1
|
Rasmussen PW, Hoffman RM, Phiri S, Makwaya A, Kominski GF, Bastani R, Moses A, Moucheraud C. Cost-effectiveness of approaches to cervical cancer screening in Malawi: comparison of frequencies, lesion treatment techniques, and risk-stratified approaches. BMC Health Serv Res 2024; 24:792. [PMID: 38982430 PMCID: PMC11234730 DOI: 10.1186/s12913-024-11226-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Accepted: 06/20/2024] [Indexed: 07/11/2024] Open
Abstract
BACKGROUND Recently-updated global guidelines for cervical cancer screening incorporated new technologies-most significantly, the inclusion of HPV DNA detection as a primary screening test-but leave many implementation decisions at countries' discretion. We sought to develop recommendations for Malawi as a test case since it has the second-highest cervical cancer burden globally and high HIV prevalence. We incorporated updated epidemiologic data, the full range of ablation methods recommended, and a more nuanced representation of how HIV status intersects with cervical cancer risk and exposure to screening to model outcomes of different approaches to screening. METHODS Using a Markov model, we estimate the relative health outcomes and costs of different approaches to cervical cancer screening among Malawian women. The model was parameterized using published data, and focused on comparing "triage" approaches-i.e., lesion treatment (cryotherapy or thermocoagulation) at differing frequencies and varying by HIV status. Health outcomes were quality-adjusted life years (QALYs) and deaths averted. The model was built using TreeAge Pro software. RESULTS Thermocoagulation was more cost-effective than cryotherapy at all screening frequencies. Screening women once per decade would avert substantially more deaths than screening only once per lifetime, at relatively little additional cost. Moreover, at this frequency, it would be advisable to ensure that all women who screen positive receive treatment (rather than investing in further increases in screening frequency): for a similar gain in QALYs, it would cost more than four times as much to implement once-per-5 years screening with only 50% of women treated versus once-per-decade screening with 100% of women treated. Stratified screening schedules by HIV status was found to be an optimal approach. CONCLUSIONS These results add new evidence about cost-effective approaches to cervical cancer screening in low-income countries. At relatively infrequent screening intervals, if resources are limited, it would be more cost-effective to invest in scaling up thermocoagulation for treatment before increasing the recommended screening frequency. In Malawi or countries in a similar stage of the HIV epidemic, a stratified approach that prioritizes more frequent screening for women living with HIV may be more cost-effective than population-wide recommendations that are HIV status neutral.
Collapse
Affiliation(s)
| | - Risa M Hoffman
- David Geffen School of Medicine, Division of Infectious Disease, University of California Los Angeles, 885 Tiverton Drive, Los Angeles, CA, 90095, USA
| | - Sam Phiri
- Partners in Hope, Area 36 Plot 8, Lilongwe, Malawi
| | - Amos Makwaya
- Partners in Hope, Area 36 Plot 8, Lilongwe, Malawi
| | - Gerald F Kominski
- Fielding School of Public Health, Department of Health Policy and Management, University of California Los Angeles, 650 Charles E Young Dr S, Los Angeles, CA, 90095, USA
| | - Roshan Bastani
- Fielding School of Public Health, Department of Health Policy and Management, University of California Los Angeles, 650 Charles E Young Dr S, Los Angeles, CA, 90095, USA
| | - Agnes Moses
- Partners in Hope, Area 36 Plot 8, Lilongwe, Malawi
| | - Corrina Moucheraud
- School of Global Public Health, Department of Public Health Policy and Management, New York University, 708 Broadway, New York, NY, 10003, USA.
| |
Collapse
|
2
|
Rojas-Roque C, Palacios A. A Systematic Review of Health Economic Evaluations and Budget Impact Analyses to Inform Healthcare Decision-Making in Central America. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2023; 21:419-440. [PMID: 36720754 DOI: 10.1007/s40258-023-00791-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 01/19/2023] [Indexed: 05/03/2023]
Abstract
BACKGROUND Little is known about the quality, quantity and disease areas analysed by health economic research that inform healthcare decision-making in Central America. This study aimed to review the existing health economic evaluations (HEEs) and budget impact analyses (BIAs) evidence in Central America based on scope and reporting quality. METHODS HEEs and BIAs published from 2000 to April 2021 were searched in five electronic databases: PubMed, Embase, LILACS (Latin American and Caribbean Health Science Literature), EconLIT and OVID Global Health. Two reviewers assessed titles, abstracts and full texts of studies for eligibility. The quality appraisal for the reporting was based on La Torre and colleagues' version of the Drummond checklist and the ISPOR good practices for BIA. For each country, we correlated the number of studies by disease area with their respective burden of disease to identify under-researched health areas. RESULTS 102 publications were eligible for this review. Ninety-four publications reported a HEE, six publications reported a BIA, and two studies reported both a HEE and a BIA. Costa Rica had the highest number of publications (n = 28, 27.5%), followed by Guatemala (n = 25, 24.5%). Cancer and respiratory infections were the most common types of disease studied. Diabetes mellitus, chronic kidney diseases, and mental disorders were under-researched relative to their disease burden in most of the countries. The overall mean quality reporting score for HEE and BIA studies were 71/119 points (60%) and 7/10 points (70%), respectively; however, these assessments were made on different scales. CONCLUSION In Central America, health economic research is sparse and is considered as suboptimal quality for reporting. The findings reported information useful to other low- and middle-income countries with similar advances in the application of economics to promote health policy decision-making.
Collapse
Affiliation(s)
- Carlos Rojas-Roque
- Health Technology Assessment and Health Economics Department, Institute for Clinical Effectiveness and Health Policy (IECS), Doctor Emilio Ravignani 2024, Buenos Aires, Argentina.
| | - Alfredo Palacios
- Health Technology Assessment and Health Economics Department, Institute for Clinical Effectiveness and Health Policy (IECS), Doctor Emilio Ravignani 2024, Buenos Aires, Argentina
- Facultad de Ciencias Económicas, Universidad de Buenos Aires, Buenos Aires, Argentina
- Centre for Health Economics (CHE), University of York, York, UK
| |
Collapse
|
3
|
Herrick T, Thomson KA, Shin M, Gannon S, Tsu V, de Sanjosé S. Acting on the call for cervical cancer elimination: Planning tools for low- and middle- income countries to increase the coverage and effectiveness of screening and treatment. BMC Health Serv Res 2022; 22:1246. [PMID: 36241993 PMCID: PMC9563118 DOI: 10.1186/s12913-022-08423-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 08/04/2022] [Indexed: 12/03/2022] Open
Abstract
Introduction Accessible planning tools tailored for low-and middle-income countries can assist decision makers in comparing implementation of different cervical cancer screening approaches and treatment delivery scenarios in settings with high cervical cancer burden. Methods The Cervical Precancer Planning Tool (CPPT) was developed by PATH for users to explore and compare the accuracy of screening approaches, what treatment equipment to procure, and how best to deploy treatment equipment in a given country. The CPPT compares four screening approaches: 1) visual inspection with acetic acid (VIA), 2) HPV testing, 3) HPV testing followed by a VIA triage, and 4) HPV testing followed by an enhanced triage test. Accuracy of screening outcomes (e.g., true positives, false positives) is based on published sensitivity and specificity of tests to detect cervical precancerous lesions. The CPPT compares five scenarios for deploying ablative treatment equipment: 1) cervical precancer equipment at every location a woman is screened (single visit approach), 2) equipment only at a hospital level, 3) a single unit of equipment in each district, 4) allowing two districts to share a single unit of equipment, and 5) equipment placed at select district hospitals paired with mobile outreach. Users can customize the CPPT by adjusting pre-populated baseline values and assumptions, including population estimates, screening age range, screening frequency, HPV and HIV prevalence, supply costs, and health facility details. Results The CPPT generates data tables and graphs that compare the results of implementing each of the four screening and five treatment scenarios disaggregated by HIV status. Outputs include the number and outcomes of women screened, cost of each screening approach, provider time and cost saved by implementing self-sampling for HPV testing, number of women treated, treatment equipment needed by type, and the financial and economic costs for each equipment deployment scenario. Conclusion The CPPT provides practical information and data to compare tradeoffs of patient access and screening accuracy as well as efficient utilization of equipment, skilled personnel, and financial resources. Country decision makers can use outputs from the CPPT to guide the scale-up of cervical cancer screening and treatment while optimizing limited resources.
Collapse
Affiliation(s)
- Tara Herrick
- Market Dynamics, PATH, 2201, Westlake Ave Suite 200, Seattle, WA, 98121, USA.
| | - Kerry A Thomson
- Sexual and Reproductive Health Program, PATH, 2201 Westlake Ave, Suite 200, Seattle, WA, 98121, USA.
| | - Michelle Shin
- Department of Global Health, University of Washington, Seattle, USA
| | - Sarah Gannon
- Market Dynamics, PATH, 2201, Westlake Ave Suite 200, Seattle, WA, 98121, USA
| | - Vivien Tsu
- Department of Global Health, University of Washington, Seattle, USA
| | - Silvia de Sanjosé
- Sexual and Reproductive Health Program, PATH, 2201 Westlake Ave, Suite 200, Seattle, WA, 98121, USA
| |
Collapse
|
4
|
Vikraman SM, Khanna D, Dandpat A. Cervical cancer elimination in indian context: Moving from barriers to facilitators. Cancer 2022; 128:4041-4046. [PMID: 36239011 DOI: 10.1002/cncr.34486] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
It has been 46 years since the launch of cancer control programs in India and yet the recent National Family Health Survey (fifth round, 2019-2021) has reported that just 1.9% of women aged 30-49 years have ever undergone cervical cancer screening. The cost of delayed diagnosis of cervical cancer and its treatment is overwhelming, and the rural population takes the worst hit. It is the need of the hour that the Indian health system and policymakers identify the barriers and facilitators for cervical cancer early detection and provide pragmatic solutions so that the targets of cervical cancer elimination can be achieved in a timely manner.
Collapse
Affiliation(s)
- Saraswathy M Vikraman
- Department of Community Medicine, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, India
- Department of Preventive Oncology, Mahamana Pandit Madan Mohan Malaviya Cancer Center and Homi Bhabha Cancer Hospital, Tata Memorial Centers, Varanasi, Uttar Pradesh, India
| | - Divya Khanna
- Department of Preventive Oncology, Mahamana Pandit Madan Mohan Malaviya Cancer Center and Homi Bhabha Cancer Hospital, Tata Memorial Centers, Varanasi, Uttar Pradesh, India
| | - Abhishek Dandpat
- Department of Preventive Oncology, Mahamana Pandit Madan Mohan Malaviya Cancer Center and Homi Bhabha Cancer Hospital, Tata Memorial Centers, Varanasi, Uttar Pradesh, India
| |
Collapse
|
5
|
Sefuthi T, Nkonki L. A systematic review of economic evaluations of cervical cancer screening methods. Syst Rev 2022; 11:162. [PMID: 35945642 PMCID: PMC9361672 DOI: 10.1186/s13643-022-02017-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 07/04/2022] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE The aims of this systematic review were to (1) identify primary- and model-based economic evaluations of cervical cancer screening methods and to (2) provide a contextual summary of valuation outcomes associated with three types of cervical cancer screening tests: visual inspection with acetic acid, human papillomavirus deoxyribonucleic acid, and Papanicolaou smear. INTRODUCTION Cervical cancer screening is an important public health priority with the potential to improve the detection of precancerous lesions in high-risk females for early intervention and disease prevention. Test performance and cost-effectiveness differ based on the specific screening method used across different platforms. There is a need to appraise existing economic evaluations of cervical cancer screening methods. METHODS This review considered primary-based and model-based full economic evaluations of cervical cancer screening methods. The evaluation methods of interest included cost-effectiveness analysis, cost-utility analysis, cost-minimization analysis, cost-benefit analysis, and cost-consequence analysis. We searched Scopus, PubMed, National Health Economic Evaluation Database (NH EED), Cochrane, and the Health Economic Evaluation Database for full economic evaluations of cancer screening methods. No formal date restrictions were applied. Model-based and primary-based full economic evaluations were included. A critical appraisal of included studies was performed by the main investigator, while a second independent reviewer assessed critical appraisal findings for any inconsistencies. Data were extracted using a standardised data extraction tool for economic evaluations. The ultimate outcomes of costs, effectiveness, benefits, and utilities of cervical cancer screening modalities were extracted from included studies, analysed, and summarised. RESULTS From a total of 671 screened studies, 44 studies met the study inclusion criteria. Forty-three studies were cost-effectiveness analyses, one study reported both cost-utility and cost-effectiveness outcomes, and another study reported cost utilities of cervical cancer screening methods only. Human papillomavirus (HPV) DNA testing was reported as a dominant stand-alone screening test by 14 studies, while five studies reported visual inspection with acetic acid (VIA) as a dominant stand-alone screening test. Primary HPV screening strategies were dominant in 21 studies, while three studies reported cytology-based screening strategies as the dominant screening method. CONCLUSIONS Existing evidence indicates that HPV-based and VIA testing strategies are cost-effective, but this is dependent on setting. Our review suggests the limited cost-effectiveness of cytology-based testing, which may be due in part to the need for specific infrastructures and human resources. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42020212454 .
Collapse
Affiliation(s)
- Thatohatsi Sefuthi
- Division of Health Systems and Public Health, Global Health Department, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa.
| | - Lungiswa Nkonki
- Health Economics, Division of Health Systems and Public Health, Global Health Department, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
| |
Collapse
|
6
|
Casas CPR, Albuquerque RDCRD, Loureiro RB, Gollner AM, Freitas MGD, Duque GPDN, Viscondi JYK. Cervical cancer screening in low- and middle-income countries: A systematic review of economic evaluation studies. Clinics (Sao Paulo) 2022; 77:100080. [PMID: 35905574 PMCID: PMC9335392 DOI: 10.1016/j.clinsp.2022.100080] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 05/04/2022] [Indexed: 11/28/2022] Open
Abstract
Economic assessments are relevant to support the decision to incorporate more cost-effective strategies to reduce Cervical Cancer (CC) mortality. This systematic review analyzes the economic evaluation studies of CC prevention strategies (HPV DNA-based tests and conventional cytology) in low- and middle-income countries. Medline, EMBASE, CRD, and LILACS were searched for economic evaluation studies that reported cost and effectiveness measures of HPV DNA-based tests for CC screening and conventional cytology in women, without age, language, or publication date restrictions. Selection and data extraction were carried out independently. For comparability of results, cost-effectiveness measures were converted to international dollars (2019). Report quality was assessed using the CHEERS checklist. The Dominance Matrix Ranking (DRM) was used to analyze and interpret the results. The review included 15 studies from 12 countries, with cost-effectiveness analyzes from the health system's perspective and a 3% discount rate. The strategies varied in age and frequency of screening. Most studies used the Markov analytical model, and the cost-benefit threshold was based on the per capita GDP of each country. The sensitivity analysis performed in most studies was deterministic. The completeness of the report was considered sufficient in most of the items evaluated by CHEERS. The Dominance Interpretation (DRM) varied; in 6 studies, the HPV test was dominant, 5 studies showed a weak dominance evaluating greater effectiveness of the HPV test at a higher cost, yet in 2 studies conventional cytology was dominant. Although the context-dependent nature of economic evaluations, this review points out the challenge of methodological standardization in the analytical models.
Collapse
Affiliation(s)
- Carmen Phang Romero Casas
- Centro de Desenvolvimento Tecnológico em Saúde (CDTS), Fundação Oswaldo Cruz (FIOCRUZ), Rio de Janeiro, RJ, Brazil.
| | | | - Rafaela Borge Loureiro
- Laboratório de Epidemiologia (Lab-Epi), Universidade Federal do Espírito Santo (UFES), Vitória, ES, Brazil
| | - Angela Maria Gollner
- Hospital Universitário da Universidade Federal de Juiz de Fora (HU-UFJF/ EBSERH), Juiz de Fora, MG, Brazil
| | - Marina Gonçalves de Freitas
- Câmara de Regulação do Mercado de Medicamentos (CMED), Agência Nacional de Vigilância Sanitária (ANVISA), Brazil
| | | | | |
Collapse
|
7
|
Shin MB, Garcia PJ, Saldarriaga EM, Fiestas JL, Ásbjörnsdóttir KH, Iribarren SJ, Barnabas RV, Gimbel S. Cost of community-based human papillomavirus self-sampling in Peru: A micro-costing study. LANCET REGIONAL HEALTH. AMERICAS 2022; 8:100160. [PMID: 35528707 PMCID: PMC9075528 DOI: 10.1016/j.lana.2021.100160] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Background Cost data of human papillomavirus (HPV) self-sampling programs from low-and-middle-income countries is limited. We estimated the total and unit costs associated with the Hope Project, a community-based HPV self-sampling social entrepreneurship in Peru. Methods We conducted a micro-costing analysis from the program perspective to determine the unit costs of (1) recruitment/training of community women (Hope Ladies); (2) Hope Ladies distributing HPV self-sampling kits in their communities and the laboratory testing; and (3) Hope Ladies linking screened women with follow-up care. A procedural manual was used to identify the program's activities. A structured questionnaire and in-depth interviews were conducted with administrators to estimate the resource/time associated with activities. We obtained unit costs for each input previously identified from budgets and expenditure reports. Findings From November 2018 to March 2020, the program recruited and trained 62 Hope Ladies who distributed 4,882 HPV self-sampling kits in their communities. Of the screened women, 586 (12%) tested HPV positive. The annual cost per Hope Lady recruited/trained was $147·51 (2018 USD). The cost per HPV self-sampling kit distributed/tested was $45·39, the cost per woman followed up with results was $55·64, and the cost per HPV-positive woman identified was $378·14. Personnel and laboratory costs represented 56·1% and 24·7% of the total programmatic cost, respectively. Interpretation Our findings indicate that implementation of a community-based HPV self-sampling has competitive prices, which increases its likelihood to be feasible in Peru. Further economic evaluation is needed to quantify the incremental benefits of HPV self-sampling compared to more established options such as Pap tests. Funding Thomas Francis Jr. Fellowship provided funding for data collection. The Hope Project was funded by grants from Grand Challenges Canada (TTS-1812-21131), Uniting for Health Innovation, Global Initiative Against HPV and Cervical Cancer, University of Manitoba, and the John E. Fogarty International Center (5D43TW009375-05).
Collapse
Affiliation(s)
- Michelle B. Shin
- School of Nursing, University of Washington, Seattle, WA, United States
| | - Patricia J. Garcia
- School of Public Health, Cayetano Heredia University, Lima, Peru
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Enrique M. Saldarriaga
- The Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, University of Washington, Seattle, WA, United States
| | - José L. Fiestas
- School of Public Health, Cayetano Heredia University, Lima, Peru
| | - Kristjana H Ásbjörnsdóttir
- Department of Epidemiology, University of Washington, Seattle, WA, United States
- Centre of Public Health Sciences, University of Iceland, Reykjavik, Iceland
| | - Sarah J. Iribarren
- Department of Biobehavioral Nursing and Health Informatics, University of Washington, Seattle, WA, United States
| | - Ruanne V. Barnabas
- Department of Global Health, University of Washington, Seattle, WA, United States
- Department of Epidemiology, University of Washington, Seattle, WA, United States
- Department of Medicine, University of Washington, Seattle, WA, United States
- Vaccine and Infectious Diseases Division, Fred Hutchinson Cancer Research Center, Seattle, WA, United States
| | - Sarah Gimbel
- Department of Global Health, University of Washington, Seattle, WA, United States
- Department of Child, Family, and Population Health Nursing, University of Washington, Seattle, WA, United States
| |
Collapse
|
8
|
Pedersen K, Portnoy A, Sy S, Hansen BT, Tropé A, Kim JJ, Burger EA. Switching clinic-based cervical cancer screening programs to human papillomavirus self-sampling: A cost-effectiveness analysis of vaccinated and unvaccinated Norwegian women. Int J Cancer 2022; 150:491-501. [PMID: 34664271 DOI: 10.1002/ijc.33850] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Revised: 08/30/2021] [Accepted: 09/28/2021] [Indexed: 11/07/2022]
Abstract
Several countries have implemented primary human papillomavirus (HPV) testing for cervical cancer screening. HPV testing enables home-based, self-collected sampling (self-sampling), which provides similar diagnostic accuracy as clinician-collected samples. We evaluated the impact and cost-effectiveness of switching an entire organized screening program to primary HPV self-sampling among cohorts of HPV vaccinated and unvaccinated Norwegian women. We conducted a model-based analysis to project long-term health and economic outcomes for birth cohorts with different HPV vaccine exposure, that is, preadolescent vaccination (2000- and 2008-cohorts), multiage cohort vaccination (1991-cohort) or no vaccination (1985-cohort). We compared the cost-effectiveness of switching current guidelines with clinician-collected HPV testing to HPV self-sampling for these cohorts and considered an additional 44 strategies involving either HPV self-sampling or clinician-collected HPV testing at different screening frequencies for the 2000- and 2008-cohorts. Given Norwegian benchmarks for cost-effectiveness, we considered a strategy with an additional cost per quality-adjusted life-year below $55 000 as cost-effective. HPV self-sampling strategies considerably reduced screening costs (ie, by 24%-40% across cohorts and alternative strategies) and were more cost-effective than clinician-collected HPV testing. For cohorts offered preadolescent vaccination, cost-effective strategies involved HPV self-sampling three times (2000-cohort) and twice (2008-cohort) per lifetime. In conclusion, we found that switching from clinician-collected to self-collected HPV testing in cervical screening may be cost-effective among both highly vaccinated and unvaccinated cohorts of Norwegian women.
Collapse
Affiliation(s)
- Kine Pedersen
- Department of Health Management and Health Economics, University of Oslo, Oslo, Norway
| | - Allison Portnoy
- Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Stephen Sy
- Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | | | | | - Jane J Kim
- Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Emily A Burger
- Department of Health Management and Health Economics, University of Oslo, Oslo, Norway
- Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| |
Collapse
|
9
|
Jeffries A, Beck-Sagué CM, Marroquin-Garcia AB, Dean M, McCoy V, Cordova-Toma DA, Fenkl E, Madhivanan P. Cervical Visual Inspection with Acetic Acid (VIA) and Oncogenic Human Papillomavirus Screening in Rural Indigenous Guatemalan Women: Time to Rethink VIA. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph182312406. [PMID: 34886133 PMCID: PMC8656883 DOI: 10.3390/ijerph182312406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 11/16/2021] [Accepted: 11/20/2021] [Indexed: 11/30/2022]
Abstract
Single-visit “screen-and-treat” strategies using visual inspection with acetic acid (VIA) and cryotherapy (liquid nitrous oxide ablation) in low-resource settings are commonly used to detect and treat precancerous lesions for cervical cancer prevention. This study compared VIA sensitivity and specificity in rural indigenous Guatemalan communities, to that of oncogenic human papillomavirus (HPV) testing for detection of precancerous changes, using cytology as the reference standard. Between 3–8 September 2017, trained nurses examined 222 women aged 23–58 years with VIA. Specimens for liquid-based cytology and HPV testing were obtained prior to VIA with a cytobrush and transported in PreservCyt to a US clinical laboratory. VIA and HPV test sensitivities were assessed as proportions of women with abnormal cytology that had abnormal VIA or HPV results, respectively, and specificities, as proportions with normal cytology with normal VIA or negative HPV tests. Of 222 women, 18 (8.1%) had abnormal cytology (1 carcinoma in a participant who received VIA-based cryotherapy in 2015, 4 high- and 5 low-grade squamous intraepithelial lesions, and 8 atypical squamous cells of undetermined significance (ASCUS)). Excluding ASCUS, sensitivities of VIA and HPV were 20.0% and 100%, respectively. VIA-based screening may not be acceptable for detecting precancerous lesions, and field cryotherapy for preventing malignancy. The World Health Organization recommended in 2021 “…using HPV DNA detection as the primary screening test rather than VIA or cytology”.
Collapse
Affiliation(s)
- Anne Jeffries
- Robert Stempel (RS) College of Public Health and Social Work, Florida International University (FIU), Miami, FL 33199, USA; (A.J.); (V.M.); (E.F.)
| | - Consuelo M. Beck-Sagué
- Robert Stempel (RS) College of Public Health and Social Work, Florida International University (FIU), Miami, FL 33199, USA; (A.J.); (V.M.); (E.F.)
- Correspondence: ; Tel.: +1-786-253-3928
| | | | - Michael Dean
- Laboratory of Translational Genomics, National Cancer Institute (NCI), National Institutes of Health, Rockville, MD 20850, USA;
| | - Virginia McCoy
- Robert Stempel (RS) College of Public Health and Social Work, Florida International University (FIU), Miami, FL 33199, USA; (A.J.); (V.M.); (E.F.)
| | | | - Eric Fenkl
- Robert Stempel (RS) College of Public Health and Social Work, Florida International University (FIU), Miami, FL 33199, USA; (A.J.); (V.M.); (E.F.)
| | - Purnima Madhivanan
- Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, AZ 85724, USA;
| |
Collapse
|
10
|
Spencer JC, Campos NG, Burger EA, Sy S, Kim JJ. Potential effectiveness of a therapeutic HPV intervention campaign in Uganda. Int J Cancer 2021; 150:847-855. [PMID: 34741526 PMCID: PMC8732308 DOI: 10.1002/ijc.33867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 10/05/2021] [Accepted: 10/19/2021] [Indexed: 12/24/2022]
Abstract
Cervical cancer is a major source of morbidity and mortality in Uganda. In addition to prophylactic HPV vaccination, secondary prevention strategies are needed to reduce cancer burden. We evaluated the potential cancer reductions associated with a hypothetical single-contact therapeutic HPV intervention-with 70% coverage and variable efficacy [30%-100%]-using a three-stage HPV modeling framework reflecting HPV and cervical cancer burden in Uganda. In the reference case, we assumed prophylactic preadolescent HPV vaccination starting in 2020 with 70% coverage. A one-time therapeutic intervention targeting 35-year-old women in 2025 (not age-eligible for prophylactic vaccination) averted 1801 cervical cancers per 100 000 women over their lifetime (100% efficacy) or 533 cancers per 100 000 (30% efficacy). Benefits were considerably smaller in birth cohorts eligible for prophylactic HPV vaccination (768 cases averted per 100 000 at 100% efficacy). Evaluating the population-level impact over 40 years, we found introduction of a therapeutic intervention in 2025 with 100% efficacy targeted annually to 30-year-old women averted 139 000 incident cervical cancers in Uganda. This benefit was greatly reduced if efficacy was lower (30% efficacy; 41 000 cases averted), introduction was delayed (2040 introduction; 72 000 cases averted) or both (22 000 cases averted). We demonstrate the potential benefits of a single-contact HPV therapeutic intervention in a low-income setting, but show the importance of high therapeutic efficacy and early introduction timing relative to existing prophylactic programs. Reduced benefits from a less efficacious intervention may be somewhat offset if available within a shorter time frame.
Collapse
Affiliation(s)
- Jennifer C Spencer
- Department of Population Health, Dell Medical School, University of Texas at Austin, Austin, Texas, USA.,Department of Internal Medicine, Dell Medical School, University of Texas at Austin, Austin, Texas, USA
| | - Nicole G Campos
- Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Emily A Burger
- Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA.,Department of Health Management and Health Economics, University of Oslo, Oslo, Norway
| | - Stephen Sy
- Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Jane J Kim
- Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| |
Collapse
|
11
|
Efficacy of VIA, VILI, PAP Smear, and FRD Tests in Screening for Cervical Cancer: A Comparative Study. INDIAN JOURNAL OF GYNECOLOGIC ONCOLOGY 2021. [DOI: 10.1007/s40944-021-00589-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
|
12
|
Gurram L, Kalra B, Mahantshetty U. Meeting the Global Need for Radiation Therapy in Cervical Cancer-An Overview. Semin Radiat Oncol 2021; 30:348-354. [PMID: 32828390 DOI: 10.1016/j.semradonc.2020.05.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Cervical cancer is the fourth most frequently diagnosed cancer and the fourth leading cause of cancer death in women. The discrepancy in cervical cancer incidence and mortality between developed and developing nations has become increasingly apparent with 84% of the incidence and 88% of the mortality of cervical cancer occurring in low income countries. Access to comprehensive cancer care is a challenge and in particular the radiotherapy facilities. The radiotherapy infrastructure requirement is grossly inadequate with only 30% of the needs available and is even worst in LIC's with only 3% facilities. Additionally, lack of brachytherapy facilities and expertise in LIC's and LMIC's compounds the issue further. Even with continued HPV vaccination programs, there will still be a substantial burden of cervical cancer patients for treatment. Introspection and review in international and national policies, augmentation of (i) infrastructure - affordable & sustainable, (ii) manpower and rigorous training in accessible regions would be vital. International and National collaborative efforts among global organizations and societies, periodic peer reviews, resource stratified treatment guidelines and research, and health education would contribute further to women health. The amalgamation of palliative and hospice care services and radiotherapy facilities seamlessly would be a major step for comprehensive management of cervical cancer patients.
Collapse
Affiliation(s)
- Lavanya Gurram
- Department of Radiation Oncology, Tata Memorial Hospital, Homi Bhabha National Institute (HBNI), Mumbai, India
| | - Babusha Kalra
- Department of Radiation Oncology, Tata Memorial Hospital, Homi Bhabha National Institute (HBNI), Mumbai, India
| | - Umesh Mahantshetty
- Department of Radiation Oncology, Tata Memorial Hospital, Homi Bhabha National Institute (HBNI), Mumbai, India; Homi Bhabha Cancer Hospital and Research Centre, Visakhapatnam, India.
| |
Collapse
|
13
|
Muhimpundu MA, Ngabo F, Sayinzoga F, Balinda JP, Rusine J, Harward S, Eagan A, Krivacsy S, Bayingana A, Uwimbabazi JC, Makuza JD, Ngirabega JDD, Binagwaho A. Screen, Notify, See, and Treat: Initial Results of Cervical Cancer Screening and Treatment in Rwanda. JCO Glob Oncol 2021; 7:632-638. [PMID: 33929873 PMCID: PMC8162968 DOI: 10.1200/go.20.00147] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To describe the first year results of Rwanda's Screen, Notify, See, and Treat cervical cancer screening program, including challenges encountered and revisions made to improve service delivery. METHODS Through public radio broadcasts, meetings of local leaders, church networks, and local women's groups, public awareness of cervical cancer screening opportunities was increased and community health workers were enlisted to recruit and inform eligible women of the locations and dates on which services would be available. Screening was performed using human papillomavirus (HPV) DNA testing technology, followed by visual inspection with acetic acid (VIA), and cryotherapy, biopsy, and surgical treatment for those who tested HPV-positive. These services were provided by five district hospitals and 15 health centers to HIV-negative women of age 35-45 and HIV-positive women of age 30-50. Service utilization data were collected from the program's initiation in September 2013 to October 2014. RESULTS Of 7,520 cervical samples tested, 874 (11.6%) screened HPV-positive, leading 780 (89%) patients to undergo VIA. Cervical lesions were found in 204 patients (26.2%) during VIA; of these, 151 were treated with cryoablation and 15 were referred for biopsies. Eight patients underwent complete hysterectomy to treat advanced cervical cancer. Challenges to service delivery included recruitment of eligible patients, patient loss to follow-up, maintaining HIV status confidentiality, and efficient use of consumable resources. CONCLUSION Providing cervical cancer screening services through public health facilities is a feasible and valuable component of comprehensive women's health care in resource-limited settings. Special caution is warranted in ensuring proper adherence to follow-up and maintaining patient confidentiality.
Collapse
Affiliation(s)
| | | | | | | | - John Rusine
- National Reference Laboratory, Kigali, Rwanda
| | - Sardis Harward
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH
| | - Arielle Eagan
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH
| | | | | | - Jean Claude Uwimbabazi
- National Reference Laboratory, Kigali, Rwanda.,Clinical Microbiology Laboratory, CHU de Liège, University of Liege, Liege, Belgium
| | | | | | - Agnes Binagwaho
- University of Global Health Equity, Kigali, Rwanda.,Harvard Medical School, Boston, MA.,Geisel School of Medicine, Dartmouth College, Hanover, NH
| |
Collapse
|
14
|
Burger EA, Portnoy A, Campos NG, Sy S, Regan C, Kim JJ. Choosing the optimal HPV vaccine: The health impact and economic value of the nonavalent and bivalent HPV vaccines in 48 Gavi-eligible countries. Int J Cancer 2020; 148:932-940. [PMID: 32706907 DOI: 10.1002/ijc.33233] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 07/06/2020] [Accepted: 07/15/2020] [Indexed: 01/03/2023]
Abstract
The human papillomavirus (HPV) vaccines may provide some level of cross-protection against high-risk HPV genotypes not directly targeted by the vaccines. We evaluated the long-term health and economic impacts of routine HPV vaccination using either the nonavalent HPV vaccine or the bivalent HPV vaccine in the context of 48 Gavi-eligible countries. We used a multi-modeling approach to compare the bivalent with or without cross-protection and the nonavalent HPV vaccine. The optimal, that is, most cost-effective, vaccine was the vaccine with an incremental cost-effectiveness ratio below the per-capita gross domestic product (GDP) for each country. By 2100 and assuming 70% HPV vaccination coverage, a bivalent vaccine without cross-protection, a bivalent vaccine with favorable cross-protection and the nonavalent vaccine were projected to avert 14.9, 17.2 and 18.5 million cumulative cases of cervical cancer across all 48 Gavi-eligible countries, respectively. The relative value of the bivalent vaccine compared to the nonavalent vaccine increased assuming a bivalent vaccine conferred high cross-protection. For example, assuming a cost-effectiveness threshold of per-capita GDP, the nonavalent vaccine was optimal in 83% (n = 40) of countries if the bivalent vaccine did not confer cross-protection; however, the proportion of countries decreased to 63% (n = 30) if the bivalent vaccine conferred high cross-protection. For lower cost-effectiveness thresholds, the bivalent vaccine was optimal in a greater proportion of countries, under both cross-protection assumptions. Although the nonavalent vaccine is projected to avert more cases of cervical cancer, the bivalent vaccine with favorable cross-protection can prevent a considerable number of cases and would be considered a high-value vaccine for many Gavi-eligible countries.
Collapse
Affiliation(s)
- Emily A Burger
- Harvard T.H. Chan School of Public Health, Center for Health Decision Science, Boston, Massachusetts, USA.,Department of Health Management and Health Economics, University of Oslo, Oslo, Norway
| | - Allison Portnoy
- Harvard T.H. Chan School of Public Health, Center for Health Decision Science, Boston, Massachusetts, USA
| | - Nicole G Campos
- Harvard T.H. Chan School of Public Health, Center for Health Decision Science, Boston, Massachusetts, USA
| | - Stephen Sy
- Harvard T.H. Chan School of Public Health, Center for Health Decision Science, Boston, Massachusetts, USA
| | - Catherine Regan
- Harvard T.H. Chan School of Public Health, Center for Health Decision Science, Boston, Massachusetts, USA
| | - Jane J Kim
- Harvard T.H. Chan School of Public Health, Center for Health Decision Science, Boston, Massachusetts, USA
| |
Collapse
|
15
|
Affordable human papillomavirus screening needed to eradicate cervical cancer for all. LANCET GLOBAL HEALTH 2020; 7:e1605-e1606. [PMID: 31708136 DOI: 10.1016/s2214-109x(19)30423-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 09/12/2019] [Indexed: 12/29/2022]
|
16
|
Perez-Guzman PN, Chung MH, De Vuyst H, Dalal S, Mutai KK, Muthoni K, Kigen B, Kilonzo N, Hallett TB, Smit M. The impact of scaling up cervical cancer screening and treatment services among women living with HIV in Kenya: a modelling study. BMJ Glob Health 2020; 5:e001886. [PMID: 32337077 PMCID: PMC7170464 DOI: 10.1136/bmjgh-2019-001886] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Revised: 02/18/2020] [Accepted: 03/08/2020] [Indexed: 12/18/2022] Open
Abstract
Introduction We aimed to quantify health outcomes and programmatic implications of scaling up cervical cancer (CC) screening and treatment options for women living with HIV in care aged 18–65 in Kenya. Methods Mathematical model comparing from 2020 to 2040: (1) visual inspection with acetic acid (VIA) and cryotherapy (Cryo); (2) VIA and Cryo or loop excision electrical procedure (LEEP), as indicated; (3) human papillomavirus (HPV)-DNA testing and Cryo or LEEP; and (4) enhanced screening technologies (either same-day HPV-DNA testing or digitally enhanced VIA) and Cryo or LEEP. Outcomes measured were annual number of CC cases, deaths, screening and treatment interventions, and engaged in care (numbers screened, treated and cured) and five yearly age-standardised incidence. Results All options will reduce CC cases and deaths compared with no scale-up. Options 1–3 will perform similarly, averting approximately 28 000 (33%) CC cases and 7700 (27%) deaths. That is, VIA screening would yield minimal losses to follow-up (LTFU). Conversely, LTFU associated with HPV-DNA testing will yield a lower care engagement, despite better diagnostic performance. In contrast, option 4 would maximise health outcomes, averting 43 200 (50%) CC cases and 11 800 (40%) deaths, given greater care engagement. Yearly rescreening with either option will impose a substantial burden on the health system, which could be reduced by spacing out frequency to three yearly without undermining health gains. Conclusions Beyond the specific choice of technologies to scale up, efficiently using available options will drive programmatic success. Addressing practical constraints around diagnostics’ performance and LTFU will be key to effectively avert CC cases and deaths.
Collapse
Affiliation(s)
| | - Michael Hoonbae Chung
- Department of Medicine, Aga Khan University, Nairobi, Kenya.,Global Health, University of Washington, Seattle, Washington, USA
| | - Hugo De Vuyst
- Infections and Cancer Epidemiology Group, International Agency for Research on Cancer, Lyon, France
| | - Shona Dalal
- Department of HIV/AIDS, World Health Organization, Geneva, Switzerland
| | | | | | | | | | - Timothy B Hallett
- Department of Infectious Disease Epidemiology, Imperial College London, London, UK
| | - Mikaela Smit
- Department of Infectious Disease Epidemiology, Imperial College London, London, UK.,Division of Infectious Diseases, University Hospitals Geneva, Geneva, Switzerland
| |
Collapse
|
17
|
Cherniak W, Tyler N, Arora K, Lapidos-Salaiz I, Sczudlo E, Lin A, Barnhart M, Flanigan J, Silkensen S. From potential to practice: how accelerating access to HPV tests and screen and treat programmes can help eliminate cervical cancer. Fam Med Community Health 2020; 7:e000182. [PMID: 32148728 PMCID: PMC6910768 DOI: 10.1136/fmch-2019-000182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Revised: 09/13/2019] [Accepted: 09/15/2019] [Indexed: 12/24/2022] Open
Abstract
Human papillomavirus (HPV) vaccination campaigns to prevent cervical cancer are being considered and implemented in countries around the world. While vaccination will protect future generations, it will not help the millions of women currently infected, leading to an estimated 311 000 deaths per year globally. This paper examines a selection of strategies that when applied to both existing and new technologies, could accelerate access to HPV testing. Authors from the US Agency for International Development, the National Institutes of Health, and the Bridge to Health Medical and Dental, a non-governmental organisation, joined forces to propose a scalable and country-directed solution for preventing cervical cancer using an end-to-end approach. Collectively, the authors offer seven evidence-based strategies, that when used alone or in combination have the ability to reduce HPV-caused cervical cancer deaths and disability. These strategies include (1) consistent HPV test intervals to decrease HPV DNA test costs; (2) exploring market shaping opportunities; (3) employing iterative user research methodologies like human-centred design; (4) target product profiles for new HPV tests; (5) encouraging innovation around cervical cancer screen and treat programmes; (6) developing national cancer control plans; and (7) integrating cervical cancer screen and treat services into existing infrastructure. By using the strategies outlined here, in combination with HPV vaccination campaigns, national governments will be able to scale and expand cervical cancer screening programmes and provide evidence-based treatment programmes for HPV-infected women.
Collapse
Affiliation(s)
- William Cherniak
- Bridge to Health Medical and Dental, Toronto, Ontario, Canada.,Family and Community Medicine, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada
| | - Nikki Tyler
- Bureau for Global Health, USAID, Washington, DC, USA
| | - Kriti Arora
- Bridge to Health Medical and Dental, Toronto, Ontario, Canada
| | | | - Emma Sczudlo
- Bridge to Health Medical and Dental, Toronto, Ontario, Canada
| | - Amy Lin
- Bureau for Global Health, USAID, Washington, DC, USA
| | | | - John Flanigan
- Center for Global Health, National Cancer Institute, Bethesda, Maryland, USA
| | - Shannon Silkensen
- Center for Global Health, National Cancer Institute, Bethesda, Maryland, USA
| |
Collapse
|
18
|
Bhatla N, Singhal S. Primary HPV screening for cervical cancer. Best Pract Res Clin Obstet Gynaecol 2020; 65:98-108. [PMID: 32291178 DOI: 10.1016/j.bpobgyn.2020.02.008] [Citation(s) in RCA: 71] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 02/21/2020] [Accepted: 02/21/2020] [Indexed: 12/24/2022]
Abstract
Cytology-based cervical screening had unequivocal success in reducing the incidence and mortality of cervical cancer in the last century. The recognition of the role of human papillomavirus (HPV) as a necessary cause of cervical cancer led to the development of HPV testing. Gradually, there has been a shift from reflex HPV testing for mild cytological abnormalities, to co-testing with cytology and HPV, and lately to primary HPV screening, based on evidence from well-designed large randomized controlled trials and meta-analyses. Advantages of primary HPV screening include higher sensitivity to detect pre-neoplastic lesions, better re-assurance with a negative test, and safe prolongation of screening intervals. However, clinicians and policy makers must ensure the availability of clinically validated HPV assays and triage protocols of screen positive cases prior to implementation of primary HPV screening. This is likely to reduce potential harm from over-treatment as well as extra burden on the health care system.
Collapse
Affiliation(s)
- Neerja Bhatla
- Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, New Delhi, India.
| | - Seema Singhal
- Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, New Delhi, India.
| |
Collapse
|
19
|
Malone C, Barnabas RV, Buist DSM, Tiro JA, Winer RL. Cost-effectiveness studies of HPV self-sampling: A systematic review. Prev Med 2020; 132:105953. [PMID: 31911163 PMCID: PMC7219564 DOI: 10.1016/j.ypmed.2019.105953] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 12/06/2019] [Accepted: 12/16/2019] [Indexed: 02/06/2023]
Abstract
HPV self-sampling (HPV-SS) can increase cervical cancer screening participation by addressing barriers in high- and low- and middle-income settings. Successful implementation of HPV-SS programs will depend on understanding potential costs and health effects. Our objectives were to summarize the methods and results of published HPV-SS cost and cost-effectiveness studies, present implications of these results for HPV-SS program implementation, and identify knowledge gaps. We followed the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. One reviewer searched online databases for articles published through June 12, 2019, identified eligible studies, and extracted data; a second reviewer checked extracted data for accuracy. Eligible studies used an economic model to compare HPV-SS outreach strategies to standard-of-care tests. Of 16 eligible studies, 14 reported HPV-SS could be a cost-effective strategy. Studies differed in model type, HPV-SS delivery methods, triage strategies for positive results, and target populations. Most (9/16) modeled HPV-SS in European screening programs, 6/16 targeted women who were underscreened for cervical cancer, and 5/16 modeled HPV-SS in low- and middle-income countries. The most commonly identified driver of HPV-SS cost-effectiveness was the level of increase in cervical cancer screening attendance. Lower HPV-SS material and testing costs, higher sensitivity to detect cervical precancer, and longer duration of underscreening among HPV-SS users were also associated with increased cost-effectiveness. Future HPV-SS models in high-income settings should explore the effect of widespread vaccination and new triage strategies such as partial HPV genotyping. Knowledge gaps remain about the cost-effectiveness of HPV-SS in low- and middle-income settings.
Collapse
Affiliation(s)
- Colin Malone
- Department of Epidemiology, University of Washington, Box 359933, 325 9th Ave, Seattle, WA 98104, USA.
| | - Ruanne V Barnabas
- Department of Global Health, University of Washington, Box 359931, 325 9th Ave, Seattle, WA 98104, USA.
| | - Diana S M Buist
- Kaiser Permanente Washington Health Research Institute,1730 Minor Ave, Suite 1600, Seattle, WA 98101, USA.
| | - Jasmin A Tiro
- Department of Clinical Sciences, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390, USA.
| | - Rachel L Winer
- Department of Epidemiology, University of Washington, Box 359933, 325 9th Ave, Seattle, WA 98104, USA; Kaiser Permanente Washington Health Research Institute,1730 Minor Ave, Suite 1600, Seattle, WA 98101, USA.
| |
Collapse
|
20
|
Brisson M, Kim JJ, Canfell K, Drolet M, Gingras G, Burger EA, Martin D, Simms KT, Bénard É, Boily MC, Sy S, Regan C, Keane A, Caruana M, Nguyen DTN, Smith MA, Laprise JF, Jit M, Alary M, Bray F, Fidarova E, Elsheikh F, Bloem PJN, Broutet N, Hutubessy R. Impact of HPV vaccination and cervical screening on cervical cancer elimination: a comparative modelling analysis in 78 low-income and lower-middle-income countries. Lancet 2020; 395:575-590. [PMID: 32007141 PMCID: PMC7043009 DOI: 10.1016/s0140-6736(20)30068-4] [Citation(s) in RCA: 394] [Impact Index Per Article: 98.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 12/20/2019] [Accepted: 01/09/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND The WHO Director-General has issued a call for action to eliminate cervical cancer as a public health problem. To help inform global efforts, we modelled potential human papillomavirus (HPV) vaccination and cervical screening scenarios in low-income and lower-middle-income countries (LMICs) to examine the feasibility and timing of elimination at different thresholds, and to estimate the number of cervical cancer cases averted on the path to elimination. METHODS The WHO Cervical Cancer Elimination Modelling Consortium (CCEMC), which consists of three independent transmission-dynamic models identified by WHO according to predefined criteria, projected reductions in cervical cancer incidence over time in 78 LMICs for three standardised base-case scenarios: girls-only vaccination; girls-only vaccination and once-lifetime screening; and girls-only vaccination and twice-lifetime screening. Girls were vaccinated at age 9 years (with a catch-up to age 14 years), assuming 90% coverage and 100% lifetime protection against HPV types 16, 18, 31, 33, 45, 52, and 58. Cervical screening involved HPV testing once or twice per lifetime at ages 35 years and 45 years, with uptake increasing from 45% (2023) to 90% (2045 onwards). The elimination thresholds examined were an average age-standardised cervical cancer incidence of four or fewer cases per 100 000 women-years and ten or fewer cases per 100 000 women-years, and an 85% or greater reduction in incidence. Sensitivity analyses were done, varying vaccination and screening strategies and assumptions. We summarised results using the median (range) of model predictions. FINDINGS Girls-only HPV vaccination was predicted to reduce the median age-standardised cervical cancer incidence in LMICs from 19·8 (range 19·4-19·8) to 2·1 (2·0-2·6) cases per 100 000 women-years over the next century (89·4% [86·2-90·1] reduction), and to avert 61·0 million (60·5-63·0) cases during this period. Adding twice-lifetime screening reduced the incidence to 0·7 (0·6-1·6) cases per 100 000 women-years (96·7% [91·3-96·7] reduction) and averted an extra 12·1 million (9·5-13·7) cases. Girls-only vaccination was predicted to result in elimination in 60% (58-65) of LMICs based on the threshold of four or fewer cases per 100 000 women-years, in 99% (89-100) of LMICs based on the threshold of ten or fewer cases per 100 000 women-years, and in 87% (37-99) of LMICs based on the 85% or greater reduction threshold. When adding twice-lifetime screening, 100% (71-100) of LMICs reached elimination for all three thresholds. In regions in which all countries can achieve cervical cancer elimination with girls-only vaccination, elimination could occur between 2059 and 2102, depending on the threshold and region. Introducing twice-lifetime screening accelerated elimination by 11-31 years. Long-term vaccine protection was required for elimination. INTERPRETATION Predictions were consistent across our three models and suggest that high HPV vaccination coverage of girls can lead to cervical cancer elimination in most LMICs by the end of the century. Screening with high uptake will expedite reductions and will be necessary to eliminate cervical cancer in countries with the highest burden. FUNDING WHO, UNDP, UN Population Fund, UNICEF-WHO-World Bank Special Program of Research, Development and Research Training in Human Reproduction, Canadian Institute of Health Research, Fonds de recherche du Québec-Santé, Compute Canada, National Health and Medical Research Council Australia Centre for Research Excellence in Cervical Cancer Control.
Collapse
Affiliation(s)
- Marc Brisson
- Centre de recherche du CHU de Québec - Universite Laval, Québec, QC, Canada; Department of Social and Preventive Medicine, Universite Laval, Québec, QC, Canada; MRC Centre for Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology, Imperial College London, London, UK.
| | - Jane J Kim
- Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Karen Canfell
- Cancer Research Division, Cancer Council NSW, Sydney, NSW, Australia; School of Public Health, Sydney Medical School, University of Sydney, Sydney, NSW, Australia; Prince of Wales Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Mélanie Drolet
- Centre de recherche du CHU de Québec - Universite Laval, Québec, QC, Canada
| | - Guillaume Gingras
- Centre de recherche du CHU de Québec - Universite Laval, Québec, QC, Canada
| | - Emily A Burger
- Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, MA, USA; Department of Health Management and Health Economics, University of Oslo, Oslo, Norway
| | - Dave Martin
- Centre de recherche du CHU de Québec - Universite Laval, Québec, QC, Canada
| | - Kate T Simms
- Cancer Research Division, Cancer Council NSW, Sydney, NSW, Australia; School of Public Health, Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Élodie Bénard
- Centre de recherche du CHU de Québec - Universite Laval, Québec, QC, Canada
| | - Marie-Claude Boily
- Centre de recherche du CHU de Québec - Universite Laval, Québec, QC, Canada; Department of Social and Preventive Medicine, Universite Laval, Québec, QC, Canada; MRC Centre for Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology, Imperial College London, London, UK
| | - Stephen Sy
- Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Catherine Regan
- Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Adam Keane
- Cancer Research Division, Cancer Council NSW, Sydney, NSW, Australia; School of Public Health, Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Michael Caruana
- Cancer Research Division, Cancer Council NSW, Sydney, NSW, Australia; School of Public Health, Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Diep T N Nguyen
- Cancer Research Division, Cancer Council NSW, Sydney, NSW, Australia; School of Public Health, Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Megan A Smith
- Cancer Research Division, Cancer Council NSW, Sydney, NSW, Australia; School of Public Health, Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | | | - Mark Jit
- Centre for Mathematical Modelling of Infectious Disease, London School of Hygiene and Tropical Medicine, London, UK; Modelling and Economics Unit, Public Health England, London, UK; School of Public Health, University of Hong Kong, Hong Kong, China
| | - Michel Alary
- Centre de recherche du CHU de Québec - Universite Laval, Québec, QC, Canada; Department of Social and Preventive Medicine, Universite Laval, Québec, QC, Canada; Institut national de santé publique du Québec, Québec, QC, Canada
| | - Freddie Bray
- Section of Cancer Surveillance, International Agency for Research on Cancer, Lyon, France
| | - Elena Fidarova
- Department for the Management of Noncommunicable Diseases, Disability, Violence and Injury Prevention, World Health Organization, Geneva, Switzerland
| | - Fayad Elsheikh
- Department of Immunization, Vaccines and Biologicals, World Health Organization, Geneva, Switzerland
| | - Paul J N Bloem
- Department of Immunization, Vaccines and Biologicals, World Health Organization, Geneva, Switzerland
| | - Nathalie Broutet
- Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Raymond Hutubessy
- Department of Immunization, Vaccines and Biologicals, World Health Organization, Geneva, Switzerland
| |
Collapse
|
21
|
Campos NG, Alfaro K, Maza M, Sy S, Melendez M, Masch R, Soler M, Conzuelo-Rodriguez G, Gage JC, Alonzo TA, Castle PE, Felix JC, Cremer M, Kim JJ. The cost-effectiveness of human papillomavirus self-collection among cervical cancer screening non-attenders in El Salvador. Prev Med 2020; 131:105931. [PMID: 31765712 DOI: 10.1016/j.ypmed.2019.105931] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Revised: 11/19/2019] [Accepted: 11/21/2019] [Indexed: 01/17/2023]
Abstract
Cervical cancer screening with human papillomavirus (HPV) DNA testing has been incorporated into El Salvador's national guidelines. The feasibility of home-based HPV self-collection among women who do not attend screening at the clinic (i.e., non-attenders) has been demonstrated, but cost-effectiveness has not been evaluated. Using cost and compliance data from El Salvador, we informed a mathematical microsimulation model of HPV infection and cervical carcinogenesis to conduct a cost-effectiveness analysis from the societal perspective. We estimated the reduction in cervical cancer risk, lifetime cost per woman (2017 US$), life expectancy, and incremental cost-effectiveness ratio (ICER, 2017 US$ per year of life saved [YLS]) of a program with home-based self-collection of HPV (facilitated by health promoters) for the 18% of women reluctant to screen at the clinic. The model was calibrated to epidemiologic data from El Salvador. We evaluated health and economic outcomes of the self-collection intervention for women aged 30 to 59 years, alone and in concert with clinic-based HPV provider-collection. Home-based self-collection of HPV was projected to reduce population cervical cancer risk by 14% and cost $1210 per YLS compared to no screening. An integrated program reaching 99% coverage with both provider- and home-based self-collection of HPV reduced cancer risk by 74% (compared to no screening), and cost $1210 per YLS compared to provider-collection alone. Self-collection facilitated by health promoters is a cost-effective strategy for increasing screening uptake in El Salvador.
Collapse
Affiliation(s)
- Nicole G Campos
- Center for Health Decision Science, Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, 718 Huntington Avenue, Boston, MA, USA.
| | - Karla Alfaro
- Basic Health International, Colonia San Francisco, Avenido Las Camelias 14, San Salvador, El Salvador; Basic Health International, 25 Broadway, 9th Floor, New York, NY 10004, USA
| | - Mauricio Maza
- Basic Health International, Colonia San Francisco, Avenido Las Camelias 14, San Salvador, El Salvador; Basic Health International, 25 Broadway, 9th Floor, New York, NY 10004, USA
| | - Stephen Sy
- Center for Health Decision Science, Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, 718 Huntington Avenue, Boston, MA, USA
| | - Mario Melendez
- Basic Health International, Colonia San Francisco, Avenido Las Camelias 14, San Salvador, El Salvador; Basic Health International, 25 Broadway, 9th Floor, New York, NY 10004, USA
| | - Rachel Masch
- Basic Health International, Colonia San Francisco, Avenido Las Camelias 14, San Salvador, El Salvador; Basic Health International, 25 Broadway, 9th Floor, New York, NY 10004, USA
| | - Montserrat Soler
- Obstetrics, Gynecology & Women's Health Institute, Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA
| | | | - Julia C Gage
- Department of Cancer Epidemiology and Genetics, National Cancer Institute, 9609 Medical Center Drive, Rockville, MD, USA
| | - Todd A Alonzo
- University of Southern California, 222 East Huntington Drive, Suite 100, Monrovia, CA 91016, USA
| | | | - Juan C Felix
- Department of Pathology, Medical College of Wisconsin, 9200 W Wisconsin Avenue, Milwaukee, WI, USA
| | - Miriam Cremer
- Basic Health International, Colonia San Francisco, Avenido Las Camelias 14, San Salvador, El Salvador; Basic Health International, 25 Broadway, 9th Floor, New York, NY 10004, USA; Obstetrics, Gynecology & Women's Health Institute, Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA
| | - Jane J Kim
- Center for Health Decision Science, Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, 718 Huntington Avenue, Boston, MA, USA
| |
Collapse
|
22
|
Portnoy A, Campos NG, Sy S, Burger EA, Cohen J, Regan C, Kim JJ. Impact and Cost-Effectiveness of Human Papillomavirus Vaccination Campaigns. Cancer Epidemiol Biomarkers Prev 2019; 29:22-30. [DOI: 10.1158/1055-9965.epi-19-0767] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Revised: 09/13/2019] [Accepted: 10/23/2019] [Indexed: 11/16/2022] Open
|
23
|
Campos NG, Maza M, Alfaro K, Gage JC, Castle PE, Felix JC, Masch R, Cremer M, Kim JJ. The cost-effectiveness of implementing HPV testing for cervical cancer screening in El Salvador. Int J Gynaecol Obstet 2019; 145:40-46. [PMID: 30702142 PMCID: PMC6988124 DOI: 10.1002/ijgo.12773] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Revised: 09/06/2018] [Accepted: 01/29/2019] [Indexed: 01/13/2023]
Abstract
Objective To assess the cost-effectiveness of HPV-based screening and management algorithms for HPV-positive women in phase 2 of the Cervical Cancer Prevention in El Salvador (CAPE) demonstration, relative to the status quo of Pap-based screening. Methods Data from phase 2 of the CAPE demonstration (n=8000 women) were used to inform a mathematical model of HPV infection and cervical cancer. The model was used to project the lifetime health and economic outcomes of HPV testing every 5 years (age 30–65 years), with referral to colposcopy for HPV-positive women; HPV testing every 5 years (age 30-65 years), with immediate cryotherapy for eligible HPV-positive women; and Pap testing every 2 years (age 20–65 years), with referral to colposcopy for Pap-positive women. Results Despite slight decreases in the proportion of HPV-positive women who received treatment relative to phase 1, the health impact of screening in phase 2 remained stable, reducing cancer risk by 58.5%. As in phase 1, HPV testing followed by cryotherapy for eligible HPV-positive women remained the least costly and most effective strategy (US$490 per year of life saved). Conclusion HPV-based screening followed by immediate cryotherapy in all eligible women would be very cost-effective in El Salvador.
Collapse
Affiliation(s)
- Nicole G Campos
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Center for Health Decision Science, Boston, MA, USA
| | - Mauricio Maza
- Basic Health International, Colonia San Francisco, San Salvador, El Salvador
| | - Karla Alfaro
- Basic Health International, Colonia San Francisco, San Salvador, El Salvador
| | - Julia C Gage
- Department of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD, USA
| | - Philip E Castle
- Albert Einstein College of Medicine, Bronx, New York, NY, USA
| | - Juan C Felix
- Department of Pathology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Rachel Masch
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Miriam Cremer
- Obstetrics, Gynecology & Women's Health Institute, Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA
| | - Jane J Kim
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Center for Health Decision Science, Boston, MA, USA
| |
Collapse
|
24
|
Campos NG, Tsu V, Jeronimo J, Regan C, Resch S, Clark A, Sy S, Kim JJ. Health impact of delayed implementation of cervical cancer screening programs in India: A modeling analysis. Int J Cancer 2018; 144:687-696. [PMID: 30132850 PMCID: PMC6519250 DOI: 10.1002/ijc.31823] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Revised: 07/27/2018] [Accepted: 08/01/2018] [Indexed: 11/22/2022]
Abstract
India has the highest burden of cervical cancer in the world. To estimate the consequences of delaying implementation of organized cervical cancer screening, we projected the avertable burden of disease under different implementation scenarios of a screening program. We used an individual‐based microsimulation model of human papillomavirus (HPV) infection and cervical cancer calibrated to epidemiologic data from India to project age‐specific cancer incidence and mortality reductions associated with screening (once‐in‐a‐lifetime among women aged 30–34 years) with one‐visit visual inspection with acetic acid (VIA) and one‐ and two‐visit HPV DNA testing. We then applied these reductions to a population model to project the lifetime cervical cancer cases and deaths averted under different implementation scenarios taking place from 2017 to 2026: (1) immediate implementation of screening with currently available screening tests (one‐visit VIA, two‐visit HPV testing); (2) immediate implementation of screening with currently available screening tests, with a switch to point‐of‐care one‐visit HPV testing in 5 years; and (3) 5‐year delayed implementation of screening with current screening tests or point‐of‐care HPV testing. Immediate implementation of two‐visit HPV testing with a switch to one‐visit HPV testing averted 574,100 cases and 382,500 deaths over the lifetimes of 81.4 million 30‐ to 34‐year‐old women screened once between 2017 and 2026. Delayed implementation with a one‐visit HPV test averted 209,300 cases and 139,100 deaths. Delaying implementation of screening programs in high‐burden settings will result in substantial morbidity and mortality among women beyond the age for adolescent HPV vaccination. What's new? Nearly one‐quarter of cervical cancer cases worldwide occur in India. Nonetheless, while the disease can be prevented through screening for precancerous lesions, very few Indian women receive Pap tests. Here, the authors estimated cervical cancer burden in India assuming different screening program implementation scenarios, including immediate implementation with both one‐visit VIA and two‐visit human papillomavirus (HPV) testing and delayed implementation with a one‐visit HPV test. Models showed that immediate implementation of two‐visit HPV testing averted more than double the number of cases and deaths from cervical cancer among 30‐ to 34‐year‐old women compared with delayed implementation with one‐visit HPV testing.
Collapse
Affiliation(s)
- Nicole G. Campos
- Center for Health Decision ScienceHarvard T.H. Chan School of Public HealthBostonMA
| | - Vivien Tsu
- PATH, Reproductive Health Global ProgramWashingtonDC
| | - Jose Jeronimo
- PATH, Reproductive Health Global ProgramWashingtonDC
- Global Coalition against Cervical CancerArligtonVA
| | - Catherine Regan
- Center for Health Decision ScienceHarvard T.H. Chan School of Public HealthBostonMA
| | - Stephen Resch
- Center for Health Decision ScienceHarvard T.H. Chan School of Public HealthBostonMA
| | - Andrew Clark
- Department of Health Services Research and PolicyLondon School of Hygiene & Tropical MedicineLondonUnited Kingdom
| | - Stephen Sy
- Center for Health Decision ScienceHarvard T.H. Chan School of Public HealthBostonMA
| | - Jane J. Kim
- Center for Health Decision ScienceHarvard T.H. Chan School of Public HealthBostonMA
| |
Collapse
|
25
|
Campos NG, Lince-Deroche N, Chibwesha CJ, Firnhaber C, Smith JS, Michelow P, Meyer-Rath G, Jamieson L, Jordaan S, Sharma M, Regan C, Sy S, Liu G, Tsu V, Jeronimo J, Kim JJ. Cost-Effectiveness of Cervical Cancer Screening in Women Living With HIV in South Africa: A Mathematical Modeling Study. J Acquir Immune Defic Syndr 2018; 79:195-205. [PMID: 29916959 PMCID: PMC6143200 DOI: 10.1097/qai.0000000000001778] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Accepted: 06/13/2018] [Indexed: 01/25/2023]
Abstract
BACKGROUND Women with HIV face an increased risk of human papillomavirus (HPV) acquisition and persistence, cervical intraepithelial neoplasia, and invasive cervical cancer. Our objective was to determine the cost-effectiveness of different cervical cancer screening strategies among women with HIV in South Africa. METHODS We modified a mathematical model of HPV infection and cervical disease to reflect coinfection with HIV. The model was calibrated to epidemiologic data from HIV-infected women in South Africa. Clinical and economic data were drawn from in-country data sources. The model was used to project reductions in the lifetime risk of cervical cancer and incremental cost-effectiveness ratios (ICERs) of Pap and HPV DNA screening and management algorithms beginning at HIV diagnosis, at 1-, 2-, or 3-year intervals. Strategies with an ICER below South Africa's 2016 per capita gross domestic product (US$5270) were considered "cost-effective." RESULTS HPV testing followed by treatment (test-and-treat) at 2-year intervals was the most effective strategy that was also cost-effective, reducing lifetime cancer risk by 56.6% with an ICER of US$3010 per year of life saved. Other cost-effective strategies included Pap (referral threshold: HSIL+) at 1-, 2-, and 3-year intervals, and HPV test-and-treat at 3-year intervals. Pap (ASCUS+), HPV testing with 16/18 genotyping, and HPV testing with Pap or visual triage of HPV-positive women were less effective and more costly than alternatives. CONCLUSIONS Considering per capita gross domestic product as the benchmark for cost-effectiveness, HPV test-and-treat is optimal in South Africa. At lower cost-effectiveness benchmarks, Pap (HSIL+) would be optimal.
Collapse
Affiliation(s)
- Nicole G. Campos
- Harvard T.H. Chan School of Public Health, Department of Health Policy and Management, Boston, MA
| | - Naomi Lince-Deroche
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Carla J. Chibwesha
- Division of Global Women's Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Clinical HIV Research Unit, Helen Joseph Hospital, Johannesburg, South Africa
| | - Cynthia Firnhaber
- Clinical HIV Research Unit, Helen Joseph Hospital, Johannesburg, South Africa
- Right to Care, Helen Joseph Hospital, Johannesburg, South Africa
| | - Jennifer S. Smith
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC
| | - Pam Michelow
- National Health Laboratory Service, Johannesburg, South Africa
- Anatomical Pathology Department, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Gesine Meyer-Rath
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Global Health and Development, School of Public Health, Boston University, Boston, MA
| | - Lise Jamieson
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Suzette Jordaan
- National Health Laboratory Service, Johannesburg, South Africa
| | - Monisha Sharma
- Harvard T.H. Chan School of Public Health, Department of Health Policy and Management, Boston, MA
- Department of Epidemiology, University of Washington, Seattle, WA
| | - Catherine Regan
- Harvard T.H. Chan School of Public Health, Department of Health Policy and Management, Boston, MA
| | - Stephen Sy
- Harvard T.H. Chan School of Public Health, Department of Health Policy and Management, Boston, MA
| | - Gui Liu
- Department of Epidemiology, University of Washington, Seattle, WA
| | | | - Jose Jeronimo
- Global Coalition Against Cervical Cancer, Arlington, VA
| | - Jane J. Kim
- Harvard T.H. Chan School of Public Health, Department of Health Policy and Management, Boston, MA
| |
Collapse
|
26
|
Burger EA, Campos NG, Sy S, Regan C, Kim JJ. Health and economic benefits of single-dose HPV vaccination in a Gavi-eligible country. Vaccine 2018; 36:4823-4829. [PMID: 29807710 PMCID: PMC6066173 DOI: 10.1016/j.vaccine.2018.04.061] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Revised: 04/13/2018] [Accepted: 04/20/2018] [Indexed: 11/02/2022]
Abstract
BACKGROUND Although guidelines for prophylactic human papillomavirus (HPV) vaccination recommend two doses for girls ages 9-14 years, several studies have demonstrated similar protection with one dose. Our objective was to evaluate the long-term health and economic impacts of routine one-dose HPV vaccination compared to (1) no vaccination and (2) two-dose HPV vaccination in a low-income country. METHODS We used a three-tiered hybrid modeling approach that captured HPV transmission, cervical carcinogenesis, and population demographics to project long-term health and economic outcomes associated with one-dose HPV vaccination (assuming 80% efficacy against HPV-16/18 infections under three waning scenarios) and two-dose HPV vaccination (assuming 100% efficacy over the lifetime) in Uganda. Costs included the vaccine program (dosage and delivery) costs over a 10-year period and cervical cancer costs over the lifetimes of the current population of Ugandan women. Health outcomes included number of cervical cancer cases and disability-adjusted life years (DALYs). Incremental cost-effectiveness ratios (i.e., cost per DALY averted) were calculated and compared against the Ugandan per-capita gross domestic product. RESULTS Routine one-dose HPV vaccination of 9-year-old girls required substantial upfront investment but was cost-saving compared to no vaccination when accounting for the cost-offsets from future cancers averted. Forty years after initiating routine vaccination and depending on assumptions of vaccine waning, one-dose HPV vaccination with equivalent coverage (70%) averted 15-16% of cervical cancer cases versus 21% with two-dose vaccination but required only half the upfront economic investment. Vaccination with two doses had an attractive cost-effectiveness profile except if one-dose vaccination enabled higher coverage (90% vs. 70%) and did not wane. CONCLUSIONS One-dose HPV vaccination resulted in cost-savings compared to no vaccination and could be cost-effective compared to two-dose vaccination if protection is longstanding and higher coverage can be achieved.
Collapse
Affiliation(s)
- Emily A Burger
- Harvard T.H. Chan School of Public Health, Center for Health Decision Science, 718 Huntington Ave, 2ndFloor, Boston, MA 02117, USA; University of Oslo, Department of Health Management and Health Economics, Postboks 1089, Blindern, 0317 Oslo, Norway.
| | - Nicole G Campos
- Harvard T.H. Chan School of Public Health, Center for Health Decision Science, 718 Huntington Ave, 2ndFloor, Boston, MA 02117, USA
| | - Stephen Sy
- Harvard T.H. Chan School of Public Health, Center for Health Decision Science, 718 Huntington Ave, 2ndFloor, Boston, MA 02117, USA
| | - Catherine Regan
- Harvard T.H. Chan School of Public Health, Center for Health Decision Science, 718 Huntington Ave, 2ndFloor, Boston, MA 02117, USA
| | - Jane J Kim
- Harvard T.H. Chan School of Public Health, Center for Health Decision Science, 718 Huntington Ave, 2ndFloor, Boston, MA 02117, USA
| |
Collapse
|
27
|
Campos NG, Tsu V, Jeronimo J, Njama-Meya D, Mvundura M, Kim JJ. Cost-effectiveness of an HPV self-collection campaign in Uganda: comparing models for delivery of cervical cancer screening in a low-income setting. Health Policy Plan 2018; 32:956-968. [PMID: 28369405 PMCID: PMC5886074 DOI: 10.1093/heapol/czw182] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/23/2016] [Indexed: 12/26/2022] Open
Abstract
With the availability of a low-cost HPV DNA test that can be administered by either a healthcare provider or a woman herself, programme planners require information on the costs and cost-effectiveness of implementing cervical cancer screening programmes in low-resource settings under different models of healthcare delivery. Using data from the START-UP demonstration project and a micro-costing approach, we estimated the health and economic impact of once-in-a-lifetime HPV self-collection campaign relative to clinic-based provider-collection of HPV specimens in Uganda. We used an individual-based Monte Carlo simulation model of the natural history of HPV and cervical cancer to estimate lifetime health and economic outcomes associated with screening with HPV DNA testing once in a lifetime (clinic-based provider-collection vs a self-collection campaign). Test performance and cost data were obtained from the START-UP demonstration project using a micro-costing approach. Model outcomes included lifetime risk of cervical cancer, total lifetime costs (in 2011 international dollars [I$]), and life expectancy. Cost-effectiveness ratios were expressed using incremental cost-effectiveness ratios (ICERs). When both strategies achieved 75% population coverage, ICERs were below Uganda's per capita GDP (self-collection: I$80 per year of life saved [YLS]; provider-collection: I$120 per YLS). When the self-collection campaign achieved coverage gains of 15-20%, it was more effective than provider-collection, and had a lower ICER unless coverage with both strategies was 50% or less. Findings were sensitive to cryotherapy compliance among screen-positive women and relative HPV test performance. The primary limitation of this analysis is that self-collection costs are based on a hypothetical campaign but are based on unit costs from Uganda. Once-in-a-lifetime screening with HPV self-collection may be very cost-effective and reduce cervical cancer risk by > 20% if coverage is high. Demonstration projects will be needed to confirm the validity of our logistical, costing and compliance assumptions.
Collapse
Affiliation(s)
- Nicole G Campos
- Center for Health Decision Science, Harvard T.H. Chan School of Public Health, 718 Huntington Avenue, Boston, MA, USA
| | - Vivien Tsu
- PATH, Reproductive Health Global Program, P.O. Box 900922, Seattle, WA, USA
| | - Jose Jeronimo
- PATH, Reproductive Health Global Program, P.O. Box 900922, Seattle, WA, USA
| | | | - Mercy Mvundura
- PATH, Devices and Tools Program, P.O. Box 900922, Seattle, WA, USA
| | - Jane J Kim
- Center for Health Decision Science, Harvard T.H. Chan School of Public Health, 718 Huntington Avenue, Boston, MA, USA
| |
Collapse
|
28
|
Community-Based Screening for Cervical Cancer Using Visual Inspection With Acetic Acid: Results and Lessons Learned From a Pilot Study in Vietnam. JOURNAL OF PUBLIC HEALTH MANAGEMENT AND PRACTICE 2018; 24 Suppl 2:S3-S8. [PMID: 29369251 DOI: 10.1097/phh.0000000000000709] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
CONTEXT Vietnam still applies the opportunistic cytology-based screening model, which failed to have an impact on the increasing burden of cervical cancer in Vietnam. OBJECTIVES To pilot a community-based screening model for cervical cancer using visual inspection with acetic acid (VIA) in Vietnam by training midwife and assistant physician working at grassroots level of health care system. DESIGN The study employed a pre-experimental design. SETTING Cases from 2 provinces of Vietnam. PARTICIPANTS The study trained 36 assistant physicians/midwives working at commune health centers to do VIA screening for cervical cancer and provided screening services for 1945 women 30 to 65 years of age. INTERVENTION The pilot intervention had 2 aims: train health care workers to do VIA screening and assess the quality of screening services provided by the trained staffs by examining the diagnostics value of VIA. RESULTS All selected health care workers were able to perform VIA screening method after training. Their VIA services had high diagnostic value: positive predicted value of 11.5% and negative predicted value of 99%; for the detection of cervical intraepithelial neoplasia (CIN) 2, the sensitivity of VIA is 100%, specificity of 67.0%, positive predicted value of 5.7%, and negative predicted value of 100%; for the detection of CIN 3, the sensitivity of VIA is 100%, specificity of 66.5%, positive predicted value of 3.8%, and negative predicted value of 100%. The diagnostic value of VIA is comparable with Papanicolaou test but requires far fewer resources and suitable with community-based setting. CONCLUSION Local midwives and assistant physicians who currently work at commune health centers and district health centers can be trained to do VIA efficiently. Regarding to implications for policy and practice, VIA can offer significant advantages over Papanicolaou test in low-resource settings like Vietnam, particularly in terms of increased screening coverage, improved follow-up care, and overall program quality.
Collapse
|
29
|
Campos NG, Tsu V, Jeronimo J, Mvundura M, Kim JJ. Estimating the value of point-of-care HPV testing in three low- and middle-income countries: a modeling study. BMC Cancer 2017; 17:791. [PMID: 29178896 PMCID: PMC5702206 DOI: 10.1186/s12885-017-3786-3] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Accepted: 11/14/2017] [Indexed: 12/30/2022] Open
Abstract
Background Where resources are available, the World Health Organization recommends cervical cancer screening with human papillomavirus (HPV) DNA testing and subsequent treatment of HPV-positive women with timely cryotherapy. Newer technologies may facilitate a same-day screen-and-treat approach, but these testing systems are generally too expensive for widespread use in low-resource settings. Methods To assess the value of a hypothetical point-of-care HPV test, we used a mathematical simulation model of the natural history of HPV and data from the START-UP multi-site demonstration project to estimate the health benefits and costs associated with a shift from a 2-visit approach (requiring a return visit for treatment) to 1-visit HPV testing (i.e., screen-and-treat). We estimated the incremental net monetary benefit (INMB), which represents the maximum additional lifetime cost per woman that could be incurred for a new point-of-care HPV test to be cost-effective, depending on expected loss to follow-up between visits (LTFU) in a given setting. Results For screening three times in a lifetime at 100% coverage of the target population, when LTFU was 10%, the INMB of the 1-visit relative to the 2-visit approach was I$13 in India, I$36 in Nicaragua, and I$17 in Uganda. If LTFU was 30% or greater, the INMB values for the 1-visit approach in all countries was equivalent to or exceeded total lifetime costs associated with screening three times in a lifetime. At a LTFU level of 70%, the INMB of the 1-visit approach was I$127 in India, I$399 in Nicaragua, and I$121 in Uganda. Conclusions These findings indicate that point-of-care technology for cervical cancer screening may be worthy of high investment if linkage to treatment can be assured, particularly in settings where LTFU is high. Electronic supplementary material The online version of this article (10.1186/s12885-017-3786-3) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Nicole G Campos
- Center for Health Decision Science, Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, 718 Huntington Avenue, 2nd Floor, Boston, Massachusetts, 02115, USA.
| | - Vivien Tsu
- PATH, Reproductive Health Global Program, P.O. Box 900922, Seattle, Washington, USA
| | - Jose Jeronimo
- Global Coalition against Cervical Cancer, Arlington, Virginia, USA
| | - Mercy Mvundura
- PATH, Devices and Tools Program, P.O. Box 90922, Seattle, Washington, USA
| | - Jane J Kim
- Center for Health Decision Science, Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, 718 Huntington Avenue, 2nd Floor, Boston, Massachusetts, 02115, USA
| |
Collapse
|
30
|
Jeronimo J, Castle PE, Temin S, Denny L, Gupta V, Kim JJ, Luciani S, Murokora D, Ngoma T, Qiao Y, Quinn M, Sankaranarayanan R, Sasieni P, Schmeler KM, Shastri SS. Secondary Prevention of Cervical Cancer: ASCO Resource-Stratified Clinical Practice Guideline. J Glob Oncol 2017; 3:635-657. [PMID: 29094101 PMCID: PMC5646891 DOI: 10.1200/jgo.2016.006577] [Citation(s) in RCA: 102] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
PURPOSE To provide resource-stratified, evidence-based recommendations on the secondary prevention of cervical cancer globally. METHODS ASCO convened a multidisciplinary, multinational panel of oncology, primary care, epidemiology, health economic, cancer control, public health, and patient advocacy experts to produce recommendations reflecting four resource-tiered settings. A review of existing guidelines, a formal consensus-based process, and a modified ADAPTE process to adapt existing guidelines were conducted. Other experts participated in formal consensus. RESULTS Seven existing guidelines were identified and reviewed, and adapted recommendations form the evidence base. Four systematic reviews plus cost-effectiveness analyses provided indirect evidence to inform consensus, which resulted in ≥ 75% agreement. RECOMMENDATIONS Human papillomavirus (HPV) DNA testing is recommended in all resource settings; visual inspection with acetic acid may be used in basic settings. Recommended age ranges and frequencies by setting are as follows: maximal: ages 25 to 65, every 5 years; enhanced: ages 30 to 65, if two consecutive negative tests at 5-year intervals, then every 10 years; limited: ages 30 to 49, every 10 years; and basic: ages 30 to 49, one to three times per lifetime. For basic settings, visual assessment is recommended as triage; in other settings, genotyping and/or cytology are recommended. For basic settings, treatment is recommended if abnormal triage results are present; in other settings, colposcopy is recommended for abnormal triage results. For basic settings, treatment options are cryotherapy or loop electrosurgical excision procedure; for other settings, loop electrosurgical excision procedure (or ablation) is recommended. Twelve-month post-treatment follow-up is recommended in all settings. Women who are HIV positive should be screened with HPV testing after diagnosis and screened twice as many times per lifetime as the general population. Screening is recommended at 6 weeks postpartum in basic settings; in other settings, screening is recommended at 6 months. In basic settings without mass screening, infrastructure for HPV testing, diagnosis, and treatment should be developed.Additional information can be found at www.asco.org/rs-cervical-cancer-secondary-prev-guideline and www.asco.org/guidelineswiki.It is the view of of ASCO that health care providers and health care system decision makers should be guided by the recommendations for the highest stratum of resources available. The guideline is intended to complement, but not replace, local guidelines.
Collapse
Affiliation(s)
- Jose Jeronimo
- , PATH, Seattle, WA; , Global Coalition Against Cervical Cancer, Albert Einstein College of Medicine, Arlington; , American Society of Clinical Oncology, Alexandria, VA; , University of Cape Town, Cape Town, South Africa; , V Care; , Tata Memorial Center, Mumbai, India; , Harvard T.H. Chan School of Public Health, Boston, MA; , PanAmerican Health Organization, Washington, DC; , Uganda Women's Health Initiative, Kampala, Uganda; , International Network for Cancer Treatment and Research, Dar Es Salaam, Tanzania; , Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China; , University of Melbourne, Melbourne, Victoria, Australia; , International Agency for Research on Cancer, Lyon, France; , Queen Mary, University of London, London, United Kingdom; and , The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Philip E Castle
- , PATH, Seattle, WA; , Global Coalition Against Cervical Cancer, Albert Einstein College of Medicine, Arlington; , American Society of Clinical Oncology, Alexandria, VA; , University of Cape Town, Cape Town, South Africa; , V Care; , Tata Memorial Center, Mumbai, India; , Harvard T.H. Chan School of Public Health, Boston, MA; , PanAmerican Health Organization, Washington, DC; , Uganda Women's Health Initiative, Kampala, Uganda; , International Network for Cancer Treatment and Research, Dar Es Salaam, Tanzania; , Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China; , University of Melbourne, Melbourne, Victoria, Australia; , International Agency for Research on Cancer, Lyon, France; , Queen Mary, University of London, London, United Kingdom; and , The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Sarah Temin
- , PATH, Seattle, WA; , Global Coalition Against Cervical Cancer, Albert Einstein College of Medicine, Arlington; , American Society of Clinical Oncology, Alexandria, VA; , University of Cape Town, Cape Town, South Africa; , V Care; , Tata Memorial Center, Mumbai, India; , Harvard T.H. Chan School of Public Health, Boston, MA; , PanAmerican Health Organization, Washington, DC; , Uganda Women's Health Initiative, Kampala, Uganda; , International Network for Cancer Treatment and Research, Dar Es Salaam, Tanzania; , Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China; , University of Melbourne, Melbourne, Victoria, Australia; , International Agency for Research on Cancer, Lyon, France; , Queen Mary, University of London, London, United Kingdom; and , The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Lynette Denny
- , PATH, Seattle, WA; , Global Coalition Against Cervical Cancer, Albert Einstein College of Medicine, Arlington; , American Society of Clinical Oncology, Alexandria, VA; , University of Cape Town, Cape Town, South Africa; , V Care; , Tata Memorial Center, Mumbai, India; , Harvard T.H. Chan School of Public Health, Boston, MA; , PanAmerican Health Organization, Washington, DC; , Uganda Women's Health Initiative, Kampala, Uganda; , International Network for Cancer Treatment and Research, Dar Es Salaam, Tanzania; , Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China; , University of Melbourne, Melbourne, Victoria, Australia; , International Agency for Research on Cancer, Lyon, France; , Queen Mary, University of London, London, United Kingdom; and , The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Vandana Gupta
- , PATH, Seattle, WA; , Global Coalition Against Cervical Cancer, Albert Einstein College of Medicine, Arlington; , American Society of Clinical Oncology, Alexandria, VA; , University of Cape Town, Cape Town, South Africa; , V Care; , Tata Memorial Center, Mumbai, India; , Harvard T.H. Chan School of Public Health, Boston, MA; , PanAmerican Health Organization, Washington, DC; , Uganda Women's Health Initiative, Kampala, Uganda; , International Network for Cancer Treatment and Research, Dar Es Salaam, Tanzania; , Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China; , University of Melbourne, Melbourne, Victoria, Australia; , International Agency for Research on Cancer, Lyon, France; , Queen Mary, University of London, London, United Kingdom; and , The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jane J Kim
- , PATH, Seattle, WA; , Global Coalition Against Cervical Cancer, Albert Einstein College of Medicine, Arlington; , American Society of Clinical Oncology, Alexandria, VA; , University of Cape Town, Cape Town, South Africa; , V Care; , Tata Memorial Center, Mumbai, India; , Harvard T.H. Chan School of Public Health, Boston, MA; , PanAmerican Health Organization, Washington, DC; , Uganda Women's Health Initiative, Kampala, Uganda; , International Network for Cancer Treatment and Research, Dar Es Salaam, Tanzania; , Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China; , University of Melbourne, Melbourne, Victoria, Australia; , International Agency for Research on Cancer, Lyon, France; , Queen Mary, University of London, London, United Kingdom; and , The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Silvana Luciani
- , PATH, Seattle, WA; , Global Coalition Against Cervical Cancer, Albert Einstein College of Medicine, Arlington; , American Society of Clinical Oncology, Alexandria, VA; , University of Cape Town, Cape Town, South Africa; , V Care; , Tata Memorial Center, Mumbai, India; , Harvard T.H. Chan School of Public Health, Boston, MA; , PanAmerican Health Organization, Washington, DC; , Uganda Women's Health Initiative, Kampala, Uganda; , International Network for Cancer Treatment and Research, Dar Es Salaam, Tanzania; , Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China; , University of Melbourne, Melbourne, Victoria, Australia; , International Agency for Research on Cancer, Lyon, France; , Queen Mary, University of London, London, United Kingdom; and , The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Daniel Murokora
- , PATH, Seattle, WA; , Global Coalition Against Cervical Cancer, Albert Einstein College of Medicine, Arlington; , American Society of Clinical Oncology, Alexandria, VA; , University of Cape Town, Cape Town, South Africa; , V Care; , Tata Memorial Center, Mumbai, India; , Harvard T.H. Chan School of Public Health, Boston, MA; , PanAmerican Health Organization, Washington, DC; , Uganda Women's Health Initiative, Kampala, Uganda; , International Network for Cancer Treatment and Research, Dar Es Salaam, Tanzania; , Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China; , University of Melbourne, Melbourne, Victoria, Australia; , International Agency for Research on Cancer, Lyon, France; , Queen Mary, University of London, London, United Kingdom; and , The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Twalib Ngoma
- , PATH, Seattle, WA; , Global Coalition Against Cervical Cancer, Albert Einstein College of Medicine, Arlington; , American Society of Clinical Oncology, Alexandria, VA; , University of Cape Town, Cape Town, South Africa; , V Care; , Tata Memorial Center, Mumbai, India; , Harvard T.H. Chan School of Public Health, Boston, MA; , PanAmerican Health Organization, Washington, DC; , Uganda Women's Health Initiative, Kampala, Uganda; , International Network for Cancer Treatment and Research, Dar Es Salaam, Tanzania; , Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China; , University of Melbourne, Melbourne, Victoria, Australia; , International Agency for Research on Cancer, Lyon, France; , Queen Mary, University of London, London, United Kingdom; and , The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Youlin Qiao
- , PATH, Seattle, WA; , Global Coalition Against Cervical Cancer, Albert Einstein College of Medicine, Arlington; , American Society of Clinical Oncology, Alexandria, VA; , University of Cape Town, Cape Town, South Africa; , V Care; , Tata Memorial Center, Mumbai, India; , Harvard T.H. Chan School of Public Health, Boston, MA; , PanAmerican Health Organization, Washington, DC; , Uganda Women's Health Initiative, Kampala, Uganda; , International Network for Cancer Treatment and Research, Dar Es Salaam, Tanzania; , Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China; , University of Melbourne, Melbourne, Victoria, Australia; , International Agency for Research on Cancer, Lyon, France; , Queen Mary, University of London, London, United Kingdom; and , The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Michael Quinn
- , PATH, Seattle, WA; , Global Coalition Against Cervical Cancer, Albert Einstein College of Medicine, Arlington; , American Society of Clinical Oncology, Alexandria, VA; , University of Cape Town, Cape Town, South Africa; , V Care; , Tata Memorial Center, Mumbai, India; , Harvard T.H. Chan School of Public Health, Boston, MA; , PanAmerican Health Organization, Washington, DC; , Uganda Women's Health Initiative, Kampala, Uganda; , International Network for Cancer Treatment and Research, Dar Es Salaam, Tanzania; , Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China; , University of Melbourne, Melbourne, Victoria, Australia; , International Agency for Research on Cancer, Lyon, France; , Queen Mary, University of London, London, United Kingdom; and , The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Rengaswamy Sankaranarayanan
- , PATH, Seattle, WA; , Global Coalition Against Cervical Cancer, Albert Einstein College of Medicine, Arlington; , American Society of Clinical Oncology, Alexandria, VA; , University of Cape Town, Cape Town, South Africa; , V Care; , Tata Memorial Center, Mumbai, India; , Harvard T.H. Chan School of Public Health, Boston, MA; , PanAmerican Health Organization, Washington, DC; , Uganda Women's Health Initiative, Kampala, Uganda; , International Network for Cancer Treatment and Research, Dar Es Salaam, Tanzania; , Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China; , University of Melbourne, Melbourne, Victoria, Australia; , International Agency for Research on Cancer, Lyon, France; , Queen Mary, University of London, London, United Kingdom; and , The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Peter Sasieni
- , PATH, Seattle, WA; , Global Coalition Against Cervical Cancer, Albert Einstein College of Medicine, Arlington; , American Society of Clinical Oncology, Alexandria, VA; , University of Cape Town, Cape Town, South Africa; , V Care; , Tata Memorial Center, Mumbai, India; , Harvard T.H. Chan School of Public Health, Boston, MA; , PanAmerican Health Organization, Washington, DC; , Uganda Women's Health Initiative, Kampala, Uganda; , International Network for Cancer Treatment and Research, Dar Es Salaam, Tanzania; , Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China; , University of Melbourne, Melbourne, Victoria, Australia; , International Agency for Research on Cancer, Lyon, France; , Queen Mary, University of London, London, United Kingdom; and , The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Kathleen M Schmeler
- , PATH, Seattle, WA; , Global Coalition Against Cervical Cancer, Albert Einstein College of Medicine, Arlington; , American Society of Clinical Oncology, Alexandria, VA; , University of Cape Town, Cape Town, South Africa; , V Care; , Tata Memorial Center, Mumbai, India; , Harvard T.H. Chan School of Public Health, Boston, MA; , PanAmerican Health Organization, Washington, DC; , Uganda Women's Health Initiative, Kampala, Uganda; , International Network for Cancer Treatment and Research, Dar Es Salaam, Tanzania; , Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China; , University of Melbourne, Melbourne, Victoria, Australia; , International Agency for Research on Cancer, Lyon, France; , Queen Mary, University of London, London, United Kingdom; and , The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Surendra S Shastri
- , PATH, Seattle, WA; , Global Coalition Against Cervical Cancer, Albert Einstein College of Medicine, Arlington; , American Society of Clinical Oncology, Alexandria, VA; , University of Cape Town, Cape Town, South Africa; , V Care; , Tata Memorial Center, Mumbai, India; , Harvard T.H. Chan School of Public Health, Boston, MA; , PanAmerican Health Organization, Washington, DC; , Uganda Women's Health Initiative, Kampala, Uganda; , International Network for Cancer Treatment and Research, Dar Es Salaam, Tanzania; , Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China; , University of Melbourne, Melbourne, Victoria, Australia; , International Agency for Research on Cancer, Lyon, France; , Queen Mary, University of London, London, United Kingdom; and , The University of Texas MD Anderson Cancer Center, Houston, TX
| |
Collapse
|
31
|
Campos NG, Tsu V, Jeronimo J, Mvundura M, Kim JJ. Evidence-based policy choices for efficient and equitable cervical cancer screening programs in low-resource settings. Cancer Med 2017; 6:2008-2014. [PMID: 28707435 PMCID: PMC5548874 DOI: 10.1002/cam4.1123] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Accepted: 05/25/2017] [Indexed: 01/25/2023] Open
Abstract
Women in developing countries disproportionately bear the burden of cervical cancer. The availability of prophylactic vaccines against human papillomavirus (HPV) types 16 and 18, which cause approximately 70% of cervical cancers, provides reason for optimism as roll-out begins with support from Gavi, the Vaccine Alliance. However, for the hundreds of millions of women beyond the target age for HPV vaccination, cervical cancer screening to detect and treat precancerous lesions remains the only form of prevention. Here we describe the challenges that confront screening programs in low-resource settings, including (1) optimizing screening test effectiveness; (2) achieving high screening coverage of the target population; and (3) managing screen-positive women. For each of these challenges, we summarize the tradeoffs between resource utilization and programmatic attributes. We then highlight opportunities for efficient and equitable programming, with supporting evidence from recent mathematical modeling analyses informed by data from the PATH demonstration projects in India, Nicaragua, and Uganda.
Collapse
Affiliation(s)
- Nicole G. Campos
- Center for Health Decision ScienceHarvard T.H. Chan School of Public Health718 Huntington AvenueBostonMassachusetts
| | - Vivien Tsu
- PATHReproductive Health ProgramSeattleWashington
| | | | | | - Jane J. Kim
- Center for Health Decision ScienceHarvard T.H. Chan School of Public Health718 Huntington AvenueBostonMassachusetts
| |
Collapse
|
32
|
Maza M, Schocken CM, Bergman KL, Randall TC, Cremer ML. Cervical Precancer Treatment in Low- and Middle-Income Countries: A Technology Overview. J Glob Oncol 2017; 3:400-408. [PMID: 28831448 PMCID: PMC5560450 DOI: 10.1200/jgo.2016.003731] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Cervical cancer is the fourth leading cause of cancer-related death in women worldwide, with 90% of cases occurring in low- and middle-income countries (LMICs). There has been a global effort to increase access to affordable screening in these settings; however, a corresponding increase in availability of effective and inexpensive treatment modalities for ablating or excising precancerous lesions is also needed to decrease mortality. This article reviews the current landscape of available and developing technologies for treatment of cervical precancer in LMICs. At present, the standard treatment of most precancerous lesions in LMICs is gas-based cryotherapy. This low-cost, effective technology is an expedient treatment in many areas; however, obtaining and transporting gas is often difficult, and unwieldy gas tanks are not conducive to mobile health campaigns. There are several promising ablative technologies in development that are gasless or require less gas than conventional cryotherapy. Although further evaluation of the efficacy and cost-effectiveness is needed, several of these technologies are safe and can now be implemented in LMICs. Nonsurgical therapies, such as therapeutic vaccines, antivirals, and topical applications, are also promising, but most remain in early-stage trials. The establishment of evidence-based standardized protocols for available treatments and the development and introduction of novel technologies are necessary steps in overcoming barriers to treatment in LMICs and decreasing the global burden of cervical cancer. Guidance from WHO on emerging treatment technologies is also needed.
Collapse
Affiliation(s)
- Mauricio Maza
- Mauricio Maza, Katherine L. Bergman, and Miriam L. Cremer, Basic Health International, New York, NY; Celina M. Schocken, Pink Ribbon Red Ribbon, Washington, DC; Thomas C. Randall, National Cancer Institute, Massachusetts General Hospital, Boston, MA; and Miriam L. Cremer, Cleveland Clinic, Cleveland, OH
| | - Celina M. Schocken
- Mauricio Maza, Katherine L. Bergman, and Miriam L. Cremer, Basic Health International, New York, NY; Celina M. Schocken, Pink Ribbon Red Ribbon, Washington, DC; Thomas C. Randall, National Cancer Institute, Massachusetts General Hospital, Boston, MA; and Miriam L. Cremer, Cleveland Clinic, Cleveland, OH
| | - Katherine L. Bergman
- Mauricio Maza, Katherine L. Bergman, and Miriam L. Cremer, Basic Health International, New York, NY; Celina M. Schocken, Pink Ribbon Red Ribbon, Washington, DC; Thomas C. Randall, National Cancer Institute, Massachusetts General Hospital, Boston, MA; and Miriam L. Cremer, Cleveland Clinic, Cleveland, OH
| | - Thomas C. Randall
- Mauricio Maza, Katherine L. Bergman, and Miriam L. Cremer, Basic Health International, New York, NY; Celina M. Schocken, Pink Ribbon Red Ribbon, Washington, DC; Thomas C. Randall, National Cancer Institute, Massachusetts General Hospital, Boston, MA; and Miriam L. Cremer, Cleveland Clinic, Cleveland, OH
| | - Miriam L. Cremer
- Mauricio Maza, Katherine L. Bergman, and Miriam L. Cremer, Basic Health International, New York, NY; Celina M. Schocken, Pink Ribbon Red Ribbon, Washington, DC; Thomas C. Randall, National Cancer Institute, Massachusetts General Hospital, Boston, MA; and Miriam L. Cremer, Cleveland Clinic, Cleveland, OH
| |
Collapse
|
33
|
Campos NG, Jeronimo J, Tsu V, Castle PE, Mvundura M, Kim JJ. The Cost-Effectiveness of Visual Triage of Human Papillomavirus-Positive Women in Three Low- and Middle-Income Countries. Cancer Epidemiol Biomarkers Prev 2017; 26:1500-1510. [PMID: 28710075 DOI: 10.1158/1055-9965.epi-16-0787] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Revised: 05/11/2017] [Accepted: 07/05/2017] [Indexed: 11/16/2022] Open
Abstract
Background: World Health Organization guidelines support human papillomavirus (HPV) testing alone (followed by treatment with cryotherapy) or in conjunction with visual inspection with acetic acid (VIA) triage testing. Our objective was to determine the cost-effectiveness of VIA triage for HPV-positive women in low-resource settings.Methods: We calibrated mathematical simulation models of HPV infection and cervical cancer to epidemiologic data from India, Nicaragua, and Uganda. Using cost and test performance data from the START-UP demonstration projects, we assumed screening took place either once or three times in a lifetime between ages 30 and 40 years. Strategies included (i) HPV alone, followed by cryotherapy for all eligible HPV-positive women; and (ii) HPV testing with VIA triage for HPV-positive women, followed by cryotherapy for eligible women who were also VIA-positive (HPV-VIA). Model outcomes included lifetime risk of cervical cancer and incremental cost-effectiveness ratios (ICERs; international dollars/year of life saved).Results: In all three countries, HPV alone was more effective than HPV-VIA. In Nicaragua and Uganda, HPV alone was also less costly than HPV-VIA; ICERs associated with screening three times in a lifetime (HPV alone) were below per capita GDP. In India, both HPV alone and HPV-VIA had ICERs below per capita GDP.Conclusions: VIA triage of HPV-positive women is not likely to be cost-effective in settings with high cervical cancer burden. HPV alone followed by treatment may achieve greater health benefits and value for public health dollars.Impact: This study provides early evidence on the cost-effectiveness of HPV testing followed by VIA triage versus an HPV screen-and-treat strategy. Cancer Epidemiol Biomarkers Prev; 26(10); 1500-10. ©2017 AACR.
Collapse
Affiliation(s)
- Nicole G Campos
- Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.
| | - Jose Jeronimo
- PATH, Reproductive Health Program, Seattle, Washington
| | - Vivien Tsu
- PATH, Reproductive Health Program, Seattle, Washington
| | - Philip E Castle
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York
- Global Coalition Against Cervical Cancer, Arlington, Virginia
| | | | - Jane J Kim
- Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| |
Collapse
|
34
|
Campos NG, Sharma M, Clark A, Lee K, Geng F, Regan C, Kim J, Resch S. The health and economic impact of scaling cervical cancer prevention in 50 low- and lower-middle-income countries. Int J Gynaecol Obstet 2017; 138 Suppl 1:47-56. [DOI: 10.1002/ijgo.12184] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Affiliation(s)
- Nicole G. Campos
- Department of Health Policy and Management; Center for Health Decision Science; Harvard T.H. Chan School of Public Health; Boston MA USA
| | - Monisha Sharma
- Department of Epidemiology; School of Public Health; University of Washington Seattle; Seattle WA USA
| | - Andrew Clark
- Department of Health Services Research and Policy; London School of Hygiene and Tropical Medicine; London UK
| | - Kyueun Lee
- Department of Health Research and Policy; Stanford University; Stanford CA USA
| | - Fangli Geng
- Department of Health Policy and Management; Center for Health Decision Science; Harvard T.H. Chan School of Public Health; Boston MA USA
| | - Catherine Regan
- Department of Health Policy and Management; Center for Health Decision Science; Harvard T.H. Chan School of Public Health; Boston MA USA
| | - Jane Kim
- Department of Health Policy and Management; Center for Health Decision Science; Harvard T.H. Chan School of Public Health; Boston MA USA
| | - Stephen Resch
- Department of Health Policy and Management; Center for Health Decision Science; Harvard T.H. Chan School of Public Health; Boston MA USA
| |
Collapse
|
35
|
Campos NG, Tsu V, Jeronimo J, Mvundura M, Lee K, Kim JJ. To expand coverage, or increase frequency: Quantifying the tradeoffs between equity and efficiency facing cervical cancer screening programs in low-resource settings. Int J Cancer 2017; 140:1293-1305. [PMID: 27925175 PMCID: PMC5516173 DOI: 10.1002/ijc.30551] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Accepted: 11/15/2016] [Indexed: 01/09/2023]
Abstract
Cervical cancer is a leading cause of cancer death worldwide, with 85% of the disease burden residing in less developed regions. To inform evidence‐based decision‐making as cervical cancer screening programs are planned, implemented, and scaled in low‐ and middle‐income countries, we used cost and test performance data from the START‐UP demonstration project in Uganda and a microsimulation model of HPV infection and cervical carcinogenesis to quantify the health benefits, distributional equity, cost‐effectiveness, and financial impact of either (1) improving access to cervical cancer screening or (2) increasing the number of lifetime screening opportunities for women who already have access. We found that when baseline screening coverage was low (i.e., 30%), expanding coverage of screening once in a lifetime to 50% can yield comparable reductions in cancer risk to screening two or three times in a lifetime at 30% coverage, lead to greater reductions in health disparities, and cost 150 international dollars (I$) per year of life saved (YLS). At higher baseline screening coverage levels (i.e., 70%), screening three times in a lifetime yielded greater health benefits than expanding screening once in a lifetime to 90% coverage, and would have a cost‐effectiveness ratio (I$590 per YLS) below Uganda's per capita GDP. Given very low baseline coverage at present, we conclude that a policy focus on increasing access for previously unscreened women appears to be more compatible with improving both equity and efficiency than a focus on increasing frequency for a small subset of women. What's new? Most cervical cancer cases and deaths occur in less‐developed countries, where resource constraints challenge the planning and implementation of screening programs. The present report examines tradeoffs between equity and efficiency in cervical cancer screening approaches specifically in Uganda, where current baseline screening coverage is low. Analyses indicate that the expansion of access to once‐in‐a lifetime cervical cancer screening in areas with initially low baseline coverage is likely to yield greater benefits for health, distributional equity and cost‐effectiveness than increasing the number of screening opportunities per woman in low‐resource settings. Improving access for previously unscreened women should be a priority in such areas.
Collapse
Affiliation(s)
- Nicole G Campos
- Harvard T.H. Chan School of Public Health, Center for Health Decision Science, 718 Huntington Avenue, Boston, MA
| | - Vivien Tsu
- PATH, Reproductive Health Program, P.O. Box 900922, Seattle, WA
| | - Jose Jeronimo
- PATH, Reproductive Health Program, P.O. Box 900922, Seattle, WA
| | - Mercy Mvundura
- Devices and Tools Program, PATH, P.O. Box 900922, Seattle, WA
| | - Kyueun Lee
- Harvard T.H. Chan School of Public Health, Center for Health Decision Science, 718 Huntington Avenue, Boston, MA.,Department of Health Research and Policy, Stanford University, Stanford, CA
| | - Jane J Kim
- Harvard T.H. Chan School of Public Health, Center for Health Decision Science, 718 Huntington Avenue, Boston, MA
| |
Collapse
|
36
|
Campos NG, Mvundura M, Jeronimo J, Holme F, Vodicka E, Kim JJ. Cost-effectiveness of HPV-based cervical cancer screening in the public health system in Nicaragua. BMJ Open 2017; 7:e015048. [PMID: 28619772 PMCID: PMC5623348 DOI: 10.1136/bmjopen-2016-015048] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Nicole G Campos
- Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Mercy Mvundura
- PATH, Devices and Tools Program, Seattle, Washington, USA
| | - Jose Jeronimo
- PATH, Reproductive Health Global Program, Seattle, Washington, USA
| | - Francesca Holme
- PATH, Reproductive Health Global Program, Seattle, Washington, USA
| | - Elisabeth Vodicka
- University of Washington, School of Pharmacy, Seattle, Washington, USA
| | - Jane J Kim
- Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| |
Collapse
|
37
|
Cost-effectiveness of cervical cancer screening methods in low- and middle-income countries: A systematic review. Int J Cancer 2017; 141:437-446. [DOI: 10.1002/ijc.30695] [Citation(s) in RCA: 85] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Revised: 02/06/2017] [Accepted: 02/08/2017] [Indexed: 01/15/2023]
|
38
|
Denny L, de Sanjose S, Mutebi M, Anderson BO, Kim J, Jeronimo J, Herrero R, Yeates K, Ginsburg O, Sankaranarayanan R. Interventions to close the divide for women with breast and cervical cancer between low-income and middle-income countries and high-income countries. Lancet 2017; 389:861-870. [PMID: 27814963 DOI: 10.1016/s0140-6736(16)31795-0] [Citation(s) in RCA: 141] [Impact Index Per Article: 20.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2015] [Revised: 07/11/2016] [Accepted: 07/19/2016] [Indexed: 01/06/2023]
Abstract
Breast and cervical cancers are the commonest cancers diagnosed in women living in low-income and middle-income countries (LMICs), where opportunities for prevention, early detection, or both, are few. Yet several cost-effective interventions could be used to reduce the burden of these two cancers in resource-limited environments. Population- wide vaccination against human papillomavirus (HPV) linked to cervical screening, at least once, for adult women has the potential to reduce the incidence of cervical cancer substantially. Strategies such as visual inspection with acetic acid and testing for oncogenic HPV types could make prevention of cervical cancer programmatically feasible. These two cancers need not be viewed as inevitably fatal, and can be cured, particularly if detected and treated at an early stage. Investing in the health of girls and women is an investment in the development of nations and their futures. Here we explore ways to lessen the divide between LMICs and high-income countries for breast and cervical cancers.
Collapse
Affiliation(s)
- Lynette Denny
- Department of Obstetrics and Gynaecology, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa.
| | - Silvia de Sanjose
- Cancer Epidemiology Research Programme, Catalan Institute of Oncology, IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain; CIBER en Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain
| | - Miriam Mutebi
- Department of Surgery, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa; Department of Surgery, Aga Khan University, Nairobi, Kenya
| | - Benjamin O Anderson
- Department of Surgery and Global Health Medicine, University of Washington, Division of Public Health Sciences, Seattle, WA, USA; Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Jane Kim
- Department of Health Policy and Management, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Jose Jeronimo
- Program for Appropriate Technology in Health (PATH), Seattle, WA, USA
| | - Rolando Herrero
- Prevention and Implementation Group, International Agency for Research on Cancer, Lyon, France
| | - Karen Yeates
- Department of Medicine, Queen's University, Kingston, ON, Canada
| | - Ophira Ginsburg
- Institute of Cancer Policy, Women's College Research Institute, Faculty of Medicine, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada; WHO, Geneva, Switzerland
| | | |
Collapse
|
39
|
Akhavan-Tabatabaei R, Sánchez DM, Yeung TG. A Markov Decision Process Model for Cervical Cancer Screening Policies in Colombia. Med Decis Making 2016; 37:196-211. [PMID: 27803361 DOI: 10.1177/0272989x16670622] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Cervical cancer is the second most common cancer in women around the world, and the human papillomavirus (HPV) is universally known as the necessary agent for developing this disease. Through early detection of abnormal cells and HPV virus types, cervical cancer incidents can be reduced and disease progression prevented. We propose a finite-horizon Markov decision process model to determine the optimal screening policies for cervical cancer prevention. The optimal decision is given in terms of when and what type of screening test to be performed on a patient based on her current diagnosis, age, HPV contraction risk, and screening test results. The cost function considers the tradeoff between the cost of prevention and treatment procedures and the risk of taking no action while taking into account a cost assigned to loss of life quality in each state. We apply the model to data collected from a representative sample of 1141 affiliates at a health care provider located in Bogotá, Colombia. To track the disease incidence more effectively and avoid higher cancer rates and future costs, the optimal policies recommend more frequent colposcopies and Pap tests for women with riskier profiles.
Collapse
Affiliation(s)
- Raha Akhavan-Tabatabaei
- Department of Industrial Engineering, Universidad de los Andes, Bogotá, Colombia (RA-T, DMS).,School of Management, Sabanci University, Istanbul, Turkey (RA-T)
| | - Diana Marcela Sánchez
- Department of Industrial Engineering, Universidad de los Andes, Bogotá, Colombia (RA-T, DMS)
| | - Thomas G Yeung
- Department of Industrial Engineering & Automatic Control, Ecole des Mines de Nantes/IRCCyN, Nantes, France (TY)
| |
Collapse
|
40
|
Affiliation(s)
- Vivien Tsu
- From PATH (formerly the Program for Appropriate Technology in Health), Seattle
| | - José Jerónimo
- From PATH (formerly the Program for Appropriate Technology in Health), Seattle
| |
Collapse
|