1
|
Kulkarni A, Chen L, Gockley A, Khoury-Collado F, Hou J, Clair CST, Melamed A, Hershman DL, Wright JD. Patterns of cervical cancer screening follow-up in the era of prolonged screening intervals. Gynecol Oncol 2023; 175:53-59. [PMID: 37327539 DOI: 10.1016/j.ygyno.2023.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 06/02/2023] [Accepted: 06/06/2023] [Indexed: 06/18/2023]
Abstract
INTRODUCTION Little is known as to how prolonged screening recommendations for cervical cancer have affected compliance. OBJECTIVE We examined compliance with repeat cervical cancer screening among U.S. women aged 30-64 who underwent index screening between 2013 and 2019. STUDY DESIGN The IBM Watson Health MarketScan Database was used to identify commercially-insured women 30-64 years old who underwent cervical cancer screening from 2013 to 2019. The cohort was limited to women with continuous insurance 12 months before and ≥ 2 months after index testing. Patients with prior hysterectomy, more frequent surveillance needs, or a history of abnormal cytology, histology, or HPV test were excluded. Index screening included cytology, co-testing, or primary HPV testing. Cumulative incidence curves described screening intervals. Compliance was considered if repeat screening occurred 2.5-4 years after index cytology and 4.5-6 years after index co-testing. Cause-specific hazard models examined factors associated with compliance. RESULTS Of 5,368,713 patients identified, co-testing was performed in 2,873,070 (53.5%), cytology in 2,422,480 (45.1%), and primary HPV testing in 73,163 (1.4%). The cumulative incidence of repeat screening among all women by seven years was 81.9%. Of those who underwent repeat screening, 85.7% with index cytology and 96.6% with index co-testing were rescreened early. Only, 12.2% with index cytology had appropriate rescreening and 2.1% had delayed rescreening. Among the index co-testing group, 3.2% had appropriate rescreening and 0.3% had delayed rescreening. CONCLUSION Appropriate cervical cancer follow-up screening is highly variable. The cumulative incidence rate of repeat screening was 81.9% and among women rescreened, the vast majority are tested earlier than recommended by current guidelines.
Collapse
Affiliation(s)
- Amita Kulkarni
- Columbia University College of Physicians and Surgeons, USA
| | - Ling Chen
- Columbia University College of Physicians and Surgeons, USA
| | - Allison Gockley
- Columbia University College of Physicians and Surgeons, USA; Herbert Irving Comprehensive Cancer Center, USA; New York Presbyterian Hospital, USA
| | - Fady Khoury-Collado
- Columbia University College of Physicians and Surgeons, USA; Herbert Irving Comprehensive Cancer Center, USA; New York Presbyterian Hospital, USA
| | - June Hou
- Columbia University College of Physicians and Surgeons, USA; Herbert Irving Comprehensive Cancer Center, USA; New York Presbyterian Hospital, USA
| | - Caryn S T Clair
- Columbia University College of Physicians and Surgeons, USA; Herbert Irving Comprehensive Cancer Center, USA; New York Presbyterian Hospital, USA
| | - Alexander Melamed
- Columbia University College of Physicians and Surgeons, USA; Herbert Irving Comprehensive Cancer Center, USA; New York Presbyterian Hospital, USA
| | - Dawn L Hershman
- Columbia University College of Physicians and Surgeons, USA; Herbert Irving Comprehensive Cancer Center, USA; New York Presbyterian Hospital, USA; Joseph L. Mailman School of Public Health, Columbia University, USA
| | - Jason D Wright
- Columbia University College of Physicians and Surgeons, USA; Herbert Irving Comprehensive Cancer Center, USA; New York Presbyterian Hospital, USA.
| |
Collapse
|
2
|
Options for triage and implications for colposcopists within European HPV-based cervical screening programmes. Eur J Obstet Gynecol Reprod Biol 2021; 258:332-342. [PMID: 33524777 DOI: 10.1016/j.ejogrb.2020.12.061] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 11/07/2020] [Accepted: 12/23/2020] [Indexed: 11/23/2022]
Abstract
The development of human papillomavirus (HPV)-based screening should detect more pre-cancerous changes and so reduce the incidence and mortality from cervical squamous carcinoma and cervical adenocarcinoma. However, many more women are high risk HPV (hrHPV) screen positive compared to cytology-based screening, especially in younger age-women. A variety of tests have become available which may triage into those hrHPV test-positive women who need immediate referral to colposcopy from those who need early repeat HPV tests or recall on the basis of their disease status. We performed a literature review of publications and a manual search from 2010, reporting cytology, HPV partial genotyping, dual-staining and DNA methylation for triage of hrHPV positive tests, including their comparative performance between these methods as well as the effectiveness of some triage combinations with reference to HPV-based screening services in Europe. Cost effectiveness and the structure of triage algorithms for colposcopists also have been considered. From one report evaluating four options for triage as single options or as combined algorithms, partial genotyping for HPV 16 and 18 with dual-staining yielded the highest risk of cervical intraepithelial neoplasia grade three or worse within an HPV positive population and with an acceptable colposcopy rate. From a separate paper, this option appeared cost effective. However, publications were difficult to compare objectively. All options have their merits but a combination triage involving any two of cytology, HPV partial genotyping or dual-staining seems most efficient at present. HPV vaccination may impact upon the performance of future partial genotyping. DNA Methylation may become an acceptable future option.
Collapse
|
3
|
Ratushnyak S, Hoogendoorn M, van Baal PHM. Cost-Effectiveness of Cancer Screening: Health and Costs in Life Years Gained. Am J Prev Med 2019; 57:792-799. [PMID: 31753260 DOI: 10.1016/j.amepre.2019.07.027] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Revised: 07/23/2019] [Accepted: 07/24/2019] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Studies reporting on the cost-effectiveness of cancer screening usually account for quality of life losses and healthcare costs owing to cancer but do not account for future costs and quality of life losses related to competing risks. This study aims to demonstrate the impact of medical costs and quality of life losses of other diseases in the life years gained on the cost-effectiveness of U.S. cancer screening. METHODS Cost-effectiveness studies of breast, cervical, and colorectal cancer screening in the U.S. were identified using a systematic literature review. Incremental cost-effectiveness ratios of the eligible articles were updated by adding lifetime expenditures and health losses per quality-adjusted life year gained because of competing risks. This was accomplished using data on medical spending and quality of life by age and disease from the Medical Expenditure Panel Survey (2011-2015) combined with cause-deleted life tables. The study was conducted in 2018. RESULTS The impact of quality of life losses and healthcare expenditures of competing risks in life years gained incurred owing to screening were the highest for breast cancer and the lowest for cervical cancer. The updates suggest that incremental cost-effectiveness ratios are underestimated by $10,300-$13,700 per quality-adjusted life year gained if quality of life losses and healthcare expenditures of competing risks are omitted in economic evaluations. Furthermore, cancer screening programs that were considered cost saving, were found not to be so following the inclusion of medical expenditures of competing risks. CONCLUSIONS Practical difficulties in quantifying quality of life losses and healthcare expenditures owing to competing risks in life years gained can be overcome. Their inclusion can have a substantial impact on the cost-effectiveness of cancer screening programs.
Collapse
Affiliation(s)
- Svetlana Ratushnyak
- Erasmus School of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands; Center of Healthcare Quality Assessment and Control, Ministry of Health of the Russian Federation, Moscow, Russia
| | - Martine Hoogendoorn
- Institute for Medical Technology Assessment, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Pieter H M van Baal
- Erasmus School of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands.
| |
Collapse
|
4
|
The Next Generation of Cervical Cancer Screening: Should Guidelines Focus on Best Practices for the Future or Current Screening Capacity? J Low Genit Tract Dis 2019; 22:91-96. [PMID: 29570563 PMCID: PMC5895142 DOI: 10.1097/lgt.0000000000000378] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
|
5
|
Sawaya GF, Sanstead E, Alarid-Escudero F, Smith-McCune K, Gregorich SE, Silverberg MJ, Leyden W, Huchko MJ, Kuppermann M, Kulasingam S. Estimated Quality of Life and Economic Outcomes Associated With 12 Cervical Cancer Screening Strategies: A Cost-effectiveness Analysis. JAMA Intern Med 2019; 179:867-878. [PMID: 31081851 PMCID: PMC6515585 DOI: 10.1001/jamainternmed.2019.0299] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Many cervical cancer screening strategies are now recommended in the United States, but the benefits, harms, and costs of each option are unclear. OBJECTIVE To estimate the cost-effectiveness of 12 cervical cancer screening strategies. DESIGN, SETTING, AND PARTICIPANTS The cross-sectional portion of this study enrolled a convenience sample of 451 English-speaking or Spanish-speaking women aged 21 to 65 years from September 22, 2014, to June 16, 2016, identified at women's health clinics in San Francisco. In this group, utilities (preferences) were measured for 23 cervical cancer screening-associated health states and were applied to a decision model of type-specific high-risk human papillomavirus (hrHPV)-induced cervical carcinogenesis. Test accuracy estimates were abstracted from systematic reviews. The evaluated strategies were cytologic testing every 3 years for women aged 21 to 65 years with either repeat cytologic testing in 1 year or immediate hrHPV triage for atypical squamous cells of undetermined significance (ASC-US), cytologic testing every 3 years for women age 21 to 29 years followed by cytologic testing plus hrHPV testing (cotesting), or primary hrHPV testing alone for women aged 30 to 65 years. Screening frequency, abnormal test result management, and the age to switch from cytologic testing to hrHPV testing (25 or 30 years) were varied. Analyses were conducted from both the societal and health care sector perspectives. MAIN OUTCOMES AND MEASURES Utilities for 23 cervical cancer screening-associated health states (cross-sectional study) and quality-adjusted life-years (QALYs) and total costs for each strategy. RESULTS Utilities were measured in a sociodemographically diverse group of 451 women (mean [SD] age, 38.2 [10.7] years; 258 nonwhite [57.2%]). Cytologic testing every 3 years with repeat cytologic testing for ASC-US yielded the most lifetime QALYs and conferred more QALYs at higher costs ($2166 per QALY) than the lowest-cost strategy (cytologic testing every 3 years with hrHPV triage of ASC-US). All cytologic testing plus hrHPV testing (cotesting) and primary hrHPV testing strategies provided fewer QALYs at higher costs. Adding indirect costs did not change the conclusions. In sensitivity analyses, hrHPV testing every 5 years with genotyping triage beginning at age 30 years was the lowest-cost strategy when hrHPV test sensitivity was markedly higher than cytologic test sensitivity or when hrHPV test cost was equated to the lowest reported cytologic test cost ($14). CONCLUSIONS AND RELEVANCE Cytologic testing every 3 years for women aged 21 to 29 years with either continued cytologic testing every 3 years or switching to a low-cost hrHPV test every 5 years confers a reasonable balance of benefits, harms, and costs. Comparative modeling is needed to confirm the association of these novel utilities with cost-effectiveness.
Collapse
Affiliation(s)
- George F Sawaya
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco.,University of California, San Francisco Center for Healthcare Value, San Francisco
| | - Erinn Sanstead
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis
| | - Fernando Alarid-Escudero
- Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis.,now at Drug Policy Program, Center for Research and Teaching in Economics, Aguascalientes, Aguascalientes, Mexico
| | - Karen Smith-McCune
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco
| | | | | | - Wendy Leyden
- Division of Research, Kaiser Permanente, Oakland, California
| | - Megan J Huchko
- Department of Obstetrics and Gynecology, Global Health Institute, Duke University, Durham, North Carolina
| | - Miriam Kuppermann
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco
| | - Shalini Kulasingam
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis
| |
Collapse
|
6
|
Felix JC, Lacey MJ, Miller JD, Lenhart GM, Spitzer M, Kulkarni R. The Clinical and Economic Benefits of Co-Testing Versus Primary HPV Testing for Cervical Cancer Screening: A Modeling Analysis. J Womens Health (Larchmt) 2016; 25:606-16. [PMID: 27023044 PMCID: PMC4900245 DOI: 10.1089/jwh.2015.5708] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Background: Consensus United States cervical cancer screening guidelines recommend use of combination Pap plus human papillomavirus (HPV) testing for women aged 30 to 65 years. An HPV test was approved by the Food and Drug Administration in 2014 for primary cervical cancer screening in women age 25 years and older. Here, we present the results of clinical-economic comparisons of Pap plus HPV mRNA testing including genotyping for HPV 16/18 (co-testing) versus DNA-based primary HPV testing with HPV 16/18 genotyping and reflex cytology (HPV primary) for cervical cancer screening. Methods: A health state transition (Markov) model with 1-year cycling was developed using epidemiologic, clinical, and economic data from healthcare databases and published literature. A hypothetical cohort of one million women receiving triennial cervical cancer screening was simulated from ages 30 to 70 years. Screening strategies compared HPV primary to co-testing. Outcomes included total and incremental differences in costs, invasive cervical cancer (ICC) cases, ICC deaths, number of colposcopies, and quality-adjusted life years for cost-effectiveness calculations. Comprehensive sensitivity analyses were performed. Results: In a simulation cohort of one million 30-year-old women modeled up to age 70 years, the model predicted that screening with HPV primary testing instead of co-testing could lead to as many as 2,141 more ICC cases and 2,041 more ICC deaths. In the simulation, co-testing demonstrated a greater number of lifetime quality-adjusted life years (22,334) and yielded $39.0 million in savings compared with HPV primary, thereby conferring greater effectiveness at lower cost. Conclusions: Model results demonstrate that co-testing has the potential to provide improved clinical and economic outcomes when compared with HPV primary. While actual cost and outcome data are evaluated, these findings are relevant to U.S. healthcare payers and women's health policy advocates seeking cost-effective cervical cancer screening technologies.
Collapse
Affiliation(s)
- Juan C Felix
- 1 Keck School of Medicine, University of Southern California , Los Angeles, California
| | | | | | | | - Mark Spitzer
- 3 Hofstra North Shore-LIJ School of Medicine , Hempstead, New York
| | | |
Collapse
|
7
|
Khodakarami N, Farzaneh F, Yavari P, Akbari ME. Cervical Cancer Screening: Recommendations for Muslim Societies. Asian Pac J Cancer Prev 2016; 17:239-47. [PMID: 26838217 DOI: 10.7314/apjcp.2016.17.1.239] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The overall cervical cancer incidence rate is low in Iran; however, because of a higher risk of death for cervical cancer, a disease that kills women in middle age, a cervical cancer control program is needed. The aim of this study was to provide consensus recommendation for cervical cancer prevention in Iran and other Muslim societies with low incidences of cervical cancer. MATERIALS AND METHODS Through a practical guideline development cycle, we developed six questions that were relevant to produce the recommendation. We reviewed 190 full text records of cervical cancer in Iran (1971 to 2013) of which 13 articles were related to the data needed to answer the recommendation questions. We also reviewed World Health Organization, IARC, GLOBOCAN report, Iran Ministry of Health cancer registry report and 8 available foreign countries guidelines. Lastly, we also evaluated the Pap smear results of 825 women who participated in the Iranian HPV survey, of whom 328 were followed-up after a 5-year interval. RESULTS The obtained data highlighted the burden of HPV and cervical cancer situation in Iran. Experts emphasized the necessity of a cervical cancer screening program for Iranian women, and recommended an organized screening program with a cytological evaluation (Pap smear) that would start at the age of 30 years, repeated every 5 years, and end at the age of 69 years. Meanwhile, there is no need for screening among women with a hysterectomy, and screening should be postponed to post-partum among pregnant women. CONCLUSIONS An organized cervical cancer screening is a necessity for Iran as more than 500-900 women in middle age diagnosed with an invasive cervical cancer every year cannot be ignored. This recommendation should be taken into account by the National Health System of Iran and Muslim countries with shared culture and behavior patterns. CUBA HPV test could be consideration in countries Muslim country with appropriate budget, resources and facility.
Collapse
Affiliation(s)
- Nahid Khodakarami
- Cancer Research Center Shahid Beheshti University of Medical Sciences Tehran, Iran E-mail :
| | | | | | | |
Collapse
|
8
|
O'Mahony JF, Naber SK, Normand C, Sharp L, O'Leary JJ, de Kok IMCM. Beware of Kinked Frontiers: A Systematic Review of the Choice of Comparator Strategies in Cost-Effectiveness Analyses of Human Papillomavirus Testing in Cervical Screening. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2015; 18:1138-1151. [PMID: 26686801 DOI: 10.1016/j.jval.2015.09.2939] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/01/2014] [Revised: 08/11/2015] [Accepted: 09/30/2015] [Indexed: 06/05/2023]
Abstract
OBJECTIVES To systematically review the choice of comparator strategies in cost-effectiveness analyses (CEAs) of human papillomavirus testing in cervical screening. METHODS The PubMed, Web of Knowledge, and Scopus databases were searched to identify eligible model-based CEAs of cervical screening programs using human papillomavirus testing. The eligible CEAs were reviewed to investigate what screening strategies were chosen for analysis and how this choice might have influenced estimates of the incremental cost-effectiveness ratio (ICER). Selected examples from the reviewed studies are presented to illustrate how the omission of relevant comparators might influence estimates of screening cost-effectiveness. RESULTS The search identified 30 eligible CEAs. The omission of relevant comparator strategies appears likely in 18 studies. The ICER estimates in these cases are probably lower than would be estimated had more comparators been included. Five of the 30 studies restricted relevant comparator strategies to sensitivity analyses or other subanalyses not part of the principal base-case analysis. Such exclusion of relevant strategies from the base-case analysis can result in cost-ineffective strategies being identified as cost-effective. CONCLUSIONS Many of the CEAs reviewed appear to include insufficient comparator strategies. In particular, they omit strategies with relatively long screening intervals. Omitting relevant comparators matters particularly if it leads to the underestimation of ICERs for strategies around the cost-effectiveness threshold because these strategies are the most policy relevant from the CEA perspective. Consequently, such CEAs may not be providing the best possible policy guidance and lead to the mistaken adoption of cost-ineffective screening strategies.
Collapse
Affiliation(s)
- James F O'Mahony
- Department of Health Policy and Management, School of Medicine, Trinity College Dublin, Dublin, Ireland.
| | - Steffie K Naber
- Department of Public Health, Erasmus Medical Centre, Erasmus University, Rotterdam, The Netherlands
| | - Charles Normand
- Department of Health Policy and Management, School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - Linda Sharp
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - John J O'Leary
- Department of Histopathology, Trinity College Dublin, Dublin, Ireland; Department of Pathology, Coombe Women's and Infants University Hospital, Dublin, Ireland
| | - Inge M C M de Kok
- Department of Public Health, Erasmus Medical Centre, Erasmus University, Rotterdam, The Netherlands
| |
Collapse
|
9
|
Mendes D, Bains I, Vanni T, Jit M. Systematic review of model-based cervical screening evaluations. BMC Cancer 2015; 15:334. [PMID: 25924871 PMCID: PMC4419493 DOI: 10.1186/s12885-015-1332-8] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2014] [Accepted: 04/22/2015] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Optimising population-based cervical screening policies is becoming more complex due to the expanding range of screening technologies available and the interplay with vaccine-induced changes in epidemiology. Mathematical models are increasingly being applied to assess the impact of cervical cancer screening strategies. METHODS We systematically reviewed MEDLINE®, Embase, Web of Science®, EconLit, Health Economic Evaluation Database, and The Cochrane Library databases in order to identify the mathematical models of human papillomavirus (HPV) infection and cervical cancer progression used to assess the effectiveness and/or cost-effectiveness of cervical cancer screening strategies. Key model features and conclusions relevant to decision-making were extracted. RESULTS We found 153 articles meeting our eligibility criteria published up to May 2013. Most studies (72/153) evaluated the introduction of a new screening technology, with particular focus on the comparison of HPV DNA testing and cytology (n = 58). Twenty-eight in forty of these analyses supported HPV DNA primary screening implementation. A few studies analysed more recent technologies - rapid HPV DNA testing (n = 3), HPV DNA self-sampling (n = 4), and genotyping (n = 1) - and were also supportive of their introduction. However, no study was found on emerging molecular markers and their potential utility in future screening programmes. Most evaluations (113/153) were based on models simulating aggregate groups of women at risk of cervical cancer over time without accounting for HPV infection transmission. Calibration to country-specific outcome data is becoming more common, but has not yet become standard practice. CONCLUSIONS Models of cervical screening are increasingly used, and allow extrapolation of trial data to project the population-level health and economic impact of different screening policy. However, post-vaccination analyses have rarely incorporated transmission dynamics. Model calibration to country-specific data is increasingly common in recent studies.
Collapse
Affiliation(s)
- Diana Mendes
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, Keppel Street, Bloomsbury, London, WC1E 7HT, UK.
- Modelling and Economics Unit, Public Health England, 61 Colindale Avenue, London, NW9 5EQ, UK.
| | - Iren Bains
- Modelling and Economics Unit, Public Health England, 61 Colindale Avenue, London, NW9 5EQ, UK.
| | - Tazio Vanni
- Brazilian Ministry of Health, Esplanada dos Ministérios Bloco G, Brasília-DF, CEP: 70058-900, Brasil.
| | - Mark Jit
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, Keppel Street, Bloomsbury, London, WC1E 7HT, UK.
- Modelling and Economics Unit, Public Health England, 61 Colindale Avenue, London, NW9 5EQ, UK.
| |
Collapse
|
10
|
Huh WK, Williams E, Huang J, Bramley T, Poulios N. Cost effectiveness of human papillomavirus-16/18 genotyping in cervical cancer screening. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2015; 13:95-107. [PMID: 25385310 PMCID: PMC5031721 DOI: 10.1007/s40258-014-0135-4] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
BACKGROUND There is limited understanding of the health economic implications of cervical screening with human papillomavirus (HPV)-16/18 genotyping. OBJECTIVE The aim of this study was to evaluate the cost effectiveness of cervical cancer primary screening with a HPV-16/18 genotyping test which simultaneously detects 12 other high-risk HPV types. METHODS A Markov cohort model compared four strategies: (1) cytology with reflex HPV testing for atypical squamous cells of undetermined significance (ASC-US); (2) co-testing with cytology and HPV testing; (3) HPV with reflex to cytology; and (4) HPV with 16/18 genotyping and reflex cytology (ASC-US threshold). Screening began at age 30 and was performed triennially over 40 years. Screening sensitivity and specificity values for cervical intraepithelial neoplasia (CIN) 3 were obtained from the Addressing THE Need for Advanced HPV Diagnostics (ATHENA) trial. Outcomes for a 1-year follow-up scenario wherein persistent disease was detected were estimated. Screening and cancer treatment costs were calculated from a US payer's perspective in 2013. Costs and quality-adjusted life-years (QALYs) were discounted at 3 % annually. RESULTS Applying a US$50,000/QALY threshold, strategy (4) dominated strategies (2) and (3) by reducing costs and cancer incidence and improving QALYs, and was cost effective versus strategy (1). Accounting for persistent ≥CIN 3 at 1 year, strategy (4) was cost effective versus all other strategies. Detecting HPV-16/18 resulted in earlier diagnosis of clinically relevant ≥CIN 3 at initial screening and efficient use of follow-up resources. Outcomes were most influenced by strategy performance. CONCLUSIONS Incorporating HPV-16/18 genotyping is cost effective and may improve detection of CIN, thereby preventing cervical cancer.
Collapse
Affiliation(s)
- Warner K Huh
- University of Alabama at Birmingham, 1700 6th Avenue South, WIC Room 10250, Birmingham, 35233, AL, USA,
| | | | | | | | | |
Collapse
|
11
|
Nahvijou A, Hadji M, BaratiMarnani A, Tourang F, NedaBayat N, Weiderpass E, Daroudi R, AkbariSari A, Zendehdel K. A Systematic Review of Economic Aspects of Cervical Cancer Screening Strategies Worldwide: Discrepancy between Economic Analysis and Policymaking. Asian Pac J Cancer Prev 2014. [DOI: 10.7314/apjcp.2014.15.19.8229] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
|
12
|
Harper DM, Groner JA. Positive high-risk HPV test with negative cytology--a conundrum and blessing of our latest technology. Cancer Epidemiol Biomarkers Prev 2014; 23:10-1. [PMID: 24420983 DOI: 10.1158/1055-9965.epi-13-0708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Diane M Harper
- Authors' Affiliations: Departments of Obstetrics and Gynecology, Community and Family Medicine, Biomedical and Health Informatics, and Community and Family Medicine, University of Missouri Kansas City, Leawood, Kansas
| | | |
Collapse
|
13
|
Richardson LA, Tota J, Franco EL. Optimizing technology for cervical cancer screening in high-resource settings. ACTA ACUST UNITED AC 2014; 6:343-353. [PMID: 26617667 DOI: 10.1586/eog.11.13] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Although historically successful in reducing the burden of cervical cancer, Papanicolaou (Pap) testing faces numerous limitations. A growing body of evidence suggests that modern screening practice will benefit from primary screening for high-risk human papillomavirus (HPV) infection, the causative agent of cervical cancer. Molecular tests detecting the presence of HPV nucleic acids consistently demonstrate high sensitivity relative to Pap testing, and provide reliable, dichotomous results. Pap cytology is ideally suited to triage HPV-positive cases owing to its high test specificity, and the accuracy of cytological readings will be maximized in high-prevalence conditions. This algorithm of primary HPV testing with Pap triage has been shown to maintain the high sensitivity of HPV testing without compromising Pap cytology's strong ability to rule out falsely positive diagnoses. Given the anticipated decline of high-risk HPV-16 and -18 infections in the emergent post-HPV vaccination era, highly sensitive primary HPV testing is especially warranted. Novel screening technologies that identify HPV viral gene expression continue to emerge and seek to complement current HPV testing by identifying those women who may be at risk of progressive disease. How to best incorporate these new technologies into clinical practice presents our next great challenge. Implementation of novel algorithms for cervical screening is not a trivial task. Avoidance of exceedingly complex screening algorithms is an important priority.
Collapse
Affiliation(s)
- Lyndsay A Richardson
- Division of Cancer Epidemiology, McGill University, 546 Pine Avenue West, Montreal, QC, H2W 1S6, Canada
| | - Joseph Tota
- Division of Cancer Epidemiology, McGill University, 546 Pine Avenue West, Montreal, QC, H2W 1S6, Canada
| | - Eduardo L Franco
- Division of Cancer Epidemiology, McGill University, 546 Pine Avenue West, Montreal, QC, H2W 1S6, Canada
| |
Collapse
|
14
|
Isidean SD, Coutlée F, Franco EL. cobas®4800 HPV Test, a real-time polymerase chain reaction assay for the detection of human papillomavirus in cervical specimens. Expert Rev Mol Diagn 2013; 14:5-16. [DOI: 10.1586/14737159.2014.865521] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
|
15
|
Cuzick J, Bergeron C, von Knebel Doeberitz M, Gravitt P, Jeronimo J, Lorincz AT, J L M Meijer C, Sankaranarayanan R, J F Snijders P, Szarewski A. New technologies and procedures for cervical cancer screening. Vaccine 2013. [PMID: 23199953 DOI: 10.1016/j.vaccine.2012.05.088] [Citation(s) in RCA: 104] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
The clearly higher sensitivity and reproducibility of human papillomavirus (HPV) DNA testing for high-grade cervical intraepithelial neoplasia (CIN) has led to widespread calls to introduce it as the primary screening test. The main concern has been its lower specificity, due to the fact that it cannot separate transient from persistent infections, and only the latter are associated with an increased risk of high-grade CIN and cancer. Thus, even proponents of HPV testing generally only recommend it for women over the age of 30 years (or in some cases 35 years). If HPV testing is to reach its full potential, new approaches with better specificity are needed, either as triage tests for HPV positive women or, if the high sensitivity of HPV DNA testing can be maintained, as alternate primary screening modalities. Approaches that may useful in this regard, especially as triage tests, include HPV typing, methylation (and consequent silencing) of host and viral genes, and new cytologic methods, such as p16(INK4a) staining, which attempt to identify proliferating cells. At an earlier stage of development are direct methods based on detection of HPV E6 or E7 proteins. Recent progress and current status of these methods is discussed in this chapter. The current status of visual inspection (VIA and VILI) methods is also surveyed and progress on self-sampling is reviewed. This article forms part of a special supplement entitled "Comprehensive Control of HPV Infections and Related Diseases" Vaccine Volume 30, Supplement 5, 2012.
Collapse
Affiliation(s)
- Jack Cuzick
- Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, United Kingdom.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
16
|
Arbyn M, Roelens J, Simoens C, Buntinx F, Paraskevaidis E, Martin-Hirsch PPL, Prendiville WJ. Human papillomavirus testing versus repeat cytology for triage of minor cytological cervical lesions. Cochrane Database Syst Rev 2013; 2013:CD008054. [PMID: 23543559 PMCID: PMC6457841 DOI: 10.1002/14651858.cd008054.pub2] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Atypical squamous cells of undetermined significance (ASCUS) and low-grade squamous intra-epithelial lesions (LSIL) are minor lesions of the cervical epithelium, detectable by cytological examination of cells collected from the surface of the cervix of a woman.Usually, women with ASCUS and LSIL do not have cervical (pre-) cancer, however a substantial proportion of them do have underlying high-grade cervical intra-epithelial neoplasia (CIN, grade 2 or 3) and so are at increased risk for developing cervical cancer. Therefore, accurate triage of women with ASCUS or LSIL is required to identify those who need further management.This review evaluates two ways to triage women with ASCUS or LSIL: repeating the cytological test, and DNA testing for high-risk types of the human papillomavirus (hrHPV) - the main causal factor of cervical cancer. OBJECTIVES Main objective To compare the accuracy of hrHPV testing with the Hybrid Capture 2 (HC2) assay against that of repeat cytology for detection of underlying cervical intraepithelial neoplasia of grade 2 or worse (CIN2+) or grade 3 or worse (CIN3+) in women with ASCUS or LSIL. For the HC2 assay, a positive result was defined as proposed by the manufacturer. For repeat cytology, different cut-offs were used to define positivity: Atypical squamous cells of undetermined significance or worse (ASCUS+), low-grade squamous intra-epithelial lesions or worse (LSIL+) or high-grade squamous intra-epithelial lesions or worse (HSIL+).Secondary objective To assess the accuracy of the HC2 assay to detect CIN2+ or CIN3+ in women with ASCUS or LSIL in a larger group of reports of studies that applied hrHPV testing and the reference standard (coloscopy and biopsy), irrespective whether or not repeat cytology was done. SEARCH METHODS We made a comprehensive literature search that included the Cochrane Register of Diagnostic Test Accuracy Studies; the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), MEDLINE (through PubMed), and EMBASE (last search 6 January 2011). Selected journals likely to contain relevant papers were handsearched from 1992 to 2010 (December). We also searched CERVIX, the bibliographic database of the Unit of Cancer Epidemiology at the Scientific Institute of Public Health (Brussels, Belgium) which contains more than 20,000 references on cervical cancer.More recent searches, up to December 2012, targeted reports on the accuracy of triage of ASCUS or LSIL with other HPV DNA assays, or HPV RNA assays and other molecular markers. These searches will be used for new Cochrane reviews as well as for updates of the current review. SELECTION CRITERIA Studies eligible for inclusion in the review had to include: women presenting with a cervical cytology result of ASCUS or LSIL, who had undergone both HC2 testing and repeat cytology, or HC2 testing alone, and were subsequently subjected to reference standard verification with colposcopy and colposcopy-directed biopsies for histologic verification. DATA COLLECTION AND ANALYSIS The review authors independently extracted data from the selected studies, and obtained additional data from report authors.Two groups of meta-analyses were performed: group I concerned triage of women with ASCUS, group II concerned women with LSIL. The bivariate model (METADAS-macro in SAS) was used to assess the absolute accuracy of the triage tests in both groups as well as the differences in accuracy between the triage tests. MAIN RESULTS The pooled sensitivity of HC2 was significantly higher than that of repeat cytology at cut-off ASCUS+ to detect CIN2+ in both triage of ASCUS and LSIL (relative sensitivity of 1.27 (95% CI 1.16 to 1.39; P value < 0.0001) and 1.23 (95% CI 1.06 to 1.4; P value 0.007), respectively. In ASCUS triage, the pooled specificity of the triage methods did not differ significantly from each other (relative specificity: 0.99 (95% CI 0.97 to 1.03; P value 0.98)). However, the specificity of HC2 was substantially, and significantly, lower than that of repeat cytology in the triage of LSIL (relative specificity: 0.66 (95% CI 0.58 to 0.75) P value < 0.0001). AUTHORS' CONCLUSIONS HPV-triage with HC2 can be recommended to triage women with ASCUS because it has higher accuracy (significantly higher sensitivity, and similar specificity) than repeat cytology. When triaging women with LSIL, an HC2 test yields a significantly higher sensitivity, but a significantly lower specificity, compared to a repeat cytology. Therefore, practice recommendations for management of women with LSIL should be balanced, taking local circumstances into account.
Collapse
Affiliation(s)
- Marc Arbyn
- Unit of Cancer Epidemiology, Scientific Institute of Public Health, Brussels, Belgium.
| | | | | | | | | | | | | |
Collapse
|
17
|
|
18
|
Performance of carcinogenic human papillomavirus (HPV) testing and HPV16 or HPV18 genotyping for cervical cancer screening of women aged 25 years and older: a subanalysis of the ATHENA study. Lancet Oncol 2011; 12:880-90. [PMID: 21865084 DOI: 10.1016/s1470-2045(11)70188-7] [Citation(s) in RCA: 367] [Impact Index Per Article: 28.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND The ATHENA study was designed to assess the performance of carcinogenic human papillomavirus (HPV) testing and HPV16 or HPV18 genotyping compared with liquid-based cytology for cervical cancer screening in a large US population aged 21 years and older. We did a subanalysis of this population to compare the screening performance of the cobas HPV test versus liquid-based cytology in women aged 25 years and older, and assess management strategies for HPV-positive women. METHODS Women aged 25 years or older who were attending routine cervical screening were enrolled from 61 clinical centres in 23 US states. Cervical specimens were obtained for liquid-based cytology and HPV DNA testing with two first-generation assays (Amplicor HPV test and Linear Array HPV genotyping test) and the second-generation cobas HPV test (with individual HPV16 and HPV18 detection). Colposcopy and diagnostic biopsies were done on women with atypical squamous cells of undetermined significance (ASC-US) or worse cytology, those who tested positive with either first-generation HPV test, and a random sample of women who tested negative for HPV and cytology. All women not selected for colposcopy received their results and exited the study. Participants and colposcopists were masked to cytology and HPV test results until the colposcopy visit was completed. The primary endpoint for this substudy was histologically confirmed cervical intraepithelial neoplasia grade 3 (CIN3) or worse. This study is registered with ClinicalTrials.gov, number NCT00709891; the study is in the follow-up phase, which is due to be completed in December, 2012. FINDINGS From May 27, 2008, to Aug 27, 2009, 47,208 women were enrolled, of whom 41,955 met our eligibility criteria. Valid cobas HPV and liquid-based cytology test results were available for 40,901 women (97%), who were included in this analysis. Of these, 4275 women (10%) tested cobas HPV positive and 2617 (6%) had abnormal cytology. 431 women were diagnosed with CIN2 or worse and 274 with CIN3 or worse. In women who had colposcopy, the cobas HPV test was more sensitive than liquid-based cytology for detection of CIN3 or worse (252/274 [92·0%, 95% CI 88·1-94·6] vs 146/274 [53·3%, 95% CI 47·4-59·1]; difference 38·7%, 95% CI 31·9-45·5; p<0·0001). Addition of liquid-based cytology to HPV testing increased sensitivity for CIN3 or worse to 96·7% (265/274, 95% CI 93·9-98·3), but increased the number of screen positives by 35·2% (5783/40,901 vs 4275/40,901) compared with HPV testing alone. As a triage test to identify CIN3 or worse in HPV-positive women, detection of HPV16, HPV18, or both alone was equivalent to detection of ASC-US or worse alone in terms of sensitivity (150/252 [59·5%] vs 133/252 [52·8%]; p=0·11) and positive predictive value (PPV) (150/966 [15·5%] vs 133/940 [14·1%]; p=0·20). Among HPV-positive women, detection of HPV16, HPV18, or both or low-grade squamous intraepithelial lesion or worse cytology had better sensitivity (182/252 [72·2%]; p<0·0001) and similar PPV (182/1314 [13·9%]; p=0·70) for detection of CIN3 or worse than ASC-US or worse cytology alone. Furthermore, detection of HPV16, HPV18, or both or high-grade squamous intraepithelial lesion or worse cytology had higher sensitivity (165/252 [65·5%]; p=0·0011) and PPV (165/1013 [16·3%]; p=0·031) for detection of CIN3 or worse than ASC-US or worse cytology alone. INTERPRETATION HPV testing with separate HPV16 and HPV18 detection could provide an alternative, more sensitive, and efficient strategy for cervical cancer screening than do methods based solely on cytology. FUNDING Roche Molecular Systems.
Collapse
|
19
|
Wong OGW, Lo CK, Szeto E, Cheung ANY. Efficacy of Abbott RealTime High Risk HPV test in evaluation of atypical squamous cells of undetermined significance from an Asian screening population. J Clin Virol 2011; 51:136-8. [PMID: 21530385 DOI: 10.1016/j.jcv.2011.03.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2010] [Revised: 03/25/2011] [Accepted: 03/26/2011] [Indexed: 11/25/2022]
Abstract
BACKGROUND Abbott RealTime High Risk HPV test is a new qualitative real-time PCR assay for the detection of 14 high risk HPV (HR-HPV) types and specific identification of HPV16 and HPV18. For each new HPV DNA test, it is important to validate its clinical performance using established tests as benchmarks. Hybrid Capture 2 (HC2) is the first USA FDA-approved HR-HPV DNA test. OBJECTIVES To compare the performance of Abbott RealTime High Risk HPV test with that of Hybrid Capture 2 in detecting cytology samples with varying prognosis. STUDY DESIGN 250 liquid-based cervical cytology samples diagnosed of Atypical Squamous cells of Undetermined Significance (ASC-US) collected from an Asian Screening Population were independently tested with both Abbott RealTime High Risk HPV test and HC2. Their utility in predicting disease progression was evaluated in 82 of the samples for which follow up cytology or colposcropic histology data was available. RESULTS Good to excellent agreement between the two tests was demonstrated (Kappa=0.800, 95% CI: 0.726-0.874). The sensitivity, specificity, positive (PPV) and negative predictive values (NPV) of the two tests in detecting cases with underlying HSIL/CIN2+ were evaluated (Abbott: 100%, 20.83%, 14.93% and 100% respectively; HC2: 100%, 12.50%, 13.70% and 100% respectively). HPV16/18 genotyping provided by the Abbott test enhanced specific identification of cases with LSIL/CIN1+ (specificity 91.30%, PPV 84.62%) and HSIL/CIN2+ (specificity 86.11%, PPV 23.08%) at follow-up. CONCLUSIONS The Abbott test performed similarly to HC2 and is unlikely to be affected by ethnicity. Abbott combined HPV detection and HPV 16/18 genotyping is found to provide enhanced sensitivity and specificity for triage of ASC-US.
Collapse
Affiliation(s)
- Oscar Gee-Wan Wong
- Department of Pathology, Queen Mary Hospital, The University of Hong Kong, Pokfulam Road, Hong Kong Special Administrative Region, Hong Kong, China
| | | | | | | |
Collapse
|