral to colposcopy for women with an atypical squamous cells of undetermined significance or worse result ('Pap'); (2) HPV testing every 5 years, with referral to cryotherapy for HPV-positive eligible women (HPV cryotherapy or 'HPV-Cryo'); (3) HPV testing every 5 years, with referral to triage with visual inspection with acetic acid (VIA) for HPV-positive women ('HPV-VIA'); and (4) HPV testing every 5 years, with referral to Pap testing for HPV-positive women ('HPV-Pap').

OUTCOME MEASURES

Reduction in lifetime risk of cancer and incremental cost-effectiveness ratios (ICER; 2015 US$ per year of life saved (YLS)).

RESULTS

HPV-based screening strategies were more effective than Pap testing. HPV-Cryo was the least costly and most effective strategy, reducing lifetime cancer risk by 29.5% and outperforming HPV-VIA, HPV-Pap and Pap only, which reduced cancer risk by 19.4%, 12.2% and 10.8%, respectively. With an ICER of US$320/YLS, HPV-Cryo every 5 years would be very cost-effective using a threshold based on Nicaragua's per capita gross domestic product of US$2090. Findings were robust across sensitivity analyses on test performance, coverage, compliance and cost parameters.

CONCLUSIONS

HPV testing is very cost-effective compared with Pap testing in Nicaragua, due to higher test sensitivity and the relatively lower number of visits required. Increasing compliance with recommended follow-up will further improve the health benefits and value for public health dollars.

Using Decision-Analytic Modeling to Isolate Interventions That Are Feasible, Efficient and Optimal: An Application from the Norwegian Cervical Cancer Screening Program

BACKGROUND

Decision makers often need to simultaneously consider multiple criteria or outcomes when deciding whether to adopt new health interventions.

OBJECTIVES

Using decision analysis within the context of cervical cancer screening in Norway, we aimed to aid decision makers in identifying a subset of relevant strategies that are simultaneously efficient, feasible, and optimal.

METHODS

We developed an age-stratified probabilistic decision tree model following a cohort of women attending primary screening through one screening round. We enumerated detected precancers (i.e., cervical intraepithelial neoplasia of grade 2 or more severe (CIN2+)), colposcopies performed, and monetary costs associated with 10 alternative triage algorithms for women with abnormal cytology results. As efficiency metrics, we calculated incremental cost-effectiveness, and harm-benefit, ratios, defined as the additional costs, or the additional number of colposcopies, per additional CIN2+ detected. We estimated capacity requirements and uncertainty surrounding which strategy is optimal according to the decision rule, involving willingness to pay (monetary or resources consumed per added benefit).

RESULTS

For ages 25 to 33 years, we eliminated four strategies that did not fall on either efficiency frontier, while one strategy was efficient with respect to both efficiency metrics. Compared with current practice in Norway, two strategies detected more precancers at lower monetary costs, but some required more colposcopies. Similar results were found for women aged 34 to 69 years.

CONCLUSIONS

Improving the effectiveness and efficiency of cervical cancer screening may necessitate additional resources. Although efficient and feasible, both society and individuals must specify their willingness to accept the additional resources and perceived harms required to increase effectiveness before a strategy can be considered optimal.

Cost analysis of different cervical cancer screening strategies in Mexico

OBJECTIVE

To compare the costs and number of undetected cases of four cervical cancer screening strategies (CCSS) in Mexico.

MATERIALS AND METHODS

We estimated the costs and outcomes of the following CCSS: a) conventional Papanicolaou smear (Pap) alone; b) high-risk human papilloma virus testing (HR-HPV) as primary screening with Pap as reflex triage; c) HR-HPV as primary screening with HPV-16/18 typing, liquid-based cytology (LBC) and immunostaining for p16/Ki67 testing as reflex triage, and d) co-testing with HR-HPV and LBC with HPV-16/18 typing and immunostaining for p16/Ki67 as reflex triage. The outcome of interest was high-grade cervical lesions or cervical cancer.

RESULTS

HR-HPV testing, HPV typing, LBC testing and immunostaining is the best alternative because it is the least expensive option with an acceptable number of missed cases.

CONCLUSIONS

The opportunity costs of a poor quality CCSS is many false negatives. Combining multiple tests may be a more cost-effective way to screen for cervical cancer in Mexico.

Adjunctive colposcopy technologies for examination of the uterine cervix--DySIS, LuViva Advanced Cervical Scan and Niris Imaging System: a systematic review and economic evaluation

BACKGROUND

Women in England (aged 25-64 years) are invited for cervical screening every 3-5 years to assess for cervical intraepithelial neoplasia (CIN) or cancer. CIN is a term describing abnormal changes in the cells of the cervix, ranging from CIN1 to CIN3, which is precancerous. Colposcopy is used to visualise the cervix. Three adjunctive colposcopy technologies for examination of the cervix have been included in this assessment: Dynamic Spectral Imaging System (DySIS), the LuViva Advanced Cervical Scan and the Niris Imaging System.

OBJECTIVE

To determine the clinical effectiveness and cost-effectiveness of adjunctive colposcopy technologies for examination of the uterine cervix for patients referred for colposcopy through the NHS Cervical Screening Programme.

DATA SOURCES

Sixteen electronic databases [Allied and Complementary Medicine Database (AMED), BIOSIS Previews, Cochrane Database of Systematic Reviews (CDSR), Cochrane Central Register of Controlled Trials (CENTRAL), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Database of Abstracts of Reviews of Effects (DARE), EMBASE, Health Management Information Consortium (HMIC), Health Technology Assessment (HTA) database; Inspec, Inside Conferences, MEDLINE, NHS Economic Evaluation Database (NHS EED), PASCAL, Science Citation Index Expanded (SCIE) and Science Citation Index (SCI) - Conference Proceedings], and two clinical trial registries [ClinicalTrials.gov and Current Controlled Trials (CCT)] were searched to September-October 2011.

REVIEW METHODS

Studies comparing DySIS, LuViva or Niris with conventional colposcopy were sought; a narrative synthesis was undertaken. A decision-analytic model was developed, which measured outcomes in terms of quality-adjusted life-years (QALYs) and costs were evaluated from the perspective of the NHS and Personal Social Services with a time horizon of 50 years.

RESULTS

Six studies were included: two studies of DySIS, one study of LuViva and three studies of Niris. The DySIS studies were well reported and had a low risk of bias; they found higher sensitivity with DySIS (both the DySISmap alone and in combination with colposcopy) than colposcopy alone for identifying CIN2+ disease, although specificity was lower with DySIS. The studies of LuViva and Niris were poorly reported and had limitations, which indicated that their results were subject to a high risk of bias; the results of these studies cannot be considered reliable. The base-case cost-effectiveness analysis suggests that both DySIS treatment options are less costly and more effective than colposcopy alone in the overall weighted population; these results were robust to the ranges tested in the sensitivity analysis. DySISmap alone was more costly and more effective in several of the referral groups but the incremental cost-effectiveness ratio (ICER) was never higher than £1687 per QALY. DySIS plus colposcopy was less costly and more effective in all reasons for referral. Only indicative analyses were carried out on Niris and LuViva and no conclusions could be made on their cost-effectiveness.

LIMITATIONS

The assessment is limited by the available evidence on the new technologies, natural history of the disease area and current treatment patterns.

CONCLUSIONS

DySIS, particularly in combination with colposcopy, has higher sensitivity than colposcopy alone. There is no reliable evidence on the clinical effectiveness of LuViva and Niris. DySIS plus colposcopy appears to be less costly and more effective than both the DySISmap alone and colposcopy alone; these results were robust to the sensitivity analyses undertaken. Given the lack of reliable evidence on LuViva and Niris, no conclusions on their potential cost-effectiveness can be drawn. There is some uncertainty about how generalisable these findings will be to the population of women referred for colposcopy in the future, owing to the introduction of the human papillomavirus (HPV) triage test and uptake of the HPV vaccine.

Abdominal Colpopexy: Comparison of Endoscopic Surgical Strategies (ACCESS)

INTRODUCTION

Robotic assistance during laparoscopic surgery for pelvic organ prolapse rapidly disseminated across the United States without level I data to support its benefit over traditional open and laparoscopic approaches [1]. This manuscript describes design and methodology of the Abdominal Colpopexy: Comparison of Endoscopic Surgical Strategies (ACCESS) Trial.

METHODS

ACCESS is a randomized comparative effectiveness trial enrolling patients at two academic teaching facilities, UCLA (Los Angeles, CA) and Loyola University (Chicago, IL). The primary aim is to compare costs of robotic assisted versus pure laparoscopic abdominal sacrocolpopexy (RASC vs LASC). Following a clinical decision for minimally-invasive abdominal sacrocolpopexy (ASC) and research consent, participants with symptomatic stage≥II pelvic organ prolapse are randomized to LASC or RASC on the day of surgery. Costs of care are based on each patient's billing record and equipment costs at each hospital. All costs associated with surgical procedure including costs for robot and initial hospitalization and any re-hospitalization in the first 6weeks are compared between groups. Secondary outcomes include post-operative pain, anatomic outcomes, symptom severity and quality of life, and adverse events. Power calculation determined that 32 women in each arm would provide 95% power to detect a $2500 difference in total charges, using a two-sided two sample t-test with a significance level of 0.05.

RESULTS

Enrollment was completed in May 2011. The 12-month follow-up was completed in May 2012.

CONCLUSIONS

This is a multi-center study to assess cost as a primary outcome in a comparative effectiveness trial of LASC versus RASC.

[Health technology assessment report. Use of liquid-based cytology for cervical cancer precursors screening]

OBJECTIVE OF THE PROJECT: Purpose of this Report is to evaluate the impact of the introduction of liquid-based cytology (LBC) in cervical cancer screening in terms of efficacy, undesired effects, costs and implications for organisation. EFFICACY AND UNDESIRED EFFECTS: LBC WITH MANUAL INTERPRETATION: The estimates of cross-sectional accuracy for high-grade intraepithelial neoplasia (CIN2 or more severe and CIN3 or more severe) obtained by a systematic review and meta-analysis published in 2008 were used. This review considered only studies in which all women underwent colposcopy or randomised controlled trials (RCTs) with complete verification of test positives. A systematic search of RCTs published thereafter was performed. Three RCTs were identified. One of these studies was conducted in 6 Italian regions and was of large size (45,174 women randomised); a second one was conducted in another Italian region (Abruzzo) and was of smaller size (8,654 women randomised); a third RCT was conducted in the Netherlands and was of large size (89,784 women randomised). No longitudinal study was available. There is currently no clear evidence that LBC increases the sensitivity of cytology and even less that its introduction increases the efficacy of cervical screening in preventing invasive cancers. The Italian randomised study NTCC showed a decrease in specificity, which was not observed in the other two RCTs available. In addition, the 2008 meta-analysis observed a reduction - even if minimal - in specificity just at the ASC-US cytological cut-off, but also a remarkable heterogeneity between studies. These results suggest that the effect of LBC on specificity is variable and plausibly related to the local style of cytology interpretation. There is evidence that LBC reduces the proportion of unsatisfactory slides, although the size of this effect varies remarkably. LBC WITH COMPUTER-ASSISTED INTERPRETATION: An Australian study, based on double testing, showed a statistically significant increase of the sensitivity for CIN2 or more of LBC with computer-assisted interpretation vs. conventional cytology with manual interpretation. However, an English RCT estimated that LBC with computer-assisted interpretation has a lower sensitivity than LBC with manual interpretation. COST AND ECONOMIC EVALUATION: In the current Italian situation the use of liquid-based cytology for primary screening is estimated to increase the costs of cytological screening. Liquid-based cytology needs shorter time for interpretation than conventional cytology. However, in the Italian situation, savings obtained from this time reduction and from the decreased number of repeats due to unsatisfactory slides are not currently sufficient to compensate the cost increase due to the prices currently applied by producers and to a possible greater number of colposcopies caused by LBC. In any case, at current prices, cost is estimated to increase even when assuming a referral rate to colposcopy with LBC similar or slightly lower than that with conventional cytology. For the costs of computer-assisted interpretation of liquid-based cytology, readers are referred to the relative HTA report (Epidemiol Prev 2012;36(5) Suppl 3:e1-43). ORGANISATIONAL AND ETHICAL ASPECTS: Ethical, legal and communication problems are judged to remain unchanged when compared to screening with conventional cytology. After having used the test for some time, interpreters prefer liquid-based to conventional cytology. Reduced time for interpretation makes the adoption of LBC a possible approach to deal with shortenings of cytology interpreters which is happening in Italy. However, alternative solutions, such as computer-assisted interpretation of cytology and the use of HPV as primary screening test, should be considered. Liquid-based cytology allows performing molecular tests, in particular the HPV test. This property allows triaging women with borderline or mild cytology by "reflex" molecular or immunocytochemical tests with no need to recall them. LBC sampling can be used also if HPV is applied as the primary screening test, allowing "reflex" triaging of HPV positive women by cytology with no need to recall them nor to take two samples, one for HPV testing and one for conventional cytology. This represents a remarkable advantage in terms of organization. However, costs are high because only 5-7% of women screened with this approach need interpretation of cytology. In addition, HPV testing with the Hybrid Capture assay on material preserved in LBC transport media needs a preliminary conversion phase, which limits the use of LBC for triaging HPV positive women. It is advisable that in the near future industry develops sampling/transport systems that allow performing both the HPV test and cytology or other validated triage tests without additional manipulations and at sustainable costs.

[Results and cost evaluation of triage with high risk HPV test in cervical cancer screening. A pilot study in Piedmont (North-West Italy)]

OBJECTIVE

causal relation between high risk Papilloma virus and cervical carcinoma is definitely ascertained. HPV test is suggested both as primary screening test and as triage test for selecting women who should undergo colposcopy examination. Evidence is clear for triage after ASC-US cytology. A recent study suggested the implementation after LSIL cytology in women 35 or older but the issue is controversial.We present a pilot study on the implementation of HPV test triage in the framework of cervical cancer screening. The study was conducted in respect to: participation, predictive value, and cost analysis, separately for ASC-US and LSIL cytology.

DESIGN

HPV test was offered to women with Pap test result ASC-US or LSIL (35 and over), as an add-on to the "Prevenzione serena Screening Program" protocol. All samples were analyzed in the same specialized laboratory. HPV positive women were invited to colposcopy, negative will be invited at the scheduled interval for negative screening tests.

SETTING AND PARTICIPANTS

Piedmont (NW Italy), LHAs of Novara and Verbano. In the 1-year study period 15,614 Pap tests were performed: 153 women were eligible for the triage.

MAIN OUTCOME MEASURES

Participation at HPV test, HPV test results, costs.

RESULTS

ninety two percent of women invited to HPV test actually participated: 66.9% of them were positive (52.8% after ASC-US and 82.8% after LSIL). Regarding colposcopy and histological results, CIN2+ were 9.4% of positive HPV tests in ASC-US group and 17.1% in LSIL group. Cost analysis showed limited differences between triage (offered after ASC-US and LSIL cytology) and traditional protocol. Triage is economically convenient when limited to women with ASC-US cytology.

CONCLUSION

the pilot study demonstrated the feasibility of adding a triage phase with HPV test in cervical cancer screening protocol. Additional cost is balanced by the saving due to the reduction in the number of colposcopy exams: the process is economically convenient when limited to women with ASC-US cytology. When extended to LSIL cytology the marginal cost increases because of the higher prevalence of HPV positive results and total cost of triage with HPV test is close to the cost of immediate colposcopy referral.

Misconceptions about routine colposcopy

Colposcopy is practised in two ways: (1) to assess women with abnormal screening findings and/or clinically suspicious cervix (called referral colposcopy), and (2) as part of a routine gynaecological examination (referred to as routine colposcopy). There are several misconceptions about routine colposcopy probably reflecting the lack of experience in using routine colposcopy. Misconceptions include: routine colposcopy is screening colposcopy, it is time-consuming, expensive, a waste of time, and the training and maintaining of colposcopic expertise is probably not sufficient in this setting. Routine colposcopy, however, is not a screening tool, it is not screening colposcopy, but capable of identifying cervical precursors and cancer, and thereby reducing the false rates of cervical cancer screening (mainly cytology). Unlike referral colposcopy, routine colposcopy is an inexpensive and rapid procedure conducted as a part of a pelvic examination and has no, or minimal, discomfort that certainly does not exceed that of smear taking, neither is it associated with any psychological burden. Routine colposcopy allows gynaecologists to be convincingly sure in their findings; ensure women having normal epithelium; evaluate abnormalities in details (without biopsy) and counsel patients immediately to alleviate the psychological effects and prepare them for a possible abnormal smear; as well as help make a diagnosis of obscure lesions.

Cost-effectiveness of high-risk human papillomavirus testing for cervical cancer screening in Québec, Canada

OBJECTIVES

Human papillomavirus (HPV) testing is not widely used for triage of equivocal Pap smears or primary screening in Québec, Canada. Our objective was to evaluate the cost-effectiveness of cervical cancer screening strategies utilizing HPV testing.

METHODS

We used a lifetime Markov model to estimate costs, quality of life, and survival associated with the following strategies: 1) cytology; 2) cytology with HPV testing to triage equivocal Pap smears; 3) HPV testing followed by colposcopy for HPV-positive women; 4) HPV testing with cytology to triage HPV-positive women; and 5) simultaneous HPV testing and cytology. Cytology was used in all strategies prior to age 30. Outcome measures included disease incidence, quality-adjusted life-years saved (QALYs), lifetime risk of cervical cancer, and incremental cost-effectiveness ratios.

RESULTS

All strategies incorporating HPV testing as a primary screening test were more effective and less expensive than annual cytology alone, while HPV testing to triage equivocal Pap smears annually was very cost-effective ($2,991 per QALY gained compared to annual cytology alone). When compared to cytology every three years, HPV-based strategies cost an additional $8,200 to $13,400 per QALY gained.

CONCLUSION

Strategies incorporating HPV testing are not only more effective than screening based on cytology alone but are also highly cost-effective. Provincial policy-makers should evaluate incorporating HPV-based strategies into current cervical cancer screening guidelines.

Cost-effectiveness of high-risk human papillomavirus testing for cervical cancer screening in Québec, Canada

OBJECTIVES

Human papillomavirus (HPV) testing is not widely used for triage of equivocal Pap smears or primary screening in Québec, Canada. Our objective was to evaluate the cost-effectiveness of cervical cancer screening strategies utilizing HPV testing.

METHODS

We used a lifetime Markov model to estimate costs, quality of life, and survival associated with the following strategies: 1) cytology; 2) cytology with HPV testing to triage equivocal Pap smears; 3) HPV testing followed by colposcopy for HPV-positive women; 4) HPV testing with cytology to triage HPV-positive women; and 5) simultaneous HPV testing and cytology. Cytology was used in all strategies prior to age 30. Outcome measures included disease incidence, quality-adjusted life-years saved (QALYs), lifetime risk of cervical cancer, and incremental cost-effectiveness ratios.

RESULTS

All strategies incorporating HPV testing as a primary screening test were more effective and less expensive than annual cytology alone, while HPV testing to triage equivocal Pap smears annually was very cost-effective ($2,991 per QALY gained compared to annual cytology alone). When compared to cytology every three years, HPV-based strategies cost an additional $8,200 to $13,400 per QALY gained.

CONCLUSION

Strategies incorporating HPV testing are not only more effective than screening based on cytology alone but are also highly cost-effective. Provincial policy-makers should evaluate incorporating HPV-based strategies into current cervical cancer screening guidelines.

Prevention of cervical cancer with screening programme in Branicevo District and cost-effectiveness analysis adjusted to the territory of the Republic of Serbia

PURPOSE

To establish the so-called positive screening instead of the current opportunistic screening for cervical cancer.

PATIENTS AND METHODS

The program of positive screening covered all female persons aged 30-49 years living in the Branicevo District. All women were sent an invitation to participate in the screening and those who responded had Papanicolaou smear test done on the results of which further diagnostic procedures would be determined.

RESULTS

The invitation to examination was responded by 11,200 (48.70%) out of 23,000 women invited. The costs of organized screening per capita amounted to Republic of Serbia dinar (RSD) 380.00 (EUR 4.75). 954 patients in total underwent colposcopy and conization, resulting in RSD total costs of 11,926,373.70 (149,079.00 EUR). Assuming the same incidence rate among the population that did not respond to the invitation, the number of women that would have such an intervention would be increased by 893.

CONCLUSION

One-year screening programme is more effective than 3-year programme (180 lives saved compared to 113), but more expensive. This is our cost-effectiveness analysis (CEA) relevant opinion, but not for adoption in practice.

Economic evaluation of human papillomavirus vaccination in the United Kingdom

OBJECTIVE

To assess the cost effectiveness of routine vaccination of 12 year old schoolgirls against human papillomavirus infection in the United Kingdom.

DESIGN

Economic evaluation.

SETTING

UK. Population Schoolgirls aged 12 or older.

MAIN OUTCOME MEASURES

Costs, quality adjusted life years (QALYs), and incremental cost effectiveness ratios for a range of vaccination options.

RESULTS

Vaccinating 12 year old schoolgirls with a quadrivalent vaccine at 80% coverage is likely to be cost effective at a willingness to pay threshold of pound30,000 (euro37,700; $59,163) per QALY gained, if the average duration of protection from the vaccine is more than 10 years. Implementing a catch-up campaign of girls up to age 18 is likely to be cost effective. Vaccination of boys is unlikely to be cost effective. A bivalent vaccine with the same efficacy against human papillomavirus types 16 and 18 costing pound13- pound21 less per dose (depending on the duration of vaccine protection) may be as cost effective as the quadrivalent vaccine although less effective as it does not prevent anogenital warts.

CONCLUSIONS

Routine vaccination of 12 year old schoolgirls combined with an initial catch-up campaign up to age 18 is likely to be cost effective in the UK. The results are robust to uncertainty in many parameters and processes. A key influential variable is the duration of vaccine protection.

Comparison of health care costs for open Burch colposuspension, laparoscopic colposuspension and tension-free vaginal tape in the treatment of female urinary incontinence

AIMS

To compare direct health care costs of treatment for stress urinary incontinence in Sweden with four different procedures: (i) open Burch colposuspension (OBC); (ii) laparoscopic colposuspension with sutures (LCS); (iii) laparoscopic colposuspension with mesh and staples (LCM), and (iv) Tension-free Vaginal Tape (TVT).

MATERIAL AND METHODS

A model was constructed representing a hospital with standardized surgical equipment, staff and average unit costs in 2003 Euros. The time used for anesthesia and surgery was calculated. Clinical data was collected from three different sources, a multicenter, randomized, prospective study comparing OBC with LCM with 1 year follow-up, a three-armed, prospective study where women were randomized to either OBC, LCM, or LCS with 1 year follow-up and a descriptive study reporting results of TVT with 5 year follow-up. Data collected from the studies and hospital cost data were put into the model to create the different cost elements.

RESULTS

The total cost per individual, showed a lower cost for TVT compared to the other alternatives. The direct costs for a TVT, euro1,366 were only 56% of the costs for an OBC, euro2,431 (P < 0.001) and 59% of the costs for a LCS, euro2,310 (P < 0.001).

CONCLUSIONS

When using a model and comparing health care costs for surgical treatment of female stress urinary incontinence in Sweden, the TVT procedure generated a lower direct cost than both open and laparoscopic colposuspension.

Resource use and cost analysis of managing abnormal Pap smears: a retrospective study in five countries

OBJECTIVE

To evaluate and compare treatment patterns and related resource use and costs in women with abnormal cervical smears in five countries.

METHODS

Data from patient charts were collected for a minimum of 24 months, starting from the first recorded abnormal cervical smear. Costs, from the public health perspective, were calculated based on country-specific unit costs per procedure and expressed in euros.

RESULTS

A total of 3,380 patient charts were reviewed. Subjects with suspected or detectable cervical cancer were excluded from the analysis (n = 380). A significant age difference of 1.8-2.6 years was observed between the lowest and highest severity of cytological and histological types (p < 0.05). The correlation between cytology and histology results was weak overall (35.8%) and varied widely between countries (ranging from 48% for Australia to 29.7% for the UK). As expected, countries with an organised screening programme (UK, Australia) diagnosed and initiated treatment at earlier disease stages. These countries demonstrated a much lower and narrower cost band for more advanced histological types. In contrast, other countries (Germany, Italy, Spain) followed an opportunistic screening programme in which advanced disease was diagnosed and treated at much higher and more varied costs. Histological, not cytological, results were the main factor underlying the cost differences per type.

CONCLUSION

Costs and treatment patterns in women with abnormal cervical smears differ among countries due to the type of screening programme (organised versus opportunistic) and, consequently, the histological type. These results need to be taken into consideration when designing cost-effectiveness studies which include cervical cancer screening data.

Cost-effectiveness of human papillomavirus testing after treatment for cervical intraepithelial neoplasia

OBJECTIVE

To compare current cytological follow up of women treated for high-grade cervical intraepithelial neoplasia (CIN) with follow up by high-risk human papillomavirus (HPV) testing together with cytology.

DESIGN

A cost-effectiveness modelling study.

SETTING

Gynaecology clinics in the Netherlands.

POPULATION

Women treated for high-grade CIN.

METHODS

A Markov model was developed to compare six follow-up strategies with HPV testing with current cytological follow up at 6, 12, and 24 months. Model parameter estimation was based on three Dutch follow-up studies and a Dutch population-based screening cohort.

MAIN OUTCOME MEASURES

The number of CIN2/3 cases missed after 5 years follow up, the number of diagnostic procedures, and costs involved.

RESULTS

Strategies with adjunct HPV testing were more effective than current follow up (reduction in missed CIN2/3 cases 32-77%, corresponding to a number needed to treat of 192-455) and less inconvenient (reduction in repeat smears 28-65%). A particularly attractive strategy was HPV testing alone at 6 months and both HPV and cytological testing at 24 months after treatment. This strategy yielded a high detection rate of post-treatment CIN, did not lead to an increase in colposcopy rate, and was 49 Euro per woman cheaper than the current strategy.

CONCLUSIONS

Our model supports the use of high-risk HPV testing for monitoring women treated for high-grade CIN.

Management of women with abnormal cervical cytology: treatment patterns and associated costs in England and Wales

OBJECTIVE

To evaluate the time from abnormal Papanicolaou smear detected during routine screening to the initiation of investigation and treatment of subjects and to evaluate its related costs.

DESIGN

Retrospective study of clinical records from women with abnormal cervical smears.

SETTING

Six specialist gynaecology/colposcopy clinics in England and Wales.

SAMPLE

Six hundred subsequent women (100 per clinic) with first abnormal cervical smear result at the specialist gynaecology/colposcopy clinic.

METHODS

Details of all clinic visits, tests and procedures during 24 months starting from the first abnormal cervical smear were collected from the year 2002.

MAIN OUTCOME MEASURES

Patterns of management after initial abnormal smear, time to start the investigation and/or treatment expressed in days/months and treatment costs by cytology and histology grades.

RESULTS

Significant age differences were observed between women with early grades of precancer lesions (32 years) and cancer (49 years) (P < 0.05). Subgroup analysis of women younger than 26 years indicates a representation of this age group in all the histology grades including cancer. Median time to initiate the investigation and/or treatment was 50 days. In contrast, for 5% of women, delay in management lasted for >1 year. Colposcopy and repeated cervical smears were the most frequent systematic investigations performed, while the large loop excision of the transformation zone procedure was the principal therapeutic procedure. Analysis of average treatment costs by referral cytology showed small differences between the three grades of cytological diagnoses (mild dyskaryosis, 408.96 British pound; moderate dyskaryosis, 442.55 British pound and severe dyskaryosis, 493.74 British pound). Analysis by histology grade showed that the cost for women with a negative result (263.34 British pound) differed markedly from that for women with cervical intraepithelial neoplasia (CIN) (CIN1, 419.39 British pound; CIN2, 572.29 British pound; and CIN3, 584.92 British pound).

CONCLUSION

Time to investigation could be improved for a subgroup of women. Costs associated with investigation and treatment of women with abnormal cervical smears differ significantly between analyses by cytology and histology grade. This needs to be borne in mind when designing cost-effectiveness studies of cervical screening.