Potential health and economic impact of adding a human papillomavirus vaccine to screening programs

CONTEXT

Recently published results suggest that effective vaccines against cervical cancer-associated human papillomavirus (HPV) may become available within the next decade.

OBJECTIVE

To examine the potential health and economic effects of an HPV vaccine in a setting of existing screening.

DESIGN, SETTING, AND POPULATION

A Markov model was used to estimate the lifetime (age 12-85 years) costs and life expectancy of a hypothetical cohort of women screened for cervical cancer in the United States. Three strategies were compared: (1) vaccination only; (2) conventional cytological screening only; and (3) vaccination followed by screening. Two of the strategies incorporated a vaccine targeted against a defined proportion of high-risk (oncogenic) HPV types. Screening intervals of 1, 2, 3, and 5 years and starting ages for screening of 18, 22, 24, 26, and 30 years were chosen for 2 of the strategies (conventional cytological screening only and vaccination followed by screening).

MAIN OUTCOME MEASURES

Incremental cost per life-year gained.

RESULTS

Vaccination only or adding vaccination to screening conducted every 3 and 5 years was not cost-effective. However, at more frequent screening intervals, strategies combining vaccination and screening were preferred. Vaccination plus biennial screening delayed until age 24 years had the most attractive cost-effectiveness ratio (44 889 dollars) compared with screening only beginning at age 18 years and conducted every 3 years. However, the strategy of vaccination with annual screening beginning at age 18 years had the largest overall reduction in cancer incidence and mortality at a cost of 236 250 dollars per life-year gained compared with vaccination and annual screening beginning at age 22 years. The cost-effectiveness of vaccination plus delayed screening was highly sensitive to age of vaccination, duration of vaccine efficacy, and cost of vaccination.

CONCLUSIONS

Vaccination for HPV in combination with screening can be a cost-effective health intervention, but it depends on maintaining effectiveness during the ages of peak oncogenic HPV incidence. Identifying the optimal age for vaccination should be a top research priority.

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.

Cost-effectiveness of alternative triage strategies for atypical squamous cells of undetermined significance

CONTEXT

Every year approximately 2 million US women are diagnosed as having a cervical cytological result of atypical squamous cells of undetermined significance (ASC-US).

OBJECTIVE

To determine the most efficient and cost-effective management strategy for women in the United States diagnosed as having ASC-US.

DESIGN AND SETTING

Cost-effectiveness analysis of data from clinical trials, prospective studies, and other published literature. A computer-based model was used to compare 4 management strategies for a cytological result of ASC-US: immediate colposcopy; human papillomavirus (HPV) triage, which includes colposcopy if high-risk HPV types are detected; repeat cytology, which includes follow-up cytology at 6 and 12 months and referral for colposcopy if a repeat abnormal result occurs; and reclassifying ASC-US as normal in which a cytological result of ASC-US is ignored. Reflex HPV DNA testing uses either residual liquid-based cytological specimens or samples co-collected at the time of the initial screening for conventional cytology. Another method, referred to as the 2-visit HPV DNA triage, requires a woman with an ASC-US result to return within 1 month to provide another speciman sample.

MAIN OUTCOME MEASURES

Years of life saved (YLS), quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios.

RESULTS

The least costly strategy for biennial screening was to reclassify ASC-US as normal, resulting in a reduction in total cancer incidence of 75% for conventional cytology and 84% for liquid-based cytology compared with no screening. The next least costly strategy was HPV DNA testing resulting in a reduction in total cancer incidence of 86% for conventional cytology and 90% for liquid-based cytology, followed by immediate colposcopy with a reduction of 87% and 91%, respectively. Compared with reflex HPV DNA testing, a strategy of repeat cervical cytology or delayed HPV testing costs more but is less effective. When all strategies were compared simultaneously, varying frequency and type of cytological test, biennial (vs every 3 years) liquid-based cytology with reflex HPV testing had a cost of $174 200 per YLS. In a similar comparison, liquid-based cytology with reflex HPV testing conducted every 3 years (vs every 5 years) had a cost of $59 600 per YLS and was more effective and less costly than a strategy of conventional cytology incorporating repeat cytology or immediate colposcopy conducted biennially.

CONCLUSION

Reflex HPV DNA testing provides the same or greater life expectancy benefits and is more cost-effective than other management strategies for women diagnosed as having ASC-US.

The costs, clinical benefits, and cost-effectiveness of screening for cervical cancer in HIV-infected women

BACKGROUND

Women with HIV infection have a higher risk for cervical squamous intraepithelial lesions than do women without HIV infection, and the optimal regimen for cervical cancer screening in these women is uncertain.

OBJECTIVE

To assess the net health consequences, costs, and cost-effectiveness of various screening strategies for cervical neoplasia and cancer in HIV-infected women.

DESIGN

A cost-effectiveness analysis from a societal perspective done by using a state-transition Markov model. Values for incidence, progression, and regression of cervical neoplasia; efficacy of screening and treatment; progression of HIV disease; mortality from HIV infection and cancer; quality of life; and costs were obtained from the literature.

SETTING

Simulated clinical practice in the United States.

PATIENTS

HIV-infected women representative of the U.S. population.

INTERVENTION

Six main screening strategies--no screening, annual Papanicolaou smears, annual Papanicolaou smears after two negative smears obtained 6 months apart (recommended by the Centers for Disease Control and Prevention), semiannual Papanicolaou smears, annual colposcopy, and semiannual colposcopy--were considered.

MEASUREMENTS

Quality-adjusted life-years (QALYs), lifetime costs, and incremental cost-effectiveness.

RESULTS

Annual Papanicolaou smear screening resulted in a 2.1-month gain in quality-adjusted life expectancy for an incremental cost of $12,800 per QALY saved. Annual Papanicolaou smear screening after two negative smears obtained 6 months apart provided an additional 0.04 QALYs at a cost of $14,800 per QALY saved. Semiannual Papanicolaou smear screening provided a further 0.17 QALYs at a cost of $27,600 per QALY saved. Annual colposcopy cost more but provided no additional benefit compared with that given by semiannual Papanicolaou smear screening, and semiannual colposcopy exceeded $375,000 per QALY saved. Results were most sensitive to the rate of progression of neoplasia to invasive cancer.

CONCLUSIONS

In HIV-infected women, cervical cancer screening with annual Papanicolaou smears after two negative smears obtained 6 months apart offers quality-adjusted life expectancy benefits at a cost comparable to that of other clinical preventive interventions.

Cost-Effectiveness Analysis Based on the Atypical Squamous Cells of Undetermined Significance/Low-Grade Squamous Intraepithelial Lesion Triage Study (ALTS)

BACKGROUND

The ALTS (atypical squamous cells of undetermined significance [ASCUS] and low-grade squamous intraepithelial lesion [LSIL] Triage Study) suggests that, for women diagnosed with ASCUS, human papillomavirus (HPV) DNA testing followed by referral to colposcopy of only those women with oncogenic HPV (i.e., HPV DNA testing) is as effective at detecting cervical intraepithelial neoplasia (CIN) 3 or cancer (CIN3+) as referring all women with ASCUS for immediate colposcopy. We conducted a cost-effectiveness analysis of the ALTS trial to determine whether HPV DNA testing is a cost-effective alternative to immediate colposcopy or conservative management with up to three cytology examinations.

METHODS

Data from the ALTS trial were used in conjunction with medical care costs in a short-term decision model. The model compared the incremental costs per case of CIN3+ detected as measured by the incremental cost-effectiveness ratio (ICER) for the following management strategies for women with ASCUS: immediate colposcopy, HPV DNA testing, and conservative management with up to three cytology examinations.

RESULTS

The least costly and least sensitive strategy was conservative management with one repeat cytology examination using a threshold of high-grade squamous intraepithelial lesion (HSIL) for referral to colposcopy. Compared with this strategy, triage to colposcopy based on a positive HPV DNA test result had an ICER of 3517 dollars per case of CIN3+ detected. Immediate colposcopy and conservative management with up to three repeat cytology visits detected fewer cases of CIN3+ and were more costly than HPV DNA testing. Immediate colposcopy became cost-effective at 20,370 dollars compared with HPV DNA testing only if colposcopy and biopsy were assumed to be 100% sensitive.

CONCLUSIONS

HPV DNA testing is an economically viable strategy for triage of ASCUS cytology. The less than perfect sensitivity of colposcopy and biopsy needs to be accounted for in future clinical guidelines and policy analyses.

Systematic review of the clinical effectiveness and cost-effectiveness of tension-free vaginal tape for treatment of urinary stress incontinence

OBJECTIVES

To evaluate the effectiveness and cost-effectiveness of tension-free vaginal tape (TVT) in comparison with the standard surgical interventions currently used.

DATA SOURCES

Literature searches were carried out on electronic databases and websites for data covering the period 1966--2002. Other sources included references lists of relevant articles; selected experts in the field; abstracts of a limited number of conference proceedings titles; and the Internet.

REVIEW METHODS

A systematic review of studies including comparisons of TVT with any of the comparators was conducted. Alternative treatments considered were abdominal retropubic colposuspension (including both open and laparoscopic colposuspension), traditional suburethral sling procedures and injectable agents (periurethral bulking agents). The identified studies were critically appraised and their results summarised. A Markov model comparing TVT with the comparators was developed using the results of the review of effectiveness and data on resource use and costs from previously conducted studies. The Markov model was used to estimate costs and quality-adjusted life-years for up to 10 years following surgery and it incorporated a probabilistic analysis and also sensitivity analysis around key assumptions of the model.

RESULTS

Based on limited data from direct comparisons with TVT and from systematic reviews, laparoscopic colposuspension and traditional slings have broadly similar cure rates to TVT and open colposuspension, whereas injectable agents appear to have lower cure rates. TVT is less invasive than colposuspension and traditional sling procedures, and is also usually performed under regional or local anaesthesia. The principal operative complication is bladder perforation. There are currently no randomised controlled trial (RCT) data beyond 2 years post-surgery, and long-term effects are therefore currently not known reliably. TVT was more likely to be considered cost-effective compared with the other surgical procedures. Increasing the absolute probability of cure following TVT reduced the likelihood that TVT would be considered cost-effective.

CONCLUSIONS

The long-term performance of TVT in terms of both continence and unanticipated adverse effects is not known reliably at the moment. Despite relatively few robust comparative data, it appears that in the short to medium term TVT's effectiveness approaches that of alternative procedures currently available, and is of lower cost. As TVT is a less invasive procedure, it is possible that some women who would currently be managed non-surgically will be considered eligible for TVT. Increased adoption of TVT will require additional surgeons proficient in the technique. It is likely that some of the higher rates of complications, e.g. bladder perforation, reported for TVT are associated with a 'learning curve'. Appropriate training will therefore be needed for surgeons new to the operation, in respect of both the technical aspects of the procedure and the choice of women suitable for the operation. Further research suggestions include unbiased assessments of longer term performance from follow-up of controlled trials or population-based registries; more data from methodologically sound RCTs using standard outcome measures; a surveillance system to detect longer term complications, if any, associated with the use of tape; and rigorous evaluation before extending the use of TVT to women who are currently managed non-surgically.

Costs of detection and treatment of cervical cancer, cervical dysplasia and genital warts in the UK

OBJECTIVE

Infection with human Papillomavirus (HPV) is a necessary cause of cervical cancer (CC) and genital warts (GW). HPV vaccination studies have shown excellent efficacy against HPV-induced lesions. To assess the cost-effectiveness of a HPV quadrivalent (6, 11, 16 and 18) vaccine it is necessary to estimate the costs of managing current levels of HPV-related diseases. This study estimates the annual 2003 expenditures in the UK for CC screening, follow-up of abnormal findings, CC treatment and GW treatment.

DESIGN AND METHODS

CC screening programmes provided the annual number of screening tests, their results and use of colposcopy procedures in women with abnormal findings. Incident CC cases and hospital admissions for CC in 2003 were used to estimate CC costs. Health Protection Agency data provided the annual number of new, recurrent or persistent cases of GW treated in Genitourinary Medicine (GUM) clinics. Treatment patterns for managing GW were estimated by GUM clinicians. The annual physician visits, tests, procedures, hospital admissions and topical genital wart medications were costed to estimate the total annual expenditures for CC and GW.

RESULTS

There were 4.8 million screening tests and 230 303 colposcopy procedures. Estimated costs for screening, management of abnormal and inadequate findings were 138.5 million pounds sterlings. Annual management costs for incident and prevalent CC cases were 46.8 million pounds sterlings. There were an estimated 76 457 incident and 55 657 recurrent/persistent GW cases in 2003. The costs for managing these cases were approximately 22.4 million pounds sterlings. Total annual estimated costs for CC screening, management and treatment of GW were 208 million pounds sterlings and ranged from 186.9 pounds sterlings to 214 million pounds sterlings based upon sensitivity analyses.

CONCLUSIONS

The direct medical costs for the NHS associated with detection and management of CC, cervical dysplasia and treatment of GW in the UK are substantial. These medical costs are invaluable for future cost-effectiveness analyses of a quadrivalent HPV vaccine programme.

Decision analysis for best management of mildly dyskaryotic smear

Should a woman with a mildly dyskaryotic cervical smear be referred for colposcopy or should the smear be repeated? One way to answer this question is to use decision analysis and compare the expected mortality and cost of each policy. Data for each component of the question were obtained from published work worldwide and were supplemented with an audit of mildly dyskaryotic smears in West Yorkshire, UK. 2 out of 1000 women with an initial mildly dyskaryotic smear will develop cancer if a conservative repeat smear policy is adopted in association with five-yearly cervical screening. This number can be reduced to 1.6 per 1000 if cervical screening is offered every three years. A policy of immediate referral for colposcopy is also associated with a subsequent cancer rate of 1.6 per 1000. Therefore, repeating the smear is almost as effective as an immediate referral to a colposcopy unit. Even if a five-yearly cervical screening programme is adopted, 2500 women with a mildly dyskaryotic smear will need to be referred for immediate colposcopy to save 1 additional cancer. A conservative policy is not financially cheaper: an average of six additional smears is required to save each colposcopy referral. Sensitivity analysis shows that the excess cost of the conservative policy increases exponentially as the risk of a subsequent cytological abnormality exceeds 60%. Local cytopathology laboratories should audit their recurrent dyskaryosis rate associated with borderline, mild, and moderate dyskaryosis before accepting the U-turn in the national recommendations.

Human papillomavirus testing as triage for atypical squamous cells of undetermined significance and low-grade squamous intraepithelial lesions: sensitivity, specificity, and cost-effectiveness

OBJECTIVE

Our purpose was to evaluate the cost-effectiveness of the use of a Food and Drug Administration-approved human papillomavirus test in triaging patients with Papanicolaou smears showing atypical squamous cells of undetermined significance or a low-grade squamous intraepithelial lesion for colposcopy compared with an algorithm that used cytologic follow-up.

STUDY DESIGN

Four hundred sixty-two women referred to our Colposcopy Clinic with a Papanicolaou smear report of atypical squamous cells of undetermined significance or a low-grade squamous intraepithelial lesion underwent repeat Papanicolaou smear, cervical colposcopy, directed cervical biopsy, and endocervical curettage. In addition, human papillomavirus testing by the Food and Drug Administration-approved HPV Profile (Digene Diagnostics, Silver Spring, Md.) test was done. A comparison of sensitivity, specificity, and cost-effectiveness of an algorithm determining the need for colposcopy on the basis of repeat cytologic testing versus an algorithm that incorporated repeat cytologic testing and human papillomavirus screening was done. The cost-effectiveness of both of these triage algorithms was also compared.

RESULTS

As expected, high-risk human papillomavirus deoxyribonucleic acid was detected with greater frequency in relation to increasing severity of cervical intraepithelial neoplasia. In 268 women, the follow-up smear obtained in our clinic was reported as negative. High-risk human papillomavirus types were found in 23.5% of these women. In the human papillomavirus-negative women, 5.9% had grade 2 or 3 cervical intraepithelial neoplasia confirmed on cervical biopsy. In comparison, 20.6% of those with a positive result of the human papillomavirus test had grade 2 or 3 cervical intraepithelial neoplasia on biopsy (p < 0.001). Despite this difference, the sensitivity of a positive result of a high-risk human papillomavirus test in predicting the presence of grade 2 or 3 cervical intraepithelial neoplasia was only 52%. Among the women for whom a follow-up clinic Papanicolaou smear was reported as showing atypical squamous cells of undetermined significance or a low-grade squamous intraepithelial lesion, there was no difference in the frequency of biopsy-proved grade 2 or 3 cervical intraepithelial neoplasia between those women with a positive human papillomavirus test result and those with a negative test result. Colposcopy would have been recommended for 194 women because of a repeat clinic smear revealing atypical squamous cells of undetermined significance, a low-grade squamous intraepithelial lesion, or a high-grade squamous intraepithelial lesion, and in 21.6% of these grade 2 or 3 cervical intraepithelial neoplasia was shown on biopsy (sensitivity 63%, specificity 62%). Colposcopy would have been recommended for 180 women because high-risk human papillomavirus or a high-grade squamous intraepithelial lesion was detected at the clinic visit, and in 25% of this group grade 2 or 3 cervical intraepithelial neoplasia was shown on biopsy (sensitivity 67%, specificity 66%). Sensitivity and specificity were virtually identical for the two algorithms, but the cost of human papillomavirus testing was nearly double that of triage based on repeat cytologic testing alone ($692 vs $1246 per case).

CONCLUSION

The Food and Drug Administration-approved HPV Profile test is not a cost-effective triage for patients referred with Papanicolaou smears reported as showing atypical squamous cells of undetermined significance or low-grade squamous lesions.

Cost-effectiveness analysis of diagnosis and management of cervical squamous intraepithelial lesions

OBJECTIVE

To compare five strategies for the diagnosis and treatment of cervical squamous intraepithelial lesions (SILs), including those that incorporate colposcopy and a new technology, fluorescence spectroscopy.

METHODS

On the basis of a health care perspective, we performed a cost-effectiveness analysis using a decision-analytic model for the diagnosis and management of SILs. We compared the five strategies based on the expected costs and number of cases that were treated appropriately, missed, treated inappropriately, and appropriately not treated in a hypothetical cohort of 100 patients referred after an abnormal Papanicolaou smear. Data on prevalence and operating characteristics were derived from the medical literature. Costs were adjusted from hospital charge data.

RESULTS

A see-and-treat strategy based on fluorescence spectroscopy was the least expensive but least effective strategy, costing $160,479 to detect 31.55 cases of cervical precancer accurately in 100 patients. The most expensive strategy was colposcopically directed biopsy, at $311,808 to find 45.78 cases; however, when both tests were used in a see-and-treat modality, slightly more cases were found (46.05) at a lower cost ($285,133). Other strategies were dominated in the base case. The incremental cost-effectiveness of the joint strategy compared with the spectroscopy-only strategy was $8596 per case of cervical precancer detected. Sensitivity analysis showed that the analysis was sensitive to the cost of the new technology of fluorescence spectroscopy.

CONCLUSION

Fluorescence spectroscopy should be considered an important innovation in the diagnosis of SILs as demonstrated by its efficacy and economic advantages.

Screening for cervical cancer in India: How much will it cost? A trial based analysis of the cost per case detected

The cost and cost effectiveness of screening previously unscreened women by VIA, cytology or HPV testing was investigated within a large cluster randomised trial involving 131,178 women in rural India. All resources involved in implementation, training, management, recruitment, screening and diagnosis were identified and costed. We estimated the total costs and detection rates for each cluster and used these data to calculate an average cluster cost and detection rate for each screening approach. These estimates were combined to estimate a cost per case of cervical intraepithelial neoplasia grade 2/3 or invasive cancer (CIN 2/3+) detected. The average total costs per 1,000 women eligible for screening were US dollar 3,917, US dollar 6,609 and US dollar 11,779 with VIA, cytology and HPV respectively. The cost of detecting a case of CIN2/3+ using VIA was dollar 522 (95% CI dollar 429- dollar 652). Our results suggest that more CIN2/3+ cases would be detected in the same population if cytology were used instead of VIA and each additional case would cost US dollar 1065 (95% CI dollar 713- dollar2175). Delivering cervical cancer screening is potentially expensive in a low-income country although costs might be lower outside a trial setting. We found screening with VIA to be the least expensive option, but it also detected fewer cases of CIN2/3+ than other methods; its long-term cost-effectiveness will depend on the long-term benefits of early detection. Cytology was more effective at detecting cases than VIA but was also more expensive. Our findings indicate that HPV may not be a cost effective screening strategy in India at current consumable prices.

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.

Prediction of cervical intraepithelial neoplasia grade 2-3 using risk assessment and human papillomavirus testing in women with atypia on papanicolaou smears

OBJECTIVE

To determine whether human papillomavirus (HPV) DNA testing and risk assessment can predict cervical intraepithelial neoplasia (CIN) 2-3 on biopsies in women with atypia on Papanicolaou smears.

METHODS

One hundred ninety-five consenting women were referred for colposcopy because of atypia on Papanicolaou smears between September 1997 and April 1999. Before colposcopy, women completed risk assessments and had cervical swabs collected for HPV testing using the Hybrid Capture-II assay (Digene Corporation, Silver Spring, MD). Associations of demographic and clinical variables were assessed by chi(2) analysis, and logistic regression was used to assess factors associated with CIN 2-3. The cost-effectiveness of routine colposcopy versus reflex HPV testing by either conventional or liquid-based Papanicolaou smear media was compared.

RESULTS

Cervical intraepithelial neoplasia was diagnosed in 70 of 195 women (35.9%), 55 (28.2%) with CIN 1 and 15 (7.7%) with CIN 2-3. High-risk HPV types were detected in 31.3% of all subjects, 36.4% of those with CIN 1, and 93.3% of those with CIN 2-3. By logistic regression, CIN 2-3 was associated only with detection of high-risk HPV (odds ratio 110.08, 95% confidence interval 8.35, 999. 00). The sensitivity of high-risk HPV for detecting CIN 2-3 was 93. 3%, specificity 73.9%, positive predictive value 23.0%, and negative predictive value 99.3%. The cost of reflex HPV testing using conventional smear or liquid-based media was less than routine colposcopy ($4809 and $4308, respectively, versus $4875 per case detected).

CONCLUSIONS

Triage based on HPV testing would result in referral of approximately 31% of patients to colposcopy and appears to be a sensitive and cost-effective alternative to colposcopy.

Role of P16(INK4a) expression in identifying CIN2 or more severe lesions among HPV-positive patients referred for colposcopy after abnormal cytology

BACKGROUND

p16 is strongly overexpressed in dysplastic cervical cells because of the transforming activity of the E7 oncogene of all high-risk human papillomavirus (HR-HPV) types and may be easily revealed by immunochemistry: p16 may, therefore, be considered a surrogate marker for the activated oncogene expression of HR-HPV in dysplastic cervical cells.

METHODS

HPV and p16(INK4a) testing were performed in a consecutive series of 283 patients with abnormal cytology referred to colposcopy assessment or follow-up. Triage of patients to colposcopy by HPV or HPV and p16 testing was simulated, and the relative sensitivity, specificity, and positive predictive value (PPV) of HPV and p16 testing for > CIN2 lesions was determined as well as the cost balance of the two triage types.

RESULTS

Compared to current protocol, triage by HPV testing reduced the number of colposcopies by 44.2%, but also reduced the > CIN2 detection rate by 10.7%, and was associated with a cost of euro 54.16 per assessed woman and of euro 613.20 per > CIN2 detected. Compared with current protocol, triage by HPV and p16 testing combined reduced the number of colposcopies by 73.1%, but reduced > CIN2 detection rate by 21.5%, and was associated with a cost of euro 54.73 per woman assessed and of euro 704.09 per > CIN2 detected.

CONCLUSIONS

Triage by HPV and p16 improves considerably the PPV of diagnostic assessment, but decreases > CIN2 detection rate, and is associated with substantially higher costs. Further decrease of molecular immunochemistry testing due to technological progress may allow HPV and p16 testing to become a cost effective procedure in the future.

Laparoscopic colposuspension and tension-free vaginal tape: a systematic review

BACKGROUND

Advances in surgical techniques have led to the availability of a number of minimal-access procedures to treat urodynamic stress incontinence (USI). These procedures have been individually compared with the 'gold standard' open Burch colposuspension; however, it now seems appropriate to compare like with like and compare these minimal-access techniques with each other.

OBJECTIVES

To determine the effectiveness of laparoscopic colposuspension with tension-free vaginal tape (TVT) for the treatment of USI.

SEARCH STRATEGY

Randomised trials in woman with USI, which compared laparoscopic colposuspension with TVT in the arms of the trial, were identified from the Cochrane Incontinence Review Group's Specialised Register of Controlled Trials.

SELECTION CRITERIA

The trials were evaluated for methodological quality and appropriateness for inclusion by the reviewers using the Incontinence Group's assessment criteria.

DATA COLLECTION AND ANALYSIS

The data were extracted independently, and when appropriate, meta-analysis was undertaken to calculate pooled estimates and their confidence intervals (CI). The main outcomes measured were: subjective cure, objective cure, quality of life (QoL) measurements, surgical outcomes and health economic measures.

MAIN RESULTS

Seven trials compare laparoscopic colposuspension (n= 264) with TVT (n= 290). There was no statistically significant difference in the reported subjective cure rate between laparoscopic colposuspension and TVT within 18 months (relative risk [RR] 1.12, 95% CI 0.98-1.29). However, within the same time period, the overall objective cure rate was statistically significantly higher for TVT (RR 1.16, 95% CI 1.07-1.25). There were no significant differences between the two procedures with regards to perioperative complication, de novo detrusor overactivity, voiding dysfunction, procedural costs and QoL scores. However, TVT procedure is quicker to perform and has a shorter hospital stay. CONCLUSIONS The evidence so far appears to be in favour of the TVT as the minimal-access technique of choice for USI in comparison with laparosopic colposuspension; however, long-tem data are needed. Further well-designed trials with standardized outcomes are required to draw accurate conclusions from this comparison.

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.

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.

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.

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.

Immediate colposcopy or cytological surveillance for women with mild dyskaryosis: a cost effectiveness analysis

BACKGROUND

The aim of the study was to compare the cost effectiveness of immediate diagnosis and treatment of mild dyskaryosis compared with the usual policy of cytological surveillance.

METHODS

A cost effectiveness analysis was carried out alongside a randomized clinical trial.

RESULTS

Immediate diagnosis and treatment increased total costs by 50 per cent from 54.42 pounds per treated woman [95 per cent confidence interval (CI) 48.85 pounds-59.98 pounds] in the surveillance group to 82.02 pounds per woman in the immediate diagnosis and treatment group with an incremental cost of 27.60 pounds (95 per cent CI 22.04 pounds-33.17 pounds). However, the number of cases of CIN III detected increased by 69 per cent for the policy of immediate diagnosis and treatment. This led to an average cost effectiveness ration of 180.18 pounds for the immediate diagnosis and treatment group and 199.94 pounds per case of CIN III detected for the surveillance group, with a marginal cost effectiveness ratio of 148.22 pounds (95 per cent CI 94.01 pounds-309.33 pounds) for the immediate diagnosis and treatment group.

CONCLUSION

Immediate diagnosis and treatment increases the total cost of managing mildly dyskaryotic smears but this increased cost is offset by a sharp increase in the number of cases of CIN III detected.

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.

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.

A cost-effectiveness analysis of tension-free vaginal tape versus laparoscopic mesh colposuspension for primary female stress incontinence

BACKGROUND

Evaluation of cost-effectiveness of new surgical techniques is important. As the data on incontinence procedures are scarce, we evaluated the cost-effectiveness of tension-free vaginal tape procedure and laparoscopic mesh colposuspension as a primary surgical treatment for female stress urinary incontinence.

METHODS

In four university teaching hospitals and two central hospitals 128 stress incontinent women were randomized to tension-free vaginal tape procedure (n=70) or laparoscopic mesh colposuspension (n=51) in order to investigate the clinical performance of these two procedures. Primary objective clinical outcome measures were: stress test and 48-h pad test. Secondary subjective outcome measures were health-related quality of life measured in terms of visual analogue scale and Urinary Incontinence Severity Score. Alongside the clinical trial, a cost-effectiveness analysis for the main outcome measures was performed.

RESULTS

The changes in the 48-h pad test result did not reach statistical significance (p=0.105). When the visual analogue scale or Urinary Incontinence Severity Score are used as the outcome measure, the tension-free vaginal tape is more cost-effective than laparoscopic mesh colposuspension over a follow-up period of one year (p<0.000).

CONCLUSION

The clinical and economic data of the present study suggest that over a follow-up period of one year the tension-free vaginal tape procedure is more cost-effective than laparoscopic mesh colposuspension as a primary treatment for female stress urinary incontinence.

Colposcopy, cervicography, speculoscopy and endoscopy. International Academy of Cytology Task Force summary. Diagnostic Cytology Towards the 21st Century: An International Expert Conference and Tutorial

ISSUES

The colposcope was developed in 1925 and is well established in clinical gynecologic practice for defining and delineating cytologically detected lesions mainly of the cervix but also the vagina and vulva. Additionally, various endoscopic procedures in gastroenterology, pulmonary and urologic lesions enhance the cytologic detection and histologic verification of precancerous and cancerous lesions. The cost-effectiveness of all these devices and their applicability, particularly in countries with a limited health budget, is a major issue. This task force considered aspects of the present state of the art and the challenges in the 21st century.

CONSENSUS POSITION

Automated cytology can interface with colposcopic examination in a number of significant ways. Automated cytologic analysis of conventional cervical smears can potentially direct colposcopic examination by predicting the nature of a lesion, assist in determining which patients should receive colposcopy and, in some settings, thereby reduce the number of colposcopies. Potentially, various combinations of automated cytology and colposcopy may be used to generate screening protocols that might result in more effective and inexpensive screening. The role of cervicography, or high-resolution cervical photography, as a screening device remains to be defined. Sensitivity for high grade lesions is generally no greater than that in cytology, and specificity appears lower. The interpretation of cervical photographs in triage of mildly abnormal cytology may prove to be useful in countries with established cytology programs. In areas of the world where cytology screening programs are not in place, the interpretation of cervical photographs may have its most dramatic effect. Cost-effectiveness analyses are needed. There are, at present, insufficient data for the evaluation of speculoscopy, a procedure using chemiluminescent illumination of the cervix for visualization of acetowhite areas. Basic training in colposcopy should be integrated into the residency programs of obstetrics and gynecology. Criteria for the adequate training of colposcopists should be developed. Continuing education programs in colposcopy should be developed when they are not already in existence. The cost-effectiveness of integrating colposcopy as a primary screening technique should be evaluated. Following a high-grade squamous intraepithelial lesion (HSIL) cytology result, colposcopically directed punch biopsy should be taken with or without endocervical curettage. This generally should precede the loop electrosurgical excision procedure (LEEP); however, in certain circumstances direct LEEP may be indicated. LEEP under colposcopic vision is an efficient way to treat an HSIL lesion of the cervix because the histologic extent and margins can be determined, unlike with laser surgery or cryosurgery. It is also more cost-effective than cold knife conization because general anesthesia and an operating room are unnecessary. Following LEEP, the endocervical canal should be examined colposcopically for any evidence of involvement. Lesions in the endocervix can then be removed with a different-shaped loop. Further research into Raman spectroscopy as a diagnostic aid in cervical pathology is needed, as is the use of micrococolpohysteroscopy for in vivo cytologic analyses, especially of the endocervical canal and transformation zone. Hysteroscopy is the most direct method for the diagnosis and treatment of intrauterine diseases. Hysteroscopic endometrial biopsy is more accurate than conventional biopsy methods. Cervical invasion of endometrial cancer can be detected by hysteroscopy. The depth of invasion, however, is more accurately determined by magnetic resonance imaging or computed tomography.

ONGOING ISSUES

Many topics for ongoing research and/or implementation are mentioned under "Consensus Position," above. (ABSTRACT TRUNCATED)