Cost-effectiveness of cervical cancer screening with human papillomavirus DNA testing and HPV-16,18 vaccination

Inclusion of marginalized populations in HPV vaccine modeling: A systematic review

OBJECTIVE

Models simulating the potential impacts of Human Papillomavirus (HPV) vaccine have been used globally to guide vaccination policies and programs. We sought to understand how and why marginalized populations have been incorporated into HPV vaccine simulation models.

METHODS

We conducted a systematic search of PubMed, CINAHL, Scopus, and Embase to identify studies using simulation models of HPV vaccination incorporating one or more marginalized population through stratification or subgroup analysis. We extracted data on study characteristics and described these overall and by included marginalized groups.

RESULTS

We identified 36 studies that met inclusion criteria, which modeled vaccination in 21 countries. Models included men who have sex with men (MSM; k = 16), stratification by HIV status (k = 9), race/ethnicity (k = 6), poverty (k = 5), rurality (k = 4), and female sex workers (k = 1). When evaluating for a marginalized group (k = 10), HPV vaccination was generally found to be cost-effective, including for MSM, individuals living with HIV, and rural populations. In studies evaluating equity in cancer prevention (k = 9), HPV vaccination generally advanced equity, but this was sensitive to differences in HPV vaccine uptake and use of absolute or relative measures of inequities. Only one study assessed the impact of an intervention promoting HPV vaccine uptake.

DISCUSSION

Incorporating marginalized populations into decision models can provide valuable insights to guide decision making and improve equity in cancer prevention. More research is needed to understand the equity impact of HPV vaccination on cancer outcomes among marginalized groups. Research should emphasize implementation - including identifying and evaluating specific interventions to increase HPV vaccine uptake.

Stochastic dynamics of human papillomavirus delineates cervical cancer progression

Starting from a deterministic model, we propose and study a stochastic model for human papillomavirus infection and cervical cancer progression. Our analysis shows that the chronic infection state as random variables which have the ergodic invariant probability measure is necessary for progression from infected cell population to cervical cancer cells. It is shown that small progression rate from infected cells to precancerous cells and small microenvironmental noises associated with the progression rate and viral infection help to establish such chronic infection states. It implicates that large environmental noises associated with viral infection and the progression rate in vivo can reduce chronic infection. We further show that there will be a cervical cancer if the noise associated with precancerous cell growth is large enough. In addition, comparable numerical studies for the deterministic model and stochastic model, together with Hopf bifurcations in both deterministic and stochastic systems, highlight our analytical results.

Can portable Colposcopes Replace Standard-of-care Colposcopes? A Crossover Trial of Two Portable Colposcopes with a Standard-of-Care Video Colposcope

BACKGROUND

Screen positive women need to be triaged by colposcopy which is a major challenge in low-middle income countries. Portable colposcopes may overcome many challenges, reduce referrals and enable a single visit approach. This study assessed the performance of portable colposcopes and potential to reduce referral.

METHOD

This crossover randomised study enrolled women aged 25 to 65 years with abnormal screening result or cervical symptoms. All women underwent visual inspection with acetic acid (VIA), HPV test, colposcopy with two portable colposcopes (Gynocular®, Gynius, Sweden, and Pocket® transvaginal colposcope, Duke University, NC, USA) and a standard video colposcope, and biopsy. Colposcopic Swede score agreement between portable and video colposcopes, as well as agreement of Swede score with histology were calculated for each device. The potential impact of portable colposcopes in a single visit approach was assessed based on the final diagnosis.

RESULTS

Among 250 subjects, 27(10.80%) had high-grade cervical intraepithelial neoplasia (CIN2+) lesions. Swede scores for Pocket and Gynocular colposcopes were similar to video colposcope in 248 (99.20%) and 247 (98.80%) subjects, respectively (agreement scores 0.9969 and 0.9954, respectively). At a Swede score cut-off of ≥5, all three devices had identical sensitivity, specificity, positive and negative predictive value of 96.30%, 92.30%, 60.50% and 99.50,. Ablative treatment offered at field setting would result in optimal treatment in 52.0% and 85.1% cases when screened with VIA and HPV test respectively; using Pocket colposcope could improve this to 94.0% and 95.9%, respectively. Overtreatment and referral rates reduced from 46.8% and 12.4% to 4.8% and 6.0%, respectively, when VIA test is followed by triage with pocket colposcope. These outcomes were comparable to screening with HPV followed by colposcopy triage.

CONCLUSIONS

Pocket colposcope performed comparably to the video colposcope. Used by healthcare providers in the field setting, they can augment the results of VIA significantly.

Acceptability, simplicity, and relevance of the new human papillomavirus/DNA test among 35-year-old ever-married women in a district of Sri Lanka: focus group discussions

Background

Two major drawbacks of the present cervical cancer screening programme in Sri Lanka are, the suboptimal sensitivity of the pap smear and the low coverage. The sensitivity of the HPV/DNA screening test is high. The objective of the study was to explore the acceptability relevance and simplicity of the new HPV/DNA screening implementation among ever-married women in a district of Sri Lanka.

Methods

Focus group discussions (FGD) (n = 3) in the public health divisions of the Kalutara district were used to collect data during December 2018. The study population comprised of ever-married women 35 years old, who, carried out an HPV/DNA test at a community Well Woman Clinics (WWCs) (n = 89). A list of WWCs was prepared according to an alphabetical order under urban, rural, and estate sector categories and allocated a number. One WWC was selected from each sector randomly for the three FGDs representing the estate, rural, and urban clinics. A convenient sampling technique was used to select participants for each FGD (n = 8). The information collected at each interview was summarized at the end of each interview. The analysis was done with manual content.

Results

Most of the participants were Sinhalese (n = 17, 70.9%), Buddhist (n = 18, n = 75%), and non-working (n = 18, n = 75%). The community awareness of HPV/DNA screening and field staff performance were highly appreciated by most of the participants. Most were aware of the high sensitivity of the HPV/DNA test, therefore the early detection rate of cervical cancer precursors is high. Most of the participants expressed the HPV/DNA test as a convenient and neutral test. Most were mentioned the necessity of repeated clinic visits for the pap test and colposcopy in HPV/DNA screened positive follow-up but there was marked acceptability (n = 23, 95.8%) for HPV/DNA test.

Conclusions

Acceptability of the new HPV/DNA screening test was high. Most of the participants perceived the HPV/DNA test to be simple and also relevant. Therefore, the HPV/DNA screening test can be recommended to be incorporated into the National Cervical Cancer Screening Programme as its suitability was well explored in the Sri Lankan setting.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12905-022-01712-2.

Proposing a novel care program: reminiscence therapy involved care for anxiety, depression, and quality of life in postoperative cervical cancer patients

BACKGROUND

Reminiscence therapy (RT) relieves mental disorders and improves quality of life (QoL) in some cancer survivors, but in postoperative cervical cancer patients, its effect is unclear. This study aimed to assess the impact of reminiscence therapy involved care (RTIC) and usual care (UC) on anxiety, depression, QoL, and survival in postoperative cervical cancer patients.

METHODS

In this randomized control study, 152 eligible postoperative cervical cancer patients were randomized as 1:1 ratio into RTIC (N = 76) and UC (N = 76) groups: the former received routine care and RT, while the latter only received routine care for 12 months. Anxiety, depression, and QoL were evaluated from baseline (month (M) 0) to M12, respectively. Patients were continuously followed up to M36 for overall survival (OS) calculation.

RESULTS

HADS-Anxiety score from M6 to M12 was decreased; both HADS-Depression score from M9 to M12 and depression rate at M12 were reduced in RTIC group compared with UC group (all P < 0.05). QLQ-C30 global health status score at M6 and M12, as well as QLQ-C30 function score at M12, was increased in RTIC group compared with UC group (all P < 0.05). However, QLQ-C30 symptom score at each visit and OS exhibited no difference between the two groups. From sub-group analysis, RTIC disclosed a distinct effect on patients whose age ≥ 50 years but not on those < 50 years.

CONCLUSION

RTIC reduces anxiety (partly) and depression and improves QoL in postoperative cervical cancer patients, especially in old patients.

Estimated Prevalence and Incidence of Disease-Associated Human Papillomavirus Types Among 15- to 59-Year-Olds in the United States

INTRODUCTION

Human papillomavirus (HPV) can cause anogenital warts and several types of cancer, including cervical cancers and precancers. We estimated the prevalence, incidence, and number of persons with prevalent and incident HPV infections in the United States in 2018.

METHODS

Prevalence and incidence were estimated for infections with any HPV (any of 37 types detected using Linear Array) and disease-associated HPV, 2 types that cause anogenital warts plus 14 types detected by tests used for cervical cancer screening (HPV 6/11/16/18/31/33/35/39/45/51/52/56/58/59/66/68). We used the 2013-2016 National Health and Nutrition Examination Survey to estimate prevalence among 15- to 59-year-olds, overall and by sex. Incidences in 2018 were estimated per 10,000 persons using an individual-based transmission-dynamic type-specific model calibrated to US data. We estimated number of infected persons by applying prevalences and incidences to 2018 US population estimates.

RESULTS

Prevalence of infection with any HPV was 40.0% overall, 41.8% in men, and 38.4% in women; prevalence of infection with disease-associated HPV was 24.2% in men and 19.9% in women. An estimated 23.4 and 19.2 million men and women had a disease-associated HPV type infection in 2018. Incidences of any and disease-associated HPV infection were 1222 and 672 per 10,000 persons; incidence of disease-associated HPV infection was 708 per 10,000 men and 636 per 10,000 women. An estimated 6.9 and 6.1 million men and women had an incident infection with a disease-associated HPV type in 2018.

CONCLUSIONS

We document a high HPV burden of infection in the United States in 2018, with 42 million persons infected with disease-associated HPV and 13 million persons acquiring a new infection. Although most infections clear, some disease-associated HPV type infections progress to disease. The HPV burden highlights the need for continued monitoring of HPV-associated cancers, cervical cancer screening, and HPV vaccination to track and prevent disease.

Estimating the direct effect of human papillomavirus vaccination on the lifetime risk of screen-detected cervical precancer

Birth cohorts vaccinated against human papillomavirus (HPV) are now entering cervical cancer screening. Assessment of (pre)cancer (CIN3+) risk is needed to assess the residual screening need in vaccinated women. We estimated the lifetime (screen-detected) CIN3+ risk under five-yearly primary HPV screening between age 30 and 60, using HPV genotyping and histology data of 21,287 women participating in a screening trial with two HPV-based screening rounds, 5 years apart. The maximum follow-up after an HPV-positive test was 9 years. We re-estimated the CIN3+ risk after projecting direct vaccine efficacy for the bivalent and the nonavalent HPV vaccines, assuming life-long protection. The lifetime CIN3+ risk was 4.1% (95% confidence interval 3.5-4.9) and declined by 53.5% and 70.5% after bivalent vaccination without and with cross-protection, respectively, translating into a residual lifetime CIN3+ risk of 1.9% (1.4-2.4) and 1.2% (0.9-1.5). The CIN3+ risk declined by 88.5% after nonavalent vaccination, translating into a residual lifetime CIN3+ risk of 0.5% (0.2-0.7). The latter risk increased to 1.6% when vaccine protection only lasted until the first screening round at age 30. Among HPV-positive women with abnormal adjunct cytology, the nine-year CIN3+ risk was 16.9% (8.7-32.4) after nonavalent vaccination. In conclusion, HPV vaccination will lead to a strong decline in the lifetime CIN3+ risk and the remaining absolute CIN3+ risk will be very low. Primary HPV testing combined with adjunct cytology at five-year intervals still seems feasible even after nonavalent vaccination, although unlikely to be cost-effective. Our results support a de-intensification of screening programs in settings with high vaccination coverage.

Aneuploidy detection for diagnostic and prognostic use in premalignant and malignant lesions of the uterine cervix: A systematic review

OBJECTIVE

To systematically review the role of aneuploidy detection alone or in combination with other methods in cervical cancer screening and to evaluate the value of aneuploidy to predict the behavior of premalignant cervical lesions.

METHOD

We conducted a systematic review based on an electronic search for articles published between 2001 and 2020 across databases including MEDLINE/PubMed, Scopus, and Web of Science. Studies were subjected to data extraction, risk of bias, and narrative synthesis.

RESULTS

A total of 15 articles were included in the review. Eight out of 15 studies (53.3%) were judged to be at a high or unclear risk of bias. From the 15 included studies, the index test to detect aneuploidy was DNA image cytometry (DNA-ICM) in 12 studies and DNA flow cytometry (DNA-FCM) in three studies. Nine studies also evaluated the performance of cytology and/or human papillomavirus (HPV) tests. For DNA-ICM, sensitivity to detect cervical intraepithelial neoplasia or worse (CIN2+) varied between 59.0% and 95.9% and specificity varied between 54.1% and 100%. For DNA-FCM, sensitivity varied between 27.3% to 96.8% and specificity was 100%. For cytological evaluation, sensitivity varied between 25.0% and 70.4% and specificity varied between 70.6% and 99.9%. For HPV detection, sensitivity varied between 39.4% and 100% and specificity varied between 23.3% and 84.3%.

CONCLUSION

DNA ploidy along with atypical cells findings in cytology and/or HPV detection revealed great value to detect CIN2+ lesions and to predict which lesions are more likely to progress to cervical cancer.

Cervical screening: ESGO-EFC position paper of the European Society of Gynaecologic Oncology (ESGO) and the European Federation of Colposcopy (EFC)

This paper summarises the position of ESGO and EFC on cervical screening based on existing guidelines and opinions of a team of lead experts. HPV test is replacing cytology as this offers greater protection against cervical cancer and allows longer screening intervals. Only a dozen of HPV tests are considered as clinically validated for screening. The lower specificity of HPV test dictates the use of triage tests that can select women for colposcopy. Reflex cytology is currently the only well validated triage test; HPV genotyping and p16 immunostaining may be used in the future, although methylation assays and viral load also look promising. A summary of quality assurance benchmarks is provided, and the importance to audit the screening histories of women who developed cancer is noted as a key objective. HPV-based screening is more cost-effective than cytology or cotesting. HPV-based screening should continue in the post-vaccination era. Only a fraction of the female population is vaccinated, and this varies across countries. A major challenge will be to personalise screening frequency according to vaccination status. Still the most important factor for successful prevention by screening is high population coverage and organised screening. Screening with self-sampling to reach under-screened women is promising.

Economic evaluation of HPV DNA test as primary screening method for cervical cancer: A health policy discussion in Greece

Background

HPV test appears to be more effective in cervical cancer (CC) screening. However, the decision of its adoption as a primary screening method by substituting the established cytology lies in the evaluation of multiple criteria. Aim of this study is to evaluate the economic and clinical impact of HPV test as primary screening method for CC.

Methods

A decision tree and a Markov model were developed to simulate the screening algorithm and the natural history of CC. Fourteen different screening strategies were evaluated, for women 25–65 years old. Clinical inputs were drawn from the HERMES study and cost inputs from the official price lists. In the absence of CC treatment cost data, the respective Spanish costs were used after being converted to 2017 Greek values. One-way and probabilistic sensitivity analyses were conducted.

Results

All screening strategies, that offer as primary screening method triennial HPV genotyping (simultaneous or reflex) alone or as co-testing with cytology appear to be more effective than all other strategies, with regards to both annual CC mortality, due to missed disease (-10.1), and CC incidence(-7.5) versus annual cytology (current practice). Of those, the strategy with HPV test with simultaneous 16/18 genotyping is the strategy that provides savings of 1.050 million euros annually. However, when the above strategy is offered quinquennially despite the fact that outcomes are decreased it remains more effective than current practice (-7.7 deaths and -1.3 incidence) and more savings per death averted (1.323 million) or incidence reduced (7.837 million) are realized.

Conclusions

HPV 16/18 genotyping as a primary screening method for CC appears to be one of the most effective strategies and dominates current practice in respect to both cost and outcomes. Even when compared with all other strategies, the outcomes that it generates justify the cost that it requires, representing a good value for money alternative.

HPV-FRAME: A consensus statement and quality framework for modelled evaluations of HPV-related cancer control

Intense research activity in HPV modelling over this decade has prompted the development of additional guidelines to those for general modelling. A specific framework is required to address different policy questions and unique complexities of HPV modelling. HPV-FRAME is an initiative to develop a consensus statement and quality-based framework for epidemiologic and economic HPV models. Its development involved an established process. Reporting standards have been structured according to seven domains reflecting distinct policy questions in HPV and cancer prevention and categorised by relevance to a population or evaluation. Population-relevant domains are: 1) HPV vaccination in pre-adolescent and young adolescent individuals; 2) HPV vaccination in older individuals; 3) targeted vaccination in men who have sex with men; 4) considerations for individuals living with HIV and 5) considerations for low- and middle-income countries. Additional considerations applicable to specific evaluations are: 6) cervical screening or integrated cervical screening and HPV vaccination approaches and 7) alternative vaccine types and alternative dosing schedules. HPV-FRAME aims to promote the development of models in accordance with an explicit framework, to better enable target audiences to understand a model's strength and weaknesses in relation to a specific policy question and ultimately improve the model's contribution to informed decision-making.

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General modelling guidelines are insufficient for reporting HPV models.

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HPV-FRAME is an initiative to develop a quality-based framework for HPV models.

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The framework has seven domains consisting of distinct reporting standards.

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HPV-FRAME aims to promote transparency and improve the quality in reporting.

Establishment of a national cervical screening programme in Ireland, CervicalCheck: the first 6 years

The national cervical screening programme, CervicalCheck, commenced in Ireland in 2008. Free cervical smear tests are offered to over 1.2 million women aged 25-60 every 3 (aged 25-44) and 5 (aged 45-60) years. The purpose of this paper is to highlight the achievements and document the experience of the first 6 years of a new cervical screening programme. Data were extracted from the programme screening register and colposcopy management systems. SAS, version 9.4 was used for statistical analysis. Over 1.98 million smear tests were performed in over 1 million women during the first 6 years of the programme. Overall 5-year coverage at the end of the sixth year was 77.0%, where coverage is presented for the target population of women aged 25-60 years and is adjusted for hysterectomy rates. The numbers of women attending colposcopy increased significantly from 10 000 new patients attending for the first time in the first year to a peak of almost 17 500 in the third year. Increased capacity in colposcopy has delivered significant improvements in waiting times; the percentage of women referred to colposcopy offered an appointment within 8 weeks increased from 41.5% in year 1 to 93.4% in year 4 and has remained above the greater than 90% standard thereafter. The number of biopsies increased markedly, with 33 768 women being diagnosed with cervical intraepithelial neoplasia-grade 2 (CIN2), CIN3 or adenocarcinoma in situ and 860 being diagnosed with invasive cancer by the end of the sixth year. Lessons from CervicalCheck include the importance of capacity planning in programme delivery. The programme continues to evolve, particularly with the increased usage of human papillomavirus testing and planning for future testing of the human papillomavirus (HPV)-vaccinated cohort.

Vaccination against HPV virus: a systematic review of economic evaluation studies for developed countries

INTRODUCTION

During the last years, a significant number economic evaluations of HPV vaccination has been published. Given that cost-effectiveness constitutes an essential part of decision-making with regards to the reimbursement of a health technology, the purpose of this study is to provide a supportive tool to decision-makers regarding the economic efficiency of the introduction of HPV vaccination to national immunization programs.

AREAS COVERED

The PubMed database was searched in order to identify cost-effectiveness studies for HPV vaccination. A total of 42 articles were finally retrieved. All retrieved cost-effectiveness ratios (ICERs) were converted in the same currency unit (I$) and then inflated to the same year (2015) in order to facilitate cross-country comparisons.

RESULTS

Overall, vaccination against HPV 6,11,16,18 types appears to have a ICER with mean value of I$25132/QALY, whereas the mean ICER of vaccination against oncogenic HPV 16,18 types is estimated at I$38,253/QALY.

EXPERT COMMENTARY

HPV vaccination would be a cost-effective intervention in the setting of high-income countries and could reduce the incidence of HPV-related diseases.

Racial/Ethnic Disparities in Cervical Cancer Screening Services Among Contractors of the Connecticut Breast and Cervical Cancer Early Detection Program

Purpose: Racial/ethnic minority women are at increased risk for cervical cancer. The objective of this study is to use performance management data from the Connecticut Breast and Cervical Cancer Early Detection Program (CBCCEDP) to determine whether race/ethnicity disparities exist in human papillomavirus (HPV) co-testing uptake across CBCCEDP contractors.

Methods: Secondary analysis of Connecticut's Minimum Data Elements data for 2013–2015 among 10 contractors participating in the CBCCEDP. Participants included women aged 30–64 years and eligible to receive routine cervical cancer screening services through the CBCCEDP (n=5,262). HPV co-testing uptake was compared across contractors and race/ethnicity groups within each contractor using chi-square and Fisher's exact tests as appropriate.

Results: Overall, 62.9% of women received HPV co-testing services. Significant differences in co-testing rates were detected between racial/ethnic groups when data were examined across all contractors (p<0.001). Black women were least likely to receive co-testing (49.1%), while Hispanic women were most likely to receive co-testing (68.2%). When data were examined at the individual contractor level, significant differences between racial/ethnic groups were observed in 50% of the contractors.

Conclusions: This study identified racial/ethnic disparities in uptake of HPV co-testing both overall and within individual contractors involved in the CBCCEDP. These findings will be used to guide program improvement with the goal of increasing quality and consistency of care for all women seeking screening services.

Determinants of the receipt of the 9-valent human papillomavirus vaccine in the first year after introduction in North Carolina

OBJECTIVES

The objective of this study was to describe the transition from bi- and quadrivalent HPV vaccines to 9vHPV in aggregate and identify determinants of the receipt of 9vHPV among youth following the introduction of 9vHPV in North Carolina.

METHODS

The study used a retrospective cohort design with data from the North Carolina Immunization Registry (NCIR). Our sample included all doses of HPV vaccine administered between July 2015 and October 2016 to age-eligible youth (ages 9-17). We used a logistic regression model to associate individual child-level and ZIP Code Tabulation Area (ZCTA)-level characteristics with an indicator variable for receiving 9vHPV (vs. other HPV vaccines).

RESULTS

Youth receiving the HPV vaccine were more likely to receive 9vHPV if they lived in a ZCTA with a larger age-eligible (i.e., 9-17) population, a health professional shortage area, or a higher number of annual outpatient visits per capita. They were less likely to receive 9vHPV if they were older, received a publicly-funded dose, or lived in a ZCTA with a higher percentage of the population with less than a high-school education or a higher number of religious organizations.

CONCLUSIONS

While the transition from other HPV vaccines to 9vHPV was relatively quick, there were disparities in the diffusion of 9vHPV across North Carolina.

Quality of life assumptions determine which cervical cancer screening strategies are cost-effective

Quality-adjusted life years are used in cost-effectiveness analyses (CEAs). To calculate QALYs, a "utility" (0-1) is used for each health state induced or prevented by the intervention. We aimed to estimate the impact of quality of life (QoL) assumptions (utilities and durations of health states) on CEAs of cervical cancer screening. To do so, 12 alternative sets of utility assumptions were retrieved from published cervical cancer screening CEAs. Two additional sets were based on empirical QoL data that were integrally obtained through two different measures (SF-6D and EQ-5D) from eight groups of women (total n = 3,087), from invitation for screening to diagnosis with cervical cancer. Per utility set we calculated the number of quality-adjusted days lost (QADL) for each relevant health state in cervical cancer screening, by multiplying the study-specific assumed disutilities (i.e., 1-utility) with study-specific durations of the loss in QoL, resulting in 14 "QADL-sets." With microsimulation model MISCAN we calculated cost-effectiveness of 342 alternative screening programs (varying in primary screening test [Human Papillomavirus (HPV) vs. cytology], starting ages, and screening interval) for each of the 14 QADL-sets. Utilities used in CEAs appeared to differ largely. We found that ten QADL-sets from the literature resulted in HPV and two in cytology as preferred primary test. The SF-6D empirical QADL-set resulted in cytology and the EQ-5D one in HPV as preferred primary test. In conclusion, assumed utilities and health state durations determine cost-effectiveness of cervical cancer screening. Also, the measure used to empirically assess utilities can be crucial for CEA conclusions.

Impact of introduction of the 9-valent human papillomavirus vaccine on vaccination coverage of youth in North Carolina

OBJECTIVES

The objective of this study was to evaluate the impact of introduction of 9vHPV vaccine on HPV vaccination uptake (doses per capita) and initiation (≥1 doses), completion (≥3 doses) and compliance (≥3 doses within 12 months) by adolescents.

METHODS

We used a retrospective cohort analysis using North Carolina Immunization Registry (NCIR) data from January 2008 through October 2016. The sample included Vaccines for Children eligible adolescents aged 9 to 17 years in 2016, for whom the NCIR contains complete vaccination history. We applied an interrupted time series design to measure associations between ZIP Code Tabulation Area (ZCTA)-level HPV vaccination outcomes over time with the introduction of 9vHPV in North Carolina (NC) in July 2015.

RESULTS

Each outcome displayed a linear upward trend over time with large seasonal spikes near August of each year, corresponding to the time when adolescents often receive other vaccines required for school entry. After accounting for these underlying trends, introduction of 9vHPV was not associated with a change in publicly funded HPV vaccination rates in NC.

CONCLUSIONS

Our results indicate that 9vHPV substituted for 4vHPV in the first year after release in NC, but the release of 9vHPV was not associated with an overall change in HPV vaccination.

Incidence of Invasive Cervical Cancer and Direct Costs Associated with its Management in Italy

Aim and background

Cervical cancer is the second most common cancer in European women aged 15–44 years. The aim of this study was to estimate the direct cost of managing invasive cervical cancer in Italy.

Methods

Data from the Italian Network of Cancer Registries were used to estimate the annual number of new cervical cancer cases. To assess the management costs, a typical management pathway for each FIGO (Fédération Internationale de Gynécologie et d'Obstétrique) cervical cancer stage was derived from published guidelines. Data from the Modena Cancer Registry were used to estimate the proportion of patients by FIGO stage. This algorithm was combined with tariffs for outpatient and inpatient procedures to obtain a mean cost for each FIGO stage.

Results

An estimated 2,927 new cases of cervical cancer occurred in Italy in 2005 (crude incidence 9.7/100,000; world age-standardized incidence 6.0/100,000). The estimated numbers of new cases by FIGO stage were: FIGO I, 1,927; FIGO II, 556; FIGO III, 259; and FIGO IV, 185. Costs for the most frequent procedures were estimated as: € 6,041 for radical hysterectomy or other surgery; € 4,901 for radio-chemotherapy; € 1,588 for brachytherapy; and € 3,795 for palliative chemotherapy. Mean management costs for incident cases (including 10 years of follow-up) were estimated at: FIGO I, € 6,024; FIGO II, € 10,572; FIGO III, € 11,367; FIGO IV, € 8707; and € 5,854 for the terminal phase (1 month). The total direct management cost was estimated at € 28.3 million per year.

Conclusions

This is one of the first studies to estimate the direct cost of treating patients newly diagnosed with invasive cervical cancer in Italy. Although according to current management pathways real treatment costs are likely to be underestimated, this information is necessary to design evidence-based vaccination policies able to harmonize primary and secondary prevention of cervical cancer.

Adapting cervical cancer screening for women vaccinated against human papillomavirus infections: The value of stratifying guidelines

BACKGROUND

Several countries have implemented vaccination against human papillomavirus (HPV) for adolescent girls and must decide whether and how to adapt cervical cancer (CC) screening for these low-risk women. We aimed to identify the optimal screening strategies for women vaccinated against HPV infections and quantify the amount that could be spent to identify vaccination status among women and stratify CC screening guidelines accordingly.

METHODS

We used a mathematical model reflecting HPV-induced CC in Norway to project the long-term health benefits, resources and costs associated with 74 candidate-screening strategies that varied by screening test, start age and frequency. Strategies were considered separately for women vaccinated with the bivalent/quadrivalent (2/4vHPV) and nonavalent (9vHPV) vaccines. We used a cost-effectiveness framework (i.e. incremental cost-effectiveness ratios and net monetary benefit) and a commonly-cited Norwegian willingness-to-pay threshold of €75,000 per quality-adjusted life-year gained.

RESULTS

The most cost-effective screening strategy for 9vHPV- and 2/4vHPV-vaccinated women involved HPV testing once and twice per lifetime, respectively. The value of stratifying guidelines by vaccination status was €599 (2/4vHPV) and €725 (9vHPV) per vaccinated woman. Consequently, for the first birth cohort of ∼22,000 women who were vaccinated in adolescence in Norway, between €10.5-13.2 million over their lifetime could be spent on identifying individual vaccination status and stratify screening while remaining cost-effective.

CONCLUSION

Less intensive strategies are required for CC screening to remain cost-effective in HPV-vaccinated women. Moreover, screening can remain cost-effective even if large investments are made to identify individual vaccination status and stratify screening guidelines accordingly.

Strategic Distributional Cost-Effectiveness Analysis for Improving National Cancer Screening Uptake in Cervical Cancer: A Focus on Regional Inequality in South Korea

PURPOSE

The purpose of this study was to conduct a cost effectiveness analysis of strategies designed to improve national cervical cancer screening rates, along with a distributional cost effectiveness analysis that considers regional disparities.

MATERIALS AND METHODS

Cost effectiveness analysis was conducted using a Markov cohort simulation model, with quality adjusted life years as the unit of effectiveness. The strategies considered were current (biennial Papanicolaou smear cytology of females aged 20 or above), strong screening recommendation by mail to target regions (effect, 12% increase in screening uptake; cost, 1,000 Korean won per person), regular universal screening recommendation by mail (effect, 6% increase in screening uptake; cost, 500 Korean won per person), and strong universal screening recommendation by mail (effect, 12% increase in screening uptake; cost, 1,000 Korean won per person). Distributional cost effectiveness analysis was conducted by calculating the cost effectiveness of strategies using the Atkinson incremental cost effectiveness ratio.

RESULTS

All strategies were under the threshold value, which was set as the Korean gross domestic product of $25,990. In particular, the 'strong screening recommendation to target regions' strategy was found to be the most cost effective (incremental cost effectiveness ratio, 7,361,145 Korean won). This was also true when societal inequality aversion increased in the distributional cost effectiveness analysis.

CONCLUSION

The 'strong screening recommendation to target regions' strategy was the most cost effective approach, even when adjusting for inequality. As efficiency and equity are objectives concurrently sought in healthcare, these findings imply a need to develop appropriate economic evaluation methodologies to assess healthcare policies.

The Need for Societal Investment to Improve Cervical Cancer Outcomes in Nigeria: A commentary

Although cervical cancer is a preventable cancer with a well-known natural history, it remains a huge burden in developing countries of sub-Saharan Africa where organized cervical cancer screening services are lacking. Developed countries that have invested on providing organized screening programs have made substantial progress in reducing both incidence and mortality due to cervical cancer. Implementing evidence-based interventions such as human papillomavirus (HPV) vaccination of young girls, early detection and treatment of premalignant conditions of the cervix through conventional Pap cytology, HPV screening or visual aided inspection with acetic acid could significantly reduce incidence of new cases at population level. Societal investment for such preventive services and provision of effective treatment for those diagnosed at early stages will yield economic benefits in reducing premature deaths of women at the prime of their productive lives. From a societal perspective, this should be a priority area for national investment towards the achievement of sustainable development in Nigeria and similar settings in Africa.

Inclusion of the value of herd immunity in economic evaluations of vaccines. A systematic review of methods used

OBJECTIVE

The objectives of this review were to identify vaccine economic evaluations that include herd immunity and describe the methodological approaches used.

METHODS

We used Kim and Goldie's search strategy from a systematic review (1976-2007) of modelling approaches used in vaccine economic evaluations and additionally searched PubMed/MEDLINE and Embase for 2007-2015. Studies were classified according to modelling approach used. Methods for estimating herd immunity effects were described, in particular for the static models.

RESULTS

We identified 625 economic evaluations of vaccines against human-transmissible diseases from 1976 to 2015. Of these, 172 (28%) included herd immunity. While 4% of studies included herd immunity in 2001, 53% of those published in 2015 did this. Pneumococcal, human papilloma and rotavirus vaccines represented the majority of studies (63%) considering herd immunity. Ninety-five of the 172 studies utilised a static model, 59 applied a dynamic model, eight a hybrid model and ten did not clearly state which method was used. Relatively crude methods and assumptions were used in the majority of the static model studies.

CONCLUSION

The proportion of economic evaluations using a dynamic model has increased in recent years. However, 55% of the included studies used a static model for estimating herd immunity. Values from a static model can only be considered reliable if high quality surveillance data are incorporated into the analysis. Without this, the results are questionable and they should only be included in sensitivity analysis.

Association between mothers' screening uptake and daughters' HPV vaccination: a quasi-experimental study on the effect of an active invitation campaign

OBJECTIVES

In Emilia-Romagna, the Human Papillomavirus (HPV) vaccination campaign started in 2008 offering free vaccines for 1996 and 1997 cohorts. Systematic active invitation was implemented for the 1997 cohort. Our study aimed at measuring the impact of the active invitation campaign on HPV vaccine coverage and on coverage inequalities in 11-year-old girls. Second, we evaluated the effect of the HPV vaccination campaign on participation in cervical cancer screening by mothers of target girls.

METHODS

We collected information on vaccination status for girls residing in Reggio Emilia in 2008 and mothers' screening history, before and after the 2008 vaccination campaign. Log-binomial regression models were performed to estimate Relative Risk (RR) and 95% confidence intervals (CIs) of being vaccinated as regarded citizenship, siblings, mothers' education, marital status and screening history, stratified by birth cohort. We also calculated RR of receiving a Pap test after the vaccination campaign as regarded education, daughter's cohort and mothers' decision to have their daughter vaccinated. Interaction between education and cohort in mothers overdue for Pap testing was calculated.

RESULTS

Vaccination coverage was 46.3% for the uninvited cohort (1046/2260) and 77.9% for the invited cohort (1798/2307). In the uninvited cohort, daughters' vaccination showed association with mothers' education (8 to 11 years of education vs. graduated mothers, RR 1.61 95% CI 1.14-2.28), citizenship (foreigners vs. Italians, RR 0.45 95% CI 0.37-0.56) and screening history (regular vs. non-participant; RR 1.72 95% CI 1.26-2.36). In the invited cohort, only a slight association with screening history persisted (regular vs. non-participant; RR 1.20 95% CI 1.04-1.40). Highly educated under-screened mothers of the invited cohort showed a higher probability of receiving a Pap test after the vaccination campaign period (RR 1.27 95% CI 1.04-1.56) compared with those not invited, CONCLUSION: Active invitation could increase overall HPV immunisation coverage and reduce socio-demographic inequalities and the association with mothers' screening participation.

Cervical Cancer Screening

Cervical cancer screening in the United States has accompanied profound decreases in cancer incidence and mortality over the last half century. Two screening strategies are currently endorsed by US-based guideline groups: (1) triennial cytology for women aged 21 to 65 years, and (2) triennial cytology for women aged 21 to 29 years followed by cytology plus testing for high-risk human papillomavirus types every 5 years for women aged 30 years and older. Providing women with affordable, easily accessible screening, follow-up of abnormal tests, and timely treatment will result in the greatest impact of screening on cervical cancer incidence and mortality.

Systematic review of cost-effectiveness analyses for combinations of prevention strategies against human papillomavirus (HPV) infection: a general trend

BACKGROUND

Due to the arrival of multi-valent HPV vaccines, it is more and more important to have a better understanding of the relationship between vaccination and screening programmes. This review aimed to: (1) collect published evidence on the cost-effectiveness profile of different HPV prevention strategies and, in particular, those combining vaccination with changes in screening practices; (2) explore the cost-effectiveness of alternative preventive strategies based on screening and vaccination.

METHODS

A systematic literature review was conducted in order to identify the relevant studies regarding the cost-effectiveness of prevention strategies against HPV infection. Analysis comparing the modelling approaches between studies was made along with an assessment of the magnitude of impact of several factors on the cost-effectiveness of different screening strategies.

RESULTS

A total of 18 papers were quantitatively summarised within the narrative. A high degree of heterogeneity was found in terms of how HPV prevention strategies have been assessed in terms of their economic and epidemiological impact, with variation in screening practice and valence of HPV vaccination found to have large implications in terms of cost-effectiveness.

CONCLUSIONS

This review demonstrated synergies between screening and vaccination. New prevention strategies involving multi-valence vaccination, HPV DNA test screening, delayed commencement and frequency of screening could be implemented in the future. Strategies implemented in the future should be chosen with care, and informed knowledge of the potential impact of all possible prevention strategies. Highlighted in this review is the difficulty in assessing multiple strategies. Appropriate modelling techniques will need to be utilised to assess the most cost-effective strategies.

Randomized trial evaluating self-sampling for HPV DNA based tests for cervical cancer screening in Nigeria

Background

Cervical cancer incidence and mortality rates in Sub-Saharan Africa (SSA) remain high due to several factors including low levels of uptake of cervical cancer screening. Self-collection of cervicovaginal samples for HPV DNA testing may be an effective modality that can increase uptake of cervical cancer screening in SSA and hard to reach populations in developed countries. We investigated whether self-collection of cervicovaginal samples for HPV DNA tests would be associated with increased uptake of screening compared with clinic based collection of samples. Furthermore, we compared the quality of samples collected by both approaches for use in HPV genotyping.

Methods

We conducted a community based randomized trial in a semi-urban district of Abuja, Nigeria with 400 women, aged 30 to 65 years randomized to either hospital-collection or self-collection of cervicovaginal samples. We compared cervical cancer screening uptake among the 2 groups and evaluated the concentration of human DNA in the samples by measuring RNase P gene levels using qPCR. High-risk HPV DNA detection and typing was done using the GP5+/6+ Luminex system.

Results

Most participants in the self-collection arm (93%, 185/200) submitted their samples while only 56% (113/200) of those invited to the hospital for sample collection attended and were screened during the study period (p value < 0.001). Human genomic DNA was detected in all but five (1.7%) participants, all of whom were in the self-collection arm. The prevalence of high-risk HPV in the study population was 10% with types 35, 52 and 18 being the commonest.

Conclusions

Our study shows that self-sampling significantly increased uptake of HPV DNA based test for cervical cancer screening in this population and the samples collected were adequate for HPV detection and genotyping. Cervical cancer screening programs that incorporate self-sampling and HPV DNA tests are feasible and may significantly improve uptake of cervical cancer screening in SSA.

Optimal Management Strategies for Primary HPV Testing for Cervical Screening: Cost-Effectiveness Evaluation for the National Cervical Screening Program in Australia

BACKGROUND

Several countries are implementing a transition to HPV testing for cervical screening in response to the introduction of HPV vaccination and evidence indicating that HPV screening is more effective than cytology. In Australia, a 2017 transition from 2-yearly conventional cytology in 18-20 to 69 years to 5-yearly primary HPV screening in 25 to 74 years will involve partial genotyping for HPV 16/18 with direct referral to colposcopy for this higher risk group. The objective of this study was to determine the optimal management of women positive for other high-risk HPV types (not 16/18) ('OHR HPV').

METHODS

We used a dynamic model of HPV transmission, vaccination, natural history and cervical screening to determine the optimal management of women positive for OHR HPV. We assumed cytology triage testing was used to inform management in this group and that those with high-grade cytology would be referred to colposcopy and those with negative cytology would receive 12-month surveillance. For those with OHR HPV and low-grade cytology (considered to be a single low-grade category in Australia incorporating ASC-US and LSIL), we evaluated (1) the 20-year risk of invasive cervical cancer assuming this group are referred for 12-month follow-up vs. colposcopy, and compared this to the risk in women with low-grade cytology under the current program (i.e. an accepted benchmark risk for 12-month follow-up in Australia); (2) the population-level impact of the whole program, assuming this group are referred to 12-month surveillance vs. colposcopy; and (3) the cost-effectiveness of immediate colposcopy compared to 12-month follow-up. Evaluation was performed both for HPV-unvaccinated cohorts and cohorts offered vaccination (coverage ~72%).

FINDINGS

The estimated 20-year risk of cervical cancer is ≤1.0% at all ages if this group are referred to colposcopy vs. ≤1.2% if followed-up in 12 months, both of which are lower than the ≤2.6% benchmark risk in women with low-grade cytology in the current program (who are returned for 12-month follow-up). At the population level, immediate colposcopy referral provides an incremental 1-3% reduction in cervical cancer incidence and mortality compared with 12-month follow-up, but this is in the context of a predicted 24-36% reduction associated with the new HPV screening program compared to the current cytology-based program. Furthermore, immediate colposcopy substantially increases the predicted number of colposcopies, with >650 additional colposcopies required to avert each additional case of cervical cancer compared to 12-month follow-up. Compared to 12-month follow-up, immediate colposcopy has an incremental cost-effectiveness ratio (ICER) of A$104,600/LYS (95%CrI:A$100,100-109,100) in unvaccinated women and A$117,100/LYS (95%CrI:A$112,300-122,000) in cohorts offered vaccination [Indicative willingness-to-pay threshold: A$50,000/LYS].

CONCLUSIONS

In primary HPV screening programs, partial genotyping for HPV16/18 or high-grade triage cytology in OHR HPV positive women can be used to refer the highest risk group to colposcopy, but 12-month follow-up for women with OHR HPV and low-grade cytology is associated with a low risk of developing cervical cancer. Direct referral to colposcopy for this group would be associated with a substantial increase in colposcopy referrals and the associated harms, and is also cost-ineffective; thus, 12-month surveillance for women with OHR HPV and low-grade cytology provides the best balance between benefits, harms and cost-effectiveness.

Optimal Cervical Cancer Screening in Women Vaccinated Against Human Papillomavirus

Background

Current US cervical cancer screening guidelines do not differentiate recommendations based on a woman's human papillomavirus (HPV) vaccination status. Changes to cervical cancer screening policies in HPV-vaccinated women should be evaluated.

Methods

We utilized an individual-based mathematical model of HPV and cervical cancer in US women to project the health benefits, costs, and harms associated with screening strategies in women vaccinated with the bivalent, quadrivalent, or nonavalent vaccine. Strategies varied by the primary screening test, including cytology, HPV, and combined cytology and HPV "cotesting"; age of screening initiation and/or switching to a new test; and interval between routine screens. Cost-effectiveness analysis was conducted from the societal perspective to identify screening strategies that would be considered good value for money according to thresholds of $50 000 to $200 000 per quality-adjusted life-year (QALY) gained.

Results

Among women fully vaccinated with the bivalent or quadrivalent vaccine, optimal screening strategies involved either cytology or HPV testing alone every five years starting at age 25 or 30 years, with cost-effectiveness ratios ranging from $34 680 to $138 560 per QALY gained. Screening earlier or more frequently was either not cost-effective or associated with exceedingly high cost-effectiveness ratios. In women vaccinated with the nonavalent vaccine, only primary HPV testing was efficient, involving decreased frequency (ie, every 10 years) starting at either age 35 years ($40 210 per QALY) or age 30 years ($127 010 per QALY); with lower nonavalent vaccine efficacy, 10-year HPV testing starting at earlier ages of 25 or 30 years was optimal. Importantly, current US guidelines for screening were inefficient in HPV-vaccinated women.

Conclusions

This model-based analysis suggests screening can be modified to start at later ages, occur at decreased frequency, and involve primary HPV testing in HPV-vaccinated women, providing more health benefit at lower harms and costs than current screening guidelines.

A comparison between Pap and HPV screening tests and screening methods

The present study assesses the results of cervical cancer (CC) screening over two 3-year periods (2008-2010 and 2011-2013) by comparing two screening tests [Papanicolaou (Pap) and human papillomavirus (HPV) tests] and two screening methods (organized and spontaneous). The study population includes women aged 25-64 years who underwent CC screening between 2008 and 2010 and/or 2011 and 2013, divided into those who responded to an invitation letter (organized screening) and those who spontaneously underwent testing at a public or private facility (non-programmed screening). Between 2008 and 2010, the response rates increased from 27.7% in 2008 to 44.5% in 2009 and 67.6% in 2010 (P<0.001). Women aged 25-34 years had the lowest response rate, whereas respondents were more frequent among women aged 35-44 and 45-54 years. Significant differences (P<0.001) were identified between organized and spontaneous screening test results with regard to diagnostic categories high-grade squamous intraepithelial lesion (50.5 vs. 49.5%), low-grade squamous intraepithelial lesion (42.8 vs. 57.2%) and undetermined lesion atypical glandular cells (AGC; 57.5 vs. 42.5%) or atypical squamous cells of undetermined significance (ASC-US; 54.2 vs. 45.8%). Compared with spontaneous screening, the organized programme resulted in a larger number of women screened for CC; it reduced the frequency of undetermined diagnoses (AGC, ASC-US), and identified a larger number of high-grade lesions.

Economic evaluation of pediatric influenza immunization program compared with other pediatric immunization programs: A systematic review

This study compared the economic value of pediatric immunisation programmes for influenza to those for rotavirus (RV), meningococcal disease (MD), pneumococcal disease (PD), human papillomavirus (HPV), hepatitis B (Hep B), and varicella reported in recent (2000 onwards) cost-effectiveness (CE) studies identified in a systematic review of PubMed, health technology, and vaccination databases. The systematic review yielded 51 economic evaluation studies of pediatric immunisation - 10 (20%) for influenza and 41 (80%) for the other selected diseases. The quality of the eligible articles was assessed using Drummond's checklist. Although inherent challenges and limitations exist when comparing economic evaluations of immunisation programmes, an overall comparison of the included studies demonstrated cost-effectiveness/cost saving for influenza from a European-Union-Five (EU5) and United States (US) perspective; point estimates for cost/quality-adjusted life-years (QALY) from dominance (cost-saving with more effect) to ≤45,444 were reported. The economic value of influenza programmes was comparable to the other vaccines of interest, with cost/QALY in general considerably lower than RV, Hep B, MD and PD. Independent of the perspective and type of analysis, the economic impact of a pediatric influenza immunisation program was influenced by vaccine efficacy, immunisation coverage, costs, and most significantly by herd immunity. This review suggests that pediatric influenza immunisation may offer a cost effective strategy when compared with HPV and varicella and possibly more value compared with other childhood vaccines (RV, Hep B, MD and PD).

The potential harms of primary human papillomavirus screening in over-screened women: a microsimulation study

BACKGROUND

It is well acknowledged that HPV testing should not be performed at young age and at short intervals. Cytological screening practices have shown that over-screening, i.e., from a younger age and at shorter intervals than recommended, is hard to avoid. We quantified the consequences of a switch to primary HPV screening for over-screened women, taking into account its higher sensitivity but lower specificity than cytology.

METHODS

The health effects of using the HPV test instead of cytology as the primary screening method were determined with the MISCAN-Cervix model. We varied the age women start screening and the interval between screens. In the sensitivity analyses, we varied the background risk of cervical cancer, the HPV prevalence, the discount rate, the triage strategy after cytology, and the test characteristics of both cytology and the HPV test.

RESULTS

For women screened 5 yearly from age 30, 32 extra deaths per 100,000 simulated women were prevented when switching from primary cytology to primary HPV testing. For annual screening from age 20, such a switch resulted in 6 extra deaths prevented. It was associated with 9,044 more positive primary screens in the former scenario versus 76,480 in the latter. Under all conditions, for women screened annually, switching to HPV screening resulted in a net loss of quality-adjusted life years.

CONCLUSION

For over-screened women, the harms associated with a lower test specificity outweigh the life years gained when switching from primary cytology to primary HPV testing. The extent of over-screening should be considered when deciding on inclusion of primary HPV screening in cervical cancer screening guidelines.

Calibrating Parameters for Microsimulation Disease Models: A Review and Comparison of Different Goodness-of-Fit Criteria

BACKGROUND

Calibration (estimation of model parameters) compares model outcomes with observed outcomes and explores possible model parameter values to identify the set of values that provides the best fit to the data. The goodness-of-fit (GOF) criterion quantifies the difference between model and observed outcomes. There is no consensus on the most appropriate GOF criterion, because a direct performance comparison of GOF criteria in model calibration is lacking.

METHODS

We systematically compared the performance of commonly used GOF criteria (sum of squared errors [SSE], Pearson chi-square, and a likelihood-based approach [Poisson and/or binomial deviance functions]) in the calibration of selected parameters of the MISCAN-Colon microsimulation model for colorectal cancer. The performance of each GOF criterion was assessed by comparing the 1) root mean squared prediction error (RMSPE) of the selected parameters, 2) computation time of the calibration procedure of various calibration scenarios, and 3) impact on estimated cost-effectiveness ratios.

RESULTS

The likelihood-based deviance resulted in the lowest RMSPE in 4 of 6 calibration scenarios and was close to best in the other 2. The SSE had a 25 times higher RMSPE in a scenario with considerable differences in the values of observed outcomes, whereas the Pearson chi-square had a 60 times higher RMSPE in a scenario with multiple studies measuring the same outcome. In all scenarios, the SSE required the most computation time. The likelihood-based approach estimated the cost-effectiveness ratio most accurately (up to -0.15% relative difference versus 0.44% [SSE] and 13% [Pearson chi-square]).

CONCLUSIONS

The likelihood-based deviance criteria lead to accurate estimation of parameters under various circumstances. These criteria are recommended for calibration in microsimulation disease models in contrast with other commonly used criteria.

Human Papillomavirus Infection in Women Who Submit Self-collected Vaginal Swabs After Internet Recruitment

Submission of vaginal samples collected at home could remove barriers that women face in getting screened for cervical cancer. From December 2013 to January 2014, women aged 21-30 years were recruited online to participate in either (1) self-collected testing for human papillomavirus (HPV) infection and an online survey, or (2) an online survey regarding their perceptions of self-collected testing for HPV infection. Demographics, risk factors, testing perceptions, and satisfaction with self-collected testing were assessed with online questionnaires. Women who performed self-collection were sent a home sampling kit by US mail, which was returned via US mail for HPV testing. A total of 197 women were enrolled, with 130 completing the online survey and 67 participating in both the survey and self-collection. Of the 67 women who were sent kits, 62 (92.5%) were returned for testing. Sixty kits contained a sample sufficient for testing. The overall prevalence of HPV infection was 17.8%, however 6 women (9.7%) were infected with >1 type of HPV. Women who self-collected a sample reported more favorable attributes of self-collection compared to women who only participated in the online survey, including ease of sampling (87.1 vs. 18.9%), no pain during sampling (72.6 vs. 5.6%), and lack of embarrassment (67.7 vs. 12.9%). A high prevalence of HPV infection was demonstrated among women recruited via the internet. Online recruitment and at home screening methods have the potential to engage women in screening by offering an approach that might be more acceptable to women of different backgrounds.

Cervical Cancer Screening in Partly HPV Vaccinated Cohorts - A Cost-Effectiveness Analysis

Background

Vaccination against the oncogenic human papillomavirus (HPV) types 16 and 18 will reduce the prevalence of these types, thereby also reducing cervical cancer risk in unvaccinated women. This (measurable) herd effect will be limited at first, but is expected to increase over time. At a certain herd immunity level, tailoring screening to vaccination status may no longer be worth the additional effort. Moreover, uniform screening may be the only viable option. We therefore investigated at what level of herd immunity it is cost-effective to also reduce screening intensity in unvaccinated women.

Methods

We used the MISCAN-Cervix model to determine the optimal screening strategy for a pre-vaccination population and for vaccinated women (~80% decreased risk), assuming a willingness-to-pay of €50,000 per quality-adjusted life year gained. We considered HPV testing, cytology testing and co-testing and varied the start age of screening, the screening interval and the number of lifetime screens. We then calculated the incremental cost-effectiveness ratio (ICER) of screening unvaccinated women with the strategy optimized to the pre-vaccination population as compared to with the strategy optimized to vaccinated women, assuming different herd immunity levels.

Results

Primary HPV screening with cytology triage was the optimal strategy, with 8 lifetime screens for the pre-vaccination population and 3 for vaccinated women. The ICER of screening unvaccinated women 8 times instead of 3 was €28,085 in the absence of herd immunity. At around 50% herd immunity, the ICER reached €50,000.

Conclusion

From a herd immunity level of 50% onwards, screening intensity based on the pre-vaccination risk level becomes cost-ineffective for unvaccinated women. Reducing the screening intensity of uniform screening may then be considered.

Human papillomavirus vaccine trials and tribulations: Vaccine efficacy

As of December 2014, there were 3 approved vaccines for human papillomavirus (HPV): bivalent Cervarix (GlaxoSmithKline, New York, NY), quadrivalent Gardasil (Merck and Co, Kenilworth, NJ), and 9-valent Gardasil-9 (Merck and Co). The average cost per dose is $120, with a recommended 3-dose course. The quadrivalent vaccine is the most widely administered worldwide. As with the bivalent and 9-valent vaccines, the vaccine is considered safe, although concerns have been raised. In addition to immunization against the targeted HPV types, there is evidence that there is cross protection against other types of HPV. This continuing medical education review evaluates the differences in vaccines that are currently on the market; part II focuses on the cost-effectiveness of vaccination, the HPV vaccination programs currently instituted around the globe, efficacy, and safety.

The Dynamics of HPV Infection and Cervical Cancer Cells

The development of cervical cells from normal cells infected by human papillomavirus into invasive cancer cells can be modeled using population dynamics of the cells and free virus. The cell populations are separated into four compartments: susceptible cells, infected cells, precancerous cells and cancer cells. The model system of differential equations also has a free virus compartment in the system, which infect normal cells. We analyze the local stability of the equilibrium points of the model and investigate the parameters, which play an important role in the progression toward invasive cancer. By simulation, we investigate the boundary between initial conditions of solutions, which tend to stable equilibrium point, representing controlled infection, and those which tend to unbounded growth of the cancer cell population. Parameters affected by drug treatment are varied, and their effect on the risk of cancer progression is explored.

Beware of Kinked Frontiers: A Systematic Review of the Choice of Comparator Strategies in Cost-Effectiveness Analyses of Human Papillomavirus Testing in Cervical Screening

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.

Cervical Cancer Screening in Average-Risk Women: Best Practice Advice From the Clinical Guidelines Committee of the American College of Physicians

DESCRIPTION

The purpose of this best practice advice article is to describe the indications for screening for cervical cancer in asymptomatic, average-risk women aged 21 years or older.

METHODS

The evidence reviewed in this work is a distillation of relevant publications (including systematic reviews) used to support current guidelines.

BEST PRACTICE ADVICE 1

Clinicians should not screen average-risk women younger than 21 years for cervical cancer.

BEST PRACTICE ADVICE 2

Clinicians should start screening average-risk women for cervical cancer at age 21 years once every 3 years with cytology (cytologic tests without human papillomavirus [HPV] tests).

BEST PRACTICE ADVICE 3

Clinicians should not screen average-risk women for cervical cancer with cytology more often than once every 3 years.

BEST PRACTICE ADVICE 4

Clinicians may use a combination of cytology and HPV testing once every 5 years in average-risk women aged 30 years or older who prefer screening less often than every 3 years.

BEST PRACTICE ADVICE 5

Clinicians should not perform HPV testing in average-risk women younger than 30 years.

BEST PRACTICE ADVICE 6

Clinicians should stop screening average-risk women older than 65 years for cervical cancer if they have had 3 consecutive negative cytology results or 2 consecutive negative cytology plus HPV test results within 10 years, with the most recent test performed within 5 years.

BEST PRACTICE ADVICE 7

Clinicians should not screen average-risk women of any age for cervical cancer if they have had a hysterectomy with removal of the cervix.

Screening for cancer: advice for high-value care from the American College of Physicians

BACKGROUND

Cancer screening is one approach to reducing cancer-related morbidity and mortality rates. Screening strategies vary in intensity. Higher-intensity strategies are not necessarily higher value. High-value strategies provide a degree of benefits that clearly justifies the harms and costs incurred; low-value screening provides limited or no benefits to justify the harms and costs. When cancer screening leads to benefits, an optimal intensity of screening maximizes value. Some aspects of screening practices, especially overuse and underuse, are low value.

METHODS

Screening strategies for asymptomatic, average-risk adults for 5 common types of cancer were evaluated by reviewing clinical guidelines and evidence syntheses from the American College of Physicians (ACP), U.S. Preventive Services Task Force, American Academy of Family Physicians, American Cancer Society, American Congress of Obstetricians and Gynecologists, American Gastroenterological Association, and American Urological Association. "High value" was defined as the lowest screening intensity threshold at which organizations agree about screening recommendations for each type of cancer and "low value" as agreement about not recommending overly intensive screening strategies. This information is supplemented with additional findings from randomized, controlled trials; modeling studies; and studies of costs or resource use, including information found in the National Cancer Institute's Physician Data Query and UpToDate. The ACP provides high-value care screening advice for 5 common types of cancer; the specifics are outlined in this article. The ACP strongly encourages clinicians to adopt a cancer screening strategy that focuses on reaching all eligible persons with these high-value screening options while reducing overly intensive, low-value screening.

An Efficient, Noniterative Method of Identifying the Cost-Effectiveness Frontier

Cost-effectiveness analysis aims to identify treatments and policies that maximize benefits subject to resource constraints. However, the conventional process of identifying the efficient frontier (i.e., the set of potentially cost-effective options) can be algorithmically inefficient, especially when considering a policy problem with many alternative options or when performing an extensive suite of sensitivity analyses for which the efficient frontier must be found for each. Here, we describe an alternative one-pass algorithm that is conceptually simple, easier to implement, and potentially faster for situations that challenge the conventional approach. Our algorithm accomplishes this by exploiting the relationship between the net monetary benefit and the cost-effectiveness plane. To facilitate further evaluation and use of this approach, we also provide scripts in R and Matlab that implement our method and can be used to identify efficient frontiers for any decision problem.

Cervical cancer screening in a sexually transmitted disease clinic: screening adoption experiences from a midwestern clinic

OBJECTIVES

We examined whether a sexually transmitted disease (STD) clinic could reach women who had not received a Papanicolau (Pap) test in the past 3 years. We also explored staff attitudes and implementation of cervical cancer screening.

METHODS

Women (n = 123) aged 30 to 50 years were offered cervical cancer screening in an Indiana STD clinic. We measured effectiveness by the patients' self-reported last Pap test. We explored adoption of screening through focus groups with 34 staff members by documenting their attitudes about cervical cancer screening and screening strategy adaptation. We also documented recruitment and screening implementation.

RESULTS

Almost half (47.9%) of participants reported a last Pap test 3 or more years previously; 30% had reported a last Pap more than 5 years ago, and 11.4% had a high-risk test outcome that required referral to colposcopy. Staff supported screening because of mission alignment and perceived patient benefit. Screening adaptations included eligibility, results provision, and follow-up.

CONCLUSIONS

Cervical cancer screening was possible and potentially beneficial in STD clinics. Future effectiveness-implementation studies should expand to include all female patients, and should examine the degree to which adaptation of selected adoption frameworks is feasible.

Vital signs: cervical cancer incidence, mortality, and screening - United States, 2007-2012

BACKGROUND

Cervical cancer screening is one of the greatest cancer prevention achievements, yet some women still develop or die from this disease.

OBJECTIVE

To assess recent trends in cervical cancer incidence and mortality, current screening percentages, and factors associated with higher incidence and death rates and inadequate screening.

METHODS

Percentages of women who had not been screened for cervical cancer in the past 5 years were estimated using data from the 2012 Behavioral Risk Factor Surveillance System survey. State-specific cervical cancer incidence data from the United States Cancer Statistics and mortality data from the National Vital Statistics System were used to calculate incidence and death rates for 2011 by state. Incidence and death rates and annual percentage changes from 2007 to 2011 were calculated by state and U.S. Census region.

RESULTS

In 2012, the percentage of women who had not been screened for cervical cancer in the past 5 years was estimated to be 11.4%; the percentage was larger for women without health insurance (23.1%) and for those without a regular health care provider (25.5%). From 2007 to 2011, the cervical cancer incidence rate decreased by 1.9% per year while the death rate remained stable. The South had the highest incidence rate (8.5 per 100,000), death rate (2.7 per 100,000), and percentage of women who had not been screened in the past 5 years (12.3%).

CONCLUSIONS

Trends in cervical cancer incidence rates have decreased slightly while death rates have been stable over the last 5 years. The proportion of inadequately screened women is higher among older women, Asians/Pacific Islanders, and American Indians/Alaska Natives.

IMPLICATIONS FOR PUBLIC HEALTH PRACTICE

There continue to be women who are not screened as recommended, and women who die from this preventable cancer. Evidence-based public health approaches are available to increase women's access to screening and timely follow-up of abnormal results.