Costs and benefits of cervical screening. II. Is it worthwhile reducing the screening interval from 5 to 3 years?

Willingness to pay for cancer prevention

Cancer inflicts great pain, burden and cost upon American society, and preventing cancer is important but not costless. The aim of this review was to explore the upper limits that American society is paying and appears willing to pay to prevent cancer, by enforced environmental regulations and implemented clinical practice guidelines. Cost-effectiveness studies of clinical and environmental cancer-prevention policies and programmes were identified through a comprehensive literature review and confirmed to be officially sanctioned and implemented, enforced or funded. Data were collected in 2005-6 and analysed in 2007. The incremental cost-effectiveness ratios (ICERs) for clinical prevention policies ranged from under $US2000 to over $US6 000 000 per life-year saved (LYS), exceeding $US100 000 per LYS for only 11 of 101 guidelines. Median ICERs for tobacco-related ($US3978/LYS), colorectal ($US22 694/LYS) and breast ($US25 687/LYS) cancer prevention were within generally accepted ranges and tended not to vary greatly, whereas those for prostate ($US73 603/LYS) and cervical ($US125 157/LYS) cancer-prevention policies were considerably higher and varied substantially more. In contrast, both the median and range of the environmental policies were enormous, with 90% exceeding $US100 000 per LYS, and ICERs ranging from $US61 004 to over $US24 billion per LYS. Notwithstanding a relatively large and accessible literature evaluating the cost effectiveness of clinical and environmental cancer-prevention policies as well as the availability of ICERs for the policies identified in this study, the apparent willingness to pay to prevent cancer in the US still varies greatly and can be extremely high, particularly for many of the environmental cancer-prevention policies.

Weaving meaning? An exploration of the interplay between lay and professional understandings of cervical cancer risk

In line with the increasing emphasis on informed choice, women invited for cervical cancer screening in England receive a leaflet containing information on the risk factors and causation of the condition. However, data from a qualitative interview study with 35 women suggest that the ways in which women make sense of this information can vary and frequently do not correspond to the causal pathways and explanations which characterise contemporary professional medical explanations. This paper examines the complex interplay between lay and professional understandings that takes place as women attempt to weave the information they receive, their prior understandings and contextual factors together into some kind of coherent framework, in which each piece of information makes sense in relation to everything else. We conclude by arguing that, while presenting full and accurate information about orthodox medical understandings of cervical cancer causation in an accessible way maybe challenging, partial presentation of 'the facts' is likely to be ineffective.

Cost-effectiveness analyses in gynecologic oncology: methodological quality and trends

OBJECTIVES

To evaluate methodological quality and trends of cost-effectiveness analyses (CEA) published in gynecologic oncology.

METHODS

A medical literature search of articles from 1966 through 2002 was performed to identify original, English-language articles that included economic analyses in gynecologic oncology. We included articles that were cost-effectiveness or cost-benefit analyses or performed these analyses as part of their study. Ten methodological principles that should be incorporated in CEAs were assessed for each study. Each article was given a score of 0, 1, or 2 for each of the 10 methodological principles (max score = 20). Data were analyzed using the Student t test, ANOVA, and linear regression.

RESULTS

We screened 693 articles to identify 68 that met our inclusion criteria. The articles focused on cervical cancer (n = 53; 78%), ovarian cancer (n = 11; 16%), uterine cancer (n = 2; 3%), and general perioperative care (n = 2; 3%). The mean (+/-SD) methodological principle score was 16.1 (+/-4.1) and we observed a significant improvement in the total score over time (P = 0.01). Primary CEA's (CEA identified as the objective of the study) were of higher quality than secondary CEA's (primary objective of the study was not CEA but CEA was included in the study; total scores 18.2 vs. 11.6, respectively; P<0.0001). Studies with at least one investigator in public health or healthcare economies also had higher quality (mean total score 17.7 vs. 15.2; P=0.006). The most common limitations of published CEAs were in methodology or presentation of incremental analyses, sensitivity analyses, and discounting.

CONCLUSIONS

Cost-effectiveness analyses in gynecologic oncology showed significant improvement in quality over the last two decades. Despite this progress, methodological improvement is still needed in the areas of incremental comparisons and sensitivity analysis. Understanding the methodology of cost-effectiveness analysis is critical for researchers, editors, and readers to accurately interpret results of the growing body of CEA articles.

Costs and benefits of cervical screening IV: valuation by women of the cervical screening programme

OBJECTIVES

To assess the value of the cervical smear test to women, taking account of the positive and negative aspects of the cervical screening service.

DESIGN

A postal survey.

SETTING

Tayside Health Board region of Scotland.

PARTICIPANTS

A sample of 2000 women aged 20-59.

MAIN OUTCOME MEASURES

Maximum willingness to pay (WTP) for a cervical smear test.

RESULTS

Women were prepared to pay 50.20 British pounds per smear on a 3-yearly basis. Willingness to pay was positively related to income, but unrelated to age and whether or not the respondent had previously had a smear.

CONCLUSIONS

Previous studies have estimated the cost per screen or cost per life year saved by cervical screening. This study used the economic instrument of WTP to take account of other potential (dis)benefits to women. The value women place on having a smear was more than the cost to the National Health Service (NHS) of providing the service. The output of a WTP study is potentially useful at the policy level. Future work should explore both the value of alternative approaches to cervical screening, and the value of competing health care interventions.

Early withdrawal from cervical cancer screening: the question of cost-effectiveness

In countries such as the UK, mass population screening for cervical cancer has been undertaken since the 1960s. Although of established effectiveness, no formal evaluation of the screening protocol was carried out prior to its implementation. On the basis of a published mathematical modelling exercise, it has been speculated that withdrawing women from the screening programme at an earlier age than at present, whilst leading to a higher rate of invasive cervical cancer (ICC), could reduce resource use. Using estimates of screening and treatment costs, and of expected life-years lost following earlier withdrawal, we simulated cost-effectiveness ratios for various scenarios described by the model. Median cost savings resulting from a life-year lost never exceeded pound10000 for any scenario, although the estimates were particularly sensitive to the assumed age at cancer presentation and the rate of cancer progression. Our findings seem to offer little economic support for the early withdrawal of subjects from the cervical screening programme.

Stage-specific treatment costs for cervical cancer in the United Kingdom

In order to examine the relationship between stage at initial diagnosis and management costs for cervical cancer, a detailed cost audit over 5 years was conducted on a sample of patients diagnosed in 1990 in one U.K. region. The mean costs of managing pre-invasive carcinoma (386 Pounds) were found to be significantly lower than those of stage 1 invasive carcinoma (6623 Pounds) and both were lower than the costs of invasive cancer at stages 2-4 (10,910 Pounds, 10,579 Pounds and 11,035 Pounds, respectively). A comparison of management costs for cervical cancer with those of breast cancer by stage revealed both that the former are invariably higher and that the cost-by-stage profiles for the two diseases are dissimilar.