Policy analysis of cervical cancer prevention in Iran based on the policy triangle model

BACKGROUND

Widespread use of screening in high-income countries has led to a significant reduction in cervical cancer mortality. Most low- and middle-income countries still have poorly organized screening programs. This study aimed at policy analysis of prevention and early detection of cervical cancer in Iran, a middle-income country.

MATERIALS AND METHOD

This qualitative retrospective study, extended by the health policy triangle model, was conducted from July 2020 to September 2021. A sample of this study consisted of 43 participants, including 16 key policy experts; nine 11 senior health system managers, 13 executives, and 3 clients selected purposefully. Data were collected through semi-structured interviews using the interview guide and analyzed using a framework analysis method based on the policy triangle model in MAXQDA2020.

RESULTS

Nine themes, 15 subthemes, and 36 codes were extracted based on the 4 dimensions of the model; stakeholder analysis challenges, including conflict of interest and decision-making challenges. Moreover, the most important policy process challenges indicated the weakness of monitoring and evaluation systems and weakness of using scientific principles in policy making. Weakness of organizational and intersectoral structure and weakness of executive management were obtained among the challenges in the context analysis. Finally, the most important challenges related to content analysis are weaknesses in applying scientific principles in policy making, including weaknesses in standard operating procedures, and low use of HTA capacity in developed guidelines.

CONCLUSION

A wide range of economic, social, and cultural problems can affect cervical cancer prevention policies. Several strategies are suggested to overcome these challenges, including allocating separate funds to cancer prevention programs, using structures to sustain prevention programs, designing, and using them to improve public awareness.

Frequency of cervical premalignant lesions in the gynecologic patients of a tertiary hospital in Mogadishu, Somalia

BACKGROUND

Cervical cancer is the fourth most common cancer worldwide and is the most frequently diagnosed cancer in 23 countries and the most common cause of death in 36 countries, mostly from Sub-Saharan African countries. Cervical screening is a key element to reduce the incidence and mortality of cervical cancer. Cancer screening is low in Sub-Saharan Africa. This study aims to provide information about cervical premalignant lesions frequency in Somalia.

METHODS

The pathology results of cervicovaginal smear samples obtained from patients aged 25-65 years who applied to the gynecology outpatient clinic between October 5 and December 5, 2021 were analyzed retrospectively. SPSS 22.0 was used for the statistical analysis of the data.

RESULT

Among the 497 results, 63 premalignant lesions were detected. The rate of premalignant lesions (63/497) was found to be 12.3%. The most common premalignant lesion was atypical squamous cells of undetermined significance (ASC-US).

CONCLUSION

In this study, the frequency of cervical premalignant lesions in Somalia was found to be higher than in the literature. Vaccination, screening, and early diagnosis are the most important components in the fight against cervical cancer. Access to vaccination, screening, and early diagnosis, which are the most important components in the fight against cervical cancer in Somalia, will be possible with the cooperation of the national health system and international organizations.

A systematic review of economic evaluations of cervical cancer screening methods

OBJECTIVE

The aims of this systematic review were to (1) identify primary- and model-based economic evaluations of cervical cancer screening methods and to (2) provide a contextual summary of valuation outcomes associated with three types of cervical cancer screening tests: visual inspection with acetic acid, human papillomavirus deoxyribonucleic acid, and Papanicolaou smear.

INTRODUCTION

Cervical cancer screening is an important public health priority with the potential to improve the detection of precancerous lesions in high-risk females for early intervention and disease prevention. Test performance and cost-effectiveness differ based on the specific screening method used across different platforms. There is a need to appraise existing economic evaluations of cervical cancer screening methods.

METHODS

This review considered primary-based and model-based full economic evaluations of cervical cancer screening methods. The evaluation methods of interest included cost-effectiveness analysis, cost-utility analysis, cost-minimization analysis, cost-benefit analysis, and cost-consequence analysis. We searched Scopus, PubMed, National Health Economic Evaluation Database (NH EED), Cochrane, and the Health Economic Evaluation Database for full economic evaluations of cancer screening methods. No formal date restrictions were applied. Model-based and primary-based full economic evaluations were included. A critical appraisal of included studies was performed by the main investigator, while a second independent reviewer assessed critical appraisal findings for any inconsistencies. Data were extracted using a standardised data extraction tool for economic evaluations. The ultimate outcomes of costs, effectiveness, benefits, and utilities of cervical cancer screening modalities were extracted from included studies, analysed, and summarised.

RESULTS

From a total of 671 screened studies, 44 studies met the study inclusion criteria. Forty-three studies were cost-effectiveness analyses, one study reported both cost-utility and cost-effectiveness outcomes, and another study reported cost utilities of cervical cancer screening methods only. Human papillomavirus (HPV) DNA testing was reported as a dominant stand-alone screening test by 14 studies, while five studies reported visual inspection with acetic acid (VIA) as a dominant stand-alone screening test. Primary HPV screening strategies were dominant in 21 studies, while three studies reported cytology-based screening strategies as the dominant screening method.

CONCLUSIONS

Existing evidence indicates that HPV-based and VIA testing strategies are cost-effective, but this is dependent on setting. Our review suggests the limited cost-effectiveness of cytology-based testing, which may be due in part to the need for specific infrastructures and human resources.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020212454 .

Research on the Economics of Cancer-Related Health Care: An Overview of the Review Literature

We reviewed current literature reviews regarding economics of cancer-related health care to identify focus areas and gaps. We searched PubMed for systematic and other reviews with the Medical Subject Headings "neoplasms" and "economics" published between January 1, 2010, and April 1, 2020, identifying 164 reviews. Review characteristics were abstracted and described. The majority (70.7%) of reviews focused on cost-effectiveness or cost-utility analyses. Few reviews addressed other types of cancer health economic studies. More than two-thirds of the reviews examined cancer treatments, followed by screening (15.9%) and survivorship or end-of-life (13.4%). The plurality of reviews (28.7%) cut across cancer site, followed by breast (20.7%), colorectal (11.6%), and gynecologic (8.5%) cancers. Specific topics addressed cancer screening modalities, novel therapies, pain management, or exercise interventions during survivorship. The results indicate that reviews do not regularly cover other phases of care or topics including financial hardship, policy, and measurement and methods.

Elderly women's experiences of self-sampling for HPV testing

BACKGROUND

Self-sampling for HPV testing, as an alternative to the conventional speculum based sampling, is highly acceptable to women of screening ages. The aim of this study was to describe older women's (60 to 75 years) experiences of self-sampling.

METHODS

In Sweden a descriptive study with quantitative and qualitative methods was designed to collect data from a survey of women who participated in self-sampling for HPV testing. Individual interviews were done with women who tested positive in the first self-sampling, and were either negative in their second HPV test or were positive in their second HPV test, but without precancerous lesions or cancer.

RESULTS

Of 893 eligible women, 868 (97.2%) answered the survey. Among the surveyed women, 49.2% reported it was very easy to perform self-sampling, 46.8% answered it was easy and 2.0% answered it was not easy. A majority (58.9%) answered that they prefer self-sampling, 16.5% that they prefer sample collection by a healthcare provider, 23.7% did not have any preference and 0.9% did not answer the question. In the interviews, 13 of 16 invited women participated. Most of them reported that they prefer self-sampling because it was easy to perform, less embarrassing and less time consuming than a visit to a clinic. The majority of women reported that they were not worried when informed about having an HPV positive test. Overall, participating women with better knowledge about the significance of an HPV infection were more worried about having a positive HPV test.

CONCLUSION

Cervical cancer remains a highly preventable disease through screening and early treatment. Our results indicated that vaginal self-sampling for HPV testing was a well-accepted method for cervical cancer prevention in this group of older women.

TRIAL REGISTRATION

https://www.researchweb.org/is/en/fouckfuu/project/272587. Registered 24 June 2019-retrospectively registered. www.researchweb.org.

The Cost-Effectiveness Analysis of Cervical Cancer Screening Using a Systematic Invitation System in Lithuania

In Lithuania, cytological screening of cervical cancer (CC) is largely opportunistic. Absence of standardized systematic invitation practice might be the reason for low participation rates. The study aimed to assess the cost-effectiveness of systematic invitation approach in CC screening programme from the perspective of a healthcare provider. A decision tree was used to compare an opportunistic invitation by a family doctor, a personal postal invitation letter with appointment time and place, and a personal postal invitation letter with appointment time and place with one reminder letter. Cost-effectiveness was defined as an incremental cost-effectiveness ratio (ICER) per one additionally screened woman and per one additional abnormal Pap smear test detected. The ICER of one personal postal invitation letter was €9.67 per one additionally screened woman and €55.21 per one additional abnormal Pap smear test detected in comparison with the current screening practice. The ICER of a personal invitation letter with an additional reminder letter compared to one invitation letter was €13.47 and €86.88 respectively. Conclusions: A personal invitation letter approach is more effective in increasing the participation rate in CC screening and the number of detected abnormal Pap smears; however, it incurs additional expenses compared with current invitation practice.

Cost-effectiveness evaluation of HPV self-testing offered to non-attendees in cervical cancer screening in Switzerland

OBJECTIVE

About 30% of women who are eligible for cervical cancer (CC) screening remain un-screened or under-screened in Switzerland. HPV testing on self-collected vaginal samples (Self-HPV) has shown to be more sensitive than cytology while also reaching non-attendees. The objective of this study was to explore the cost-effectiveness of offering Self-HPV to non-attendees in Switzerland.

METHODS

A recursive decision-tree with one-year cycles was used to model the life-long natural HPV history. Markov cohort simulations were used to assess the expected outcomes from the model. The outcomes of three strategies were compared with the absence of screening: Self-HPV and triage with colposcopy (Self-HPV/colpo), Self-HPV and triage with Pap cytology (Self-HPV/PAP), cytological screening and triage with HPV (PAP/HPV). Sensitivity analyses for the key parameters of the model were conducted to check the robustness of findings.

RESULTS

Offering a Self-HPV screening to non-attendees could prevent 90% of CC and 94% of CC-related deaths in the study population. The current cytology-based program could reduce by 83% the number of CC cases and by 88% the number of CC-related deaths over the population's lifetime. Compared to the absence of screening, incremental cost-effectiveness ratios (ICER) were estimated to be, per saved Quality Adjusted Life Year (QALY), 12413US$ for the strategy Self-HPV/colpo, 11138US$ for the strategy Self-HPV/Pap and 22488US$ for the strategy PAP/HPV.

CONCLUSIONS

Offering Self-HPV as a CC screening strategy to non-attendees in Switzerland is a cost-effective solution that is associated with a reduction of CC cases and related deaths. Self-HPV is more cost-effective than the currently used cytology-based screening.

Simple but not simpler: a systematic review of Markov models for economic evaluation of cervical cancer screening

The aim of this study was to critically evaluate the quality of the models used in economic evaluations of screening strategies for cervical cancer prevention. We systematically searched multiple databases, selecting model-based full economic evaluations (cost-effectiveness analyses, cost-utility analyses, and cost-benefit analyses) of cervical cancer screening strategies. Two independent reviewers screened articles for relevance and performed data extraction. Methodological assessment of the quality of the models utilized formal checklists, and a qualitative narrative synthesis was performed. Thirty-eight articles were reviewed. The majority of the studies were conducted in high-income countries (82%, n=31). The Pap test was the most used screening strategy investigated, which was present in 86% (n=33) of the studies. Half of the studies (n=19) used a previously published Markov model. The deterministic sensitivity analysis was performed in 92% (n=35) of the studies. The mean number of properly reported checklist items was 9 out of the maximum possible 18. Items that were better reported included the statement of decision problem, the description of the strategies/comparators, the statement of time horizon, and information regarding the disease states. Compliance with some items of the checklist was poor. The Markov models for economic evaluation of screening strategies for cervical cancer varied in quality. The following points require improvement: 1) assessment of methodological, structural, heterogeneity, and parameter uncertainties; 2) model type and cycle length justification; 3) methods to account for heterogeneity; and 4) report of consistency evaluation (through calibration and validation methods).

Comparative Assessment of a Self-sampling Device and Gynecologist Sampling for Cytology and HPV DNA Detection in a Rural and Low Resource Setting: Malaysian Experience

PURPOSE

This study was conducted to assess the agreement and differences between cervical self-sampling with a Kato device (KSSD) and gynecologist sampling for Pap cytology and human papillomavirus DNA (HPV DNA) detection.

MATERIALS AND METHODS

Women underwent self-sampling followed by gynecologist sampling during screening at two primary health clinics. Pap cytology of cervical specimens was evaluated for specimen adequacy, presence of endocervical cells or transformation zone cells and cytological interpretation for cells abnormalities. Cervical specimens were also extracted and tested for HPV DNA detection. Positive HPV smears underwent gene sequencing and HPV genotyping by referring to the online NCBI gene bank. Results were compared between samplings by Kappa agreement and McNemar test.

RESULTS

For Pap specimen adequacy, KSSD showed 100% agreement with gynecologist sampling but had only 32.3% agreement for presence of endocervical cells. Both sampling showed 100% agreement with only 1 case detected HSIL favouring CIN2 for cytology result. HPV DNA detection showed 86.2%agreement (K=0.64, 95% CI 0.524-0.756, p=0.001) between samplings. KSSD and gynaecologist sampling identified high risk HPV in 17.3% and 23.9% respectively (p= 0.014).

CONCLUSION

The self-sampling using Kato device can serve as a tool in Pap cytology and HPV DNA detection in low resource settings in Malaysia. Self-sampling devices such as KSSD can be used as an alternative technique to gynaecologist sampling for cervical cancer screening among rural populations in Malaysia.

Cost-Effectiveness of Different Cervical Screening Strategies in Islamic Republic of Iran: A Middle-Income Country with a Low Incidence Rate of Cervical Cancer

OBJECTIVE

Invasive cervical cancer (ICC) is the fourth most common cancer among women worldwide. Cervical screening programs have reduced the incidence and mortality rates of ICC. We studied the cost-effectiveness of different cervical screening strategies in the Islamic Republic of Iran, a Muslim country with a low incidence rate of ICC.

METHODS

We constructed an 11-state Markov model, in which the parameters included regression and progression probabilities, test characteristics, costs, and utilities; these were extracted from primary data and the literature. Our strategies included Pap smear screening and human papillomavirus (HPV) DNA testing plus Pap smear triaging with different starting ages and screening intervals. Model outcomes included lifetime costs, life years gained, quality-adjusted life years (QALY), and incremental cost-effectiveness ratios (ICERs). One-way sensitivity analysis was performed to examine the stability of the results.

RESULTS

We found that the prevented mortalities for the 11 strategies compared with no screening varied from 26% to 64%. The most cost-effective strategy was HPV screening, starting at age 35 years and repeated every 10 years. The ICER of this strategy was $8,875 per QALY compared with no screening. We found that screening at 5-year intervals was also cost-effective based on GDP per capita in Iran.

CONCLUSION

We recommend organized cervical screening with HPV DNA testing for women in Iran, beginning at age 35 and repeated every 10 or 5 years. The results of this study could be generalized to other countries with low incidence rates of cervical cancer.

Reimbursed Costs of Management of Uterine Cervical Lesions in Poland--a Descriptive Analysis of Data from the National Health Fund and the Ministry of Health

BACKGROUND

Despite implementation of organised screening programme in 2006/2007, cervical cancer (CC) incidence and mortality in Poland are still higher than the average in the European Union. CC and preceding cervical intraepithelial neoplasia (CIN) caused by human papillomaviruses (HPVs) can be prevented by vaccines which are reimbursed in around 20 European countries but not in Poland. CC and CIN can be also detected with the use of HPV tests which are not included in the Polish screening programme. Reimbursement for HPV vaccines and HPV testing requires cost-effectiveness analyses which include country-specific data on the burden and costs of management of cervical neoplasia. Therefore, we investigated the burden of cervical neoplasia and direct costs associated with its detection and management in Poland in 2012 reimbursed by the National Health Fund (NHF) - the only public healthcare insurance institution. We also report administrative costs of the organised screening programme covered by the Ministry of Health.

METHODS

Data on the burden and reimbursed costs of organised and opportunistic screening as well as management of cervical neoplasia were drawn from the NHF databases. Numbers of women reported with CIN and CC were ascertained.

RESULTS

In 2012, there were 765,266 and 1,288,358 reimbursed Pap smears collected within and outside the organised screening programme, respectively. Expenditures on medical and administrative procedures in organised screening reached PLN (Polish Zloty) 41,470,664 and 12,150,398 respectively. The number of women with particular diagnosis and reimbursement for the management of these lesions were as follows: glandular ectropion 208,033 and PLN 37,349,515; CIN1 10,521 and PLN 6,616,375; CIN2 5,812 and PLN 5,071,155; CIN3 6,487 and PLN 7,611,062; unspecified grade CIN 36,575 and PLN 12,352,034; and CC 33,482 and PLN 52,377,006, respectively. In women with ectropion and CIN the total number of local excision/ablative therapeutic procedures on the cervix reached 47,658 and the total number of hysterectomies was 1,321.

CONCLUSION

In 2012, management of approximately 93 thousand women with HPV-related cervical lesions reimbursed in Poland amounted to PLN 84,027,632 which makes it a considerable public health problem. The number of women managed for glandular ectropion is considerable and related costs are high. Total reimbursement for detection, treatment and follow-up of all cervical lesions reaches at least PLN 137 million annually.

Evaluation of several screening approaches for detection of cervical lesions in rural Shandong, China

PURPOSE

The study was designed to: (1) investigate the prevalence of high-risk human papillomavirus (HR- HPV) infection and cervical neoplasia; and (2) evaluate clinical performance of visual inspection with acetic acid/ Lugol's iodine (VIA /VILI), Pap smear, high-risk human papillomavirus (HR-HPV) DNA test for detecting cervical intraepithelial neoplasia grade 2 or worse (CIN2+) and (3) explore appropriate screening approach in rural areas of Shandong Province.

MATERIALS AND METHODS

A total of 3,763 eligible women from Yiyuan County in Yimeng mountainous areas of rural Shandong, China, were enrolled and underwent Pap smear, HR-HPV DNA testing by Hybrid Capture 2 (HC2), and VIA /VILI tests. Women positive in any test were referred to colposcopy and biopsy as indicated.

RESULTS

The prevalence of HR-HPV infection among all enrolled women was 11.1% and that in healthy women was 9.9%. In total 33 cases of CIN1, 16 cases of CIN2, 6 cases of CIN3 but none of cervical cancer were detected and the crude prevalence of CIN2+ was 0.58%. For detecting CIN2+, the sensitivity of HR-HPV DNA testing, VIA/VILI, Pap smear was 90.9%, 77.3%, 81.8%, respectively. Pap smear had the best specificity of 98.2%, followed by HR-HPV DNA testing with specificity of 89.4%, VIA/VILI had the lowest specificity of 81.2%. Colposcopy referral rate of HR-HPV DNA testing, VIA/VILI, Pap smear was 11.1%, 18.5%, 2.3%, respectively.

CONCLUSIONS

Our results suggest that HR-HPV DNA testing alone might be appropriate for primary cervical cancer screening in rural low-resource areas of Shandong Province, China.

Priority Setting for Improvement of Cervical Cancer Prevention in Iran

BACKGROUND

Cervical cancer is the fourth most common cancer among women worldwide. Organized cervical screening and vaccination against human papilloma virus (HPV) have been successful interventions for prevention of invasive cervical cancer (ICC). Because of cultural and religious considerations, ICC has low incidence in Iran and many other Muslim countries. There is no organized cervical screening in these countries. Therefore, ICC is usually diagnosed in advanced stages with poor prognosis in these countries. We performed a priority setting exercise and suggested priorities for prevention of ICC in this setting.

METHODS

We invited experts and researchers to a workshop and asked them to list important suggestions for ICC prevention in Iran. After merging similar items and removing the duplicates, we asked the experts to rank the list of suggested items. We used a strategy grid and Go-zone analysis to determine final list of priorities for ICC prevention in Iran.

RESULTS

From 26 final items suggested as priorities for prevention of ICC, the most important priorities were developing national guidelines for cervical screening and quality control protocol for patient follow-up and management of precancerous lesions. In addition, we emphasized considering insurance coverage for cervical screening, public awareness, and research priorities, and establishment of a cervical screening registry.

CONCLUSION

A comprehensive approach and implementation of organized cervical screening program is necessary for prevention of ICC in Iran and other low incidence Muslim countries. Because of high cost for vaccination and low incidence of cervical cancer, we do not recommend HPV vaccination for the time being in Iran.

Assessment of the reliability of a novel self-sampling device for performing cervical sampling in Malaysia

BACKGROUND

The participation of women in cervical cancer screening in Malaysia is low. Self-sampling might be able to overcome this problem.The aim of this study was to assess the reliability of self-sampling for cervical smear in our country.

MATERIALS AND METHODS

This cross-sectional study was conducted on 258 community dwelling women from urban and rural settings who participated in health campaigns. In order to reduce the sampling bias, half of the study population performed the self-sampling prior to the physician sampling while the other half performed the self-sampling after the physician sampling, randomly. Acquired samples were assessed for cytological changes as well as HPV DNA detection.

RESULTS

The mean age of the subjects was 40.4±11.3 years. The prevalence of abnormal cervical changes was 2.7%. High risk and low risk HPV genotypes were found in 4.0% and 2.7% of the subjects, respectively. A substantial agreement was observed between self-sampling and the physician obtained sampling in cytological diagnosis (k=0.62, 95%CI=0.50, 0.74), micro-organism detection (k=0.77, 95%CI=0.66, 0.88) and detection of hormonal status (k=0.75, 95%CI=0.65, 0.85) as well as detection of high risk (k=0.77, 95%CI=0.4, 0.98) and low risk (K=0.77, 95%CI=0.50, 0.92) HPV. Menopausal state was found to be related with 8.39 times more adequate cell specimens for cytology but 0.13 times less adequate cell specimens for virological assessment.

CONCLUSIONS

This study revealed that self-sampling has a good agreement with physician sampling in detecting HPV genotypes. Self-sampling can serve as a tool in HPV screening while it may be useful in detecting cytological abnormalities in Malaysia.