Costs and benefits of cervical screening. III. Cost/benefit analysis of a call of previously unscreened women

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.

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.