1
|
Spencer JC, Burger EA, Campos NG, Regan MC, Sy S, Kim JJ. Adapting a model of cervical carcinogenesis to self-identified Black women to evaluate racial disparities in the United States. J Natl Cancer Inst Monogr 2023; 2023:188-195. [PMID: 37947333 PMCID: PMC10637021 DOI: 10.1093/jncimonographs/lgad015] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 05/31/2023] [Accepted: 06/11/2023] [Indexed: 11/12/2023] Open
Abstract
BACKGROUND Self-identified Black women in the United States have higher cervical cancer incidence and mortality than the general population, but these differences have not been clearly attributed across described cancer care inequities. METHODS A previously established microsimulation model of cervical cancer was adapted to reflect demographic, screening, and survival data for Black US women and compared with a model reflecting data for all US women. Each model input with stratified data (all-cause mortality, hysterectomy rates, screening frequency, screening modality, follow-up, and cancer survival) was sequentially replaced with Black-race specific data to arrive at a fully specified model reflecting Black women. At each step, we estimated the relative contribution of inputs to observed disparities. RESULTS Estimated (hysterectomy-adjusted) cervical cancer incidence was 8.6 per 100 000 in the all-race model vs 10.8 per 100 000 in the Black-race model (relative risk [RR] = 1.24, range = 1.23-1.27). Estimated all-race cervical cancer mortality was 2.9 per 100 000 vs 5.5 per 100 000 in the Black-race model (RR = 1.92, range = 1.85-2.00). We found the largest contributors of incidence disparities were follow-up from positive screening results (47.3% of the total disparity) and screening frequency (32.7%). For mortality disparities, the largest contributor was cancer survival differences (70.1%) followed by screening follow-up (12.7%). CONCLUSION To reduce disparities in cervical cancer incidence and mortality, it is important to understand and address differences in care access and quality across the continuum of care. Focusing on the practices and policies that drive differences in treatment and follow-up from cervical abnormalities may have the highest impact.
Collapse
Affiliation(s)
- Jennifer C Spencer
- Department of Population Health, Dell Medical School, University of Texas at Austin, Austin, TX, USA
- Department of Internal Medicine, Dell Medical School, University of Texas at Austin, Austin, TX, USA
| | - Emily A Burger
- Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Department of Health Management and Health Economics, University of Oslo, Oslo, Norway
| | - Nicole G Campos
- Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Mary Caroline Regan
- Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Stephen Sy
- Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Jane J Kim
- Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| |
Collapse
|
2
|
de Sanjosé S, Perkins RB, Campos NG, Inturrisi F, Egemen D, Befano B, Rodriguez AC, Jerónimo J, Cheung LC, Desai K, Han P, Novetsky AP, Ukwuani A, Marcus J, Ahmed SR, Wentzensen N, Kalpathy-Cramer J, Schiffman M. Design of the HPV-Automated Visual Evaluation (PAVE) Study: Validating a Novel Cervical Screening Strategy. medRxiv 2023:2023.08.30.23294826. [PMID: 37693492 PMCID: PMC10491363 DOI: 10.1101/2023.08.30.23294826] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/12/2023]
Abstract
Objective To describe the HPV-Automated Visual Evaluation (PAVE) Study, an international, multi-centric study designed to evaluate a novel cervical screen-triage-treat strategy for resource-limited settings as part of a global strategy to reduce cervical cancer burden. The PAVE strategy involves: 1) screening with self-sampled HPV testing; 2) triage of HPV-positive participants with a combination of extended genotyping and visual evaluation of the cervix assisted by deep-learning-based automated visual evaluation (AVE); and 3) treatment with thermal ablation or excision (Large Loop Excision of the Transformation Zone). The PAVE study has two phases: efficacy (2023-2024) and effectiveness (planned to begin in 2024-2025). The efficacy phase aims to refine and validate the screen-triage portion of the protocol. The effectiveness phase will examine acceptability and feasibility of the PAVE strategy into clinical practice, cost-effectiveness, and health communication within the PAVE sites. Study design Phase 1 Efficacy: Around 100,000 nonpregnant women, aged 25-49 years, without prior hysterectomy, and irrespective of HIV status, are being screened at nine study sites in resource-limited settings. Eligible and consenting participants perform self-collection of vaginal specimens for HPV testing using a FLOQSwab (Copan). Swabs are transported dry and undergo testing for HPV using a newly-redesigned isothermal DNA amplification HPV test (ScreenFire HPV RS), which has been designed to provide HPV genotyping by hierarchical risk groups: HPV16, else HPV18/45, else HPV31/33/35/52/58, else HPV39/51/56/59/68. HPV-negative individuals are considered negative for precancer/cancer and do not undergo further testing. HPV-positive individuals undergo pelvic examination with collection of cervical images and targeted biopsies of all acetowhite areas or endocervical sampling in the absence of visible lesions. Accuracy of histology diagnosis is evaluated across all sites. Cervical images are used to refine a deep learning AVE algorithm that classifies images as normal, indeterminate, or precancer+. AVE classifications are validated against the histologic endpoint of high-grade precancer determined by biopsy. The combination of HPV genotype and AVE classification is used to generate a risk score that corresponds to the risk of precancer (lower, medium, high, highest). During the efficacy phase, clinicians and patients within the PAVE sites will receive HPV testing results but not AVE results or risk scores. Treatment during the efficacy phase will be performed per local standard of care: positive Visual Inspection with Acetic Acid impression, high-grade colposcopic impression or CIN2+ on colposcopic biopsy, HPV positivity, or HPV 16,18/45 positivity. Follow up of triage negative patients and post treatment will follow standard of care protocols. The sensitivity of the PAVE strategy for detection of precancer will be compared to current SOC at a given level of specificity.Phase 2 Effectiveness: The AVE software will be downloaded to the new dedicated image analysis and thermal ablation devices (Liger Iris) into which the HPV genotype information can be entered to provide risk HPV-AVE risk scores for precancer to clinicians in real time. The effectiveness phase will examine clinician use of the PAVE strategy in practice, including feasibility and acceptability for clinicians and patients, cost-effectiveness, and health communication within the PAVE sites. Conclusion The goal of the PAVE study is to validate a screen-triage-treat protocol using novel biomarkers to provide an accurate, feasible, cost-effective strategy for cervical cancer prevention in resource-limited settings. If validated, implementation of PAVE at larger scale can be encouraged. Funding The consortial sites are responsible for their own study costs. Research equipment and supplies, and the NCI-affiliated staff are funded by the National Cancer Institute Intramural Research Program including supplemental funding from the Cancer Cures Moonshot Initiative. No commercial support was obtained. Brian Befano was supported by NCI/NIH under Grant T32CA09168. Date of protocol latest review: September 24 th 2023.
Collapse
|
3
|
Shiels MS, Lipkowitz S, Campos NG, Schiffman M, Schiller JT, Freedman ND, Berrington de González A. Opportunities for Achieving the Cancer Moonshot Goal of a 50% Reduction in Cancer Mortality by 2047. Cancer Discov 2023; 13:1084-1099. [PMID: 37067240 PMCID: PMC10164123 DOI: 10.1158/2159-8290.cd-23-0208] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 03/14/2023] [Accepted: 03/14/2023] [Indexed: 04/18/2023]
Abstract
On February 2, 2022, President Biden and First Lady Dr. Biden reignited the Cancer Moonshot, setting a new goal to reduce age-standardized cancer mortality rates by at least 50% over the next 25 years in the United States. We estimated trends in U.S. cancer mortality during 2000 to 2019 for all cancers and the six leading types (lung, colorectum, pancreas, breast, prostate, liver). Cancer death rates overall declined by 1.4% per year from 2000 to 2015, accelerating to 2.3% per year during 2016 to 2019, driven by strong declines in lung cancer mortality (-4.7%/year, 2014 to 2019). Recent declines in colorectal (-2.0%/year, 2010-2019) and breast cancer death rates (-1.2%/year, 2013-2019) also contributed. However, trends for other cancer types were less promising. To achieve the Moonshot goal, progress against lung, colorectal, and breast cancer deaths needs to be maintained and/or accelerated, and new strategies for prostate, liver, pancreatic, and other cancers are needed. We reviewed opportunities to prevent, detect, and treat these common cancers that could further reduce population-level cancer death rates and also reduce disparities. SIGNIFICANCE We reviewed opportunities to prevent, detect, and treat common cancers, and show that to achieve the Moonshot goal, progress against lung, colorectal, and breast cancer deaths needs to be maintained and/or accelerated, and new strategies for prostate, liver, pancreatic, and other cancers are needed. See related commentary by Bertagnolli et al., p. 1049. This article is highlighted in the In This Issue feature, p. 1027.
Collapse
Affiliation(s)
- Meredith S Shiels
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, Maryland
| | - Stanley Lipkowitz
- Center for Cancer Research, National Cancer Institute, Bethesda, Maryland
| | - Nicole G Campos
- Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Mark Schiffman
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, Maryland
| | - John T Schiller
- Center for Cancer Research, National Cancer Institute, Bethesda, Maryland
| | - Neal D Freedman
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, Maryland
| | - Amy Berrington de González
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, Maryland
- The Institute of Cancer Research, London, United Kingdom
| |
Collapse
|
4
|
Perkins RB, Smith DL, Jeronimo J, Campos NG, Gage JC, Hansen N, Rodriguez AC, Cheung LC, Egemen D, Befano B, Novetsky AP, Martins S, Kalpathy-Cramer J, Inturrisi F, Ahmed SR, Marcus J, Wentzensen N, de Sanjose S, Schiffman M. Use of risk-based cervical screening programs in resource-limited settings. Cancer Epidemiol 2023; 84:102369. [PMID: 37105017 DOI: 10.1016/j.canep.2023.102369] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 03/29/2023] [Accepted: 04/16/2023] [Indexed: 04/29/2023]
Abstract
Cervical cancer screening and management in the U.S. has adopted a risk-based approach. However, the majority of cervical cancer cases and deaths occur in resource-limited settings, where screening and management are not widely available. We describe a conceptual model that optimizes cervical cancer screening and management in resource-limited settings by utilizing a risk-based approach. The principles of risk-based screening and management in resource limited settings include (1) ensure that the screening method effectively separates low-risk from high-risk patients; (2) directing resources to populations at the highest cancer risk; (3) screen using HPV testing via self-sampling; (4) utilize HPV genotyping to improve risk stratification and better determine who will benefit from treatment, and (5) automated visual evaluation with artificial intelligence may further improve risk stratification. Risk-based screening and management in resource limited settings can optimize prevention by focusing triage and treatment resources on the highest risk patients while minimizing interventions in lower risk patients.
Collapse
Affiliation(s)
- Rebecca B Perkins
- Boston University Chobanian and Avedisian School of Medicine/Boston Medical Center, Boston, MA, USA.
| | | | | | - Nicole G Campos
- Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | | | | | | | - Li C Cheung
- National Cancer Institute, Bethesda, MD, USA
| | | | - Brian Befano
- Information Management Services Inc, 3901 Calverton Blvd Suite 200, Calverton, MD, USA
| | - Akiva P Novetsky
- Westchester Medical Center/New York Medical College, Valhalla, NY, USA
| | | | | | | | - Syed Rakin Ahmed
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Boston, MA 02129, USA; Harvard Graduate Program in Biophysics, Harvard Medical School, Harvard University, Cambridge, MA 02115, USA; Massachusetts Institute of Technology, Cambridge, MA 02139, USA; Geisel School of Medicine at Dartmouth, Dartmouth College, Hanover, NH 02139,USA
| | - Jenna Marcus
- Feinberg School of Medicine at Northwestern University, Chicago, IL, USA
| | | | - Silvia de Sanjose
- National Cancer Institute, Bethesda, MD, USA; ISGlobal, Barcelona, Spain
| | | |
Collapse
|
5
|
Befano B, Campos NG, Egemen D, Herrero R, Schiffman M, Porras C, Lowy DR, Rodriguez AC, Schiller JT, Ocampo R, Hildesheim A, Sampson JN, Das S, Kreimer AR, Cheung LC. Estimating human papillomavirus vaccine efficacy from a single-arm trial: Proof-of-principle in the Costa Rica Vaccine Trial. J Natl Cancer Inst 2023:7114548. [PMID: 37040086 DOI: 10.1093/jnci/djad064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 02/14/2023] [Accepted: 04/02/2023] [Indexed: 04/12/2023] Open
Abstract
BACKGROUND WHO recommends a one- or two-dose human papillomavirus (HPV) vaccination schedule for females aged nine to twenty years. Studies confirming the efficacy of a single dose and of vaccine modifications are needed but randomized controlled trials (RCTs) are costly and face logistical and ethical challenges. We propose a resource-efficient single-arm trial design that uses untargeted and unaffected HPV types as controls. METHODS We estimated HPV vaccine efficacy (VE) from a single arm by comparing two ratios: the ratio of the rate of persistent incident infection with vaccine-targeted and cross-protected types (HPV16/18/31/33/45) to vaccine-unaffected HPV types (HPV35/39/51/52/56/58/59/66) versus the ratio of prevalences of these types at the time of trial enrollment. We compare VE estimates using only data from the bivalent HPV16/18 vaccine arm of the Costa Rica Vaccine Trial to published VE estimates that used both the vaccine and control arms. RESULTS Our single-arm approach among 3,727 women yielded VE estimates for persistent HPV16/18 infections similar to published two-arm estimates from the trial (according-to-protocol cohort: 91.0% (95% CI = 82.9%-95.3%) [single-arm] vs. 90.9% (95% CI: 82.0%-95.9%) [two arm]; intention-to-treat cohort: 41.7% (95% CI = 32.4%-49.8%) [single-arm] vs. 49.0% (95% CI = 38.1%-58.1%) [two-arm]). VE estimates were also similar in analytic sub-groups (number of doses received; baseline HPV serology status). CONCLUSION We demonstrate that a single-arm design yields valid VE estimates with similar precision to an RCT. Single-arm studies can reduce the sample size and costs of future HPV vaccine trials while avoiding concerns related to unvaccinated control groups. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT00128661.
Collapse
Affiliation(s)
- Brian Befano
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, 9609 Medical Center Drive MSC 9776, Rockville, MD, United States
- Information Management Services Inc, Calverton Blvd Suite 200, Calverton, 3901, MD, United States
| | - Nicole G Campos
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, 9609 Medical Center Drive MSC 9776, Rockville, MD, United States
- Center for Health Decision Science, Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, 718 Huntington Avenue, Boston, MA, United States
| | - Didem Egemen
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, 9609 Medical Center Drive MSC 9776, Rockville, MD, United States
| | - Rolando Herrero
- Early Detection, Prevention and Infection Branch, International Agency for Research on Cancer, 150 Cours Albert Thomas, Lyon, France
| | - Mark Schiffman
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, 9609 Medical Center Drive MSC 9776, Rockville, MD, United States
| | - Carolina Porras
- Agencia Costarricense de Investigaciones Biomédicas (ACIB), Formerly Proyecto Epidemiológico Guanacaste, Fundación INCIENSA, San José, Costa Rica
| | - Douglas R Lowy
- Center for Cancer Research, National Cancer Institute, 31 Center Drive, Bethesda, MD, USA
| | - Ana Cecilia Rodriguez
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, 9609 Medical Center Drive MSC 9776, Rockville, MD, United States
| | - John T Schiller
- Center for Cancer Research, National Cancer Institute, 31 Center Drive, Bethesda, MD, USA
| | - Rebecca Ocampo
- Agencia Costarricense de Investigaciones Biomédicas (ACIB), Formerly Proyecto Epidemiológico Guanacaste, Fundación INCIENSA, San José, Costa Rica
| | - Allan Hildesheim
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, 9609 Medical Center Drive MSC 9776, Rockville, MD, United States
| | - Joshua N Sampson
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, 9609 Medical Center Drive MSC 9776, Rockville, MD, United States
| | - Shrutikona Das
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, 9609 Medical Center Drive MSC 9776, Rockville, MD, United States
| | - Aimée R Kreimer
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, 9609 Medical Center Drive MSC 9776, Rockville, MD, United States
| | - Li C Cheung
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, 9609 Medical Center Drive MSC 9776, Rockville, MD, United States
| |
Collapse
|
6
|
Landy R, Haber G, Graubard BI, Campos NG, Sy S, Kim JJ, Burger EA, Cheung LC, Katki HA, Gillison ML, Chaturvedi AK. Upper age-limits for US male HPV-vaccination for oropharyngeal cancer prevention: A microsimulation-based modeling study. J Natl Cancer Inst 2023; 115:429-436. [PMID: 36655795 PMCID: PMC10086634 DOI: 10.1093/jnci/djad009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 11/29/2022] [Accepted: 01/11/2023] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND HPV-positive oropharyngeal cancer is the most common HPV-associated cancer in the United States. The age at acquisition of oral HPV infections that cause oropharyngeal cancer (causal infections) is unknown; consequently, the benefit of vaccination of US men aged 27-45 remains uncertain. METHODS We developed a microsimulation-based, individual-level, state-transition model of oral HPV16 and HPV16-positive oropharyngeal cancer among heterosexual US men aged 15-84 years, calibrated to population-level data. We estimated the benefit of vaccination of men aged 27-45 for prevention of oropharyngeal cancer, while accounting for direct- and indirect/herd-effects of male and female vaccination. RESULTS In the absence of vaccination, most (70%) causal oral HPV16 infections are acquired by age 26, and 29% are acquired between ages 27-45. Among men aged 15-45 in 2021 (1976-2006 birth cohorts), status-quo vaccination of men through age 26 is estimated to prevent 95% of 153,450 vaccine-preventable cancers. Assuming 100% vaccination in 2021, extending the upper age-limit to 30, 35, 40, or 45 for men aged 27-45 (1976-1994 cohorts) is estimated to yield small benefit (3.0%, 4.2%, 5.1%, and 5.6% additional cancers prevented, respectively). Importantly, status-quo vaccination of men through age 26 is predicted to result in notable declines in HPV16-positive oropharyngeal cancer incidence in young men by 2035 (51% and 24% declines at ages 40-44 and 45-49, respectively) and noticeable declines (12%) overall by 2045. CONCLUSION Most causal oral HPV16 infections in US men are acquired by age 26, underscoring limited benefit from vaccination of men aged 27-45 for prevention of HPV16-positive oropharyngeal cancers.
Collapse
Affiliation(s)
- Rebecca Landy
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD, USA
| | - Gregory Haber
- Information Technology Laboratory, National Institute of Standards and Technology, Gaithersburg, MD, USA
| | - Barry I Graubard
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD, USA
| | | | - Stephen Sy
- Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - Jane J Kim
- Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - Emily A Burger
- Harvard T. H. Chan School of Public Health, Boston, MA, USA.,Department of Health Management and Health Economics, University of Oslo, Norway
| | - Li C Cheung
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD, USA
| | - Hormuzd A Katki
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD, USA
| | | | - Anil K Chaturvedi
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD, USA
| |
Collapse
|
7
|
Adebamowo SN, Befano B, Cheung LC, Rodriguez AC, Demarco M, Rydzak G, Chen X, Porras C, Herrero R, Kim JJ, Castle PE, Wentzensen N, Kreimer AR, Schiffman M, Campos NG. Different human papillomavirus types share early natural history transitions in immunocompetent women. Int J Cancer 2022; 151:920-929. [PMID: 35603904 PMCID: PMC9329241 DOI: 10.1002/ijc.34128] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 03/30/2022] [Accepted: 04/27/2022] [Indexed: 11/07/2022]
Abstract
Necessary stages of cervical carcinogenesis include acquisition of a carcinogenic human papillomavirus (HPV) type, persistence associated with the development of precancerous lesions, and invasion. Using prospective data from immunocompetent women in the Guanacaste HPV Natural History Study (NHS), the ASCUS-LSIL Triage Study (ALTS) and the Costa Rica HPV Vaccine Trial (CVT), we compared the early natural history of HPV types to inform transition probabilities for health decision models. We excluded women with evidence of high-grade cervical abnormalities at any point during follow-up and restricted the analysis to incident infections in all women and prevalent infections in young women (aged <30 years). We used survival approaches accounting for interval-censoring to estimate the time to clearance distribution for 20 529 HPV infections (64% were incident and 51% were carcinogenic). Time to clearance was similar across HPV types and risk classes (HPV16, HPV18/45, HPV31/33/35/52/58, HPV 39/51/56/59 and noncarcinogenic HPV types); and by age group (18-29, 30-44 and 45-54 years), among carcinogenic and noncarcinogenic infections. Similar time to clearance across HPV types suggests that relative prevalence can predict relative incidence. We confirmed that there was a uniform linear association between incident and prevalent infections for all HPV types within each study cohort. In the absence of progression to precancer, we observed similar time to clearance for incident infections across HPV types and risk classes. A singular clearance function for incident HPV infections has important implications for the refinement of microsimulation models used to evaluate the cost-effectiveness of novel prevention technologies.
Collapse
Affiliation(s)
- Sally N. Adebamowo
- Department of Epidemiology and Public Health, Greenebaum Comprehensive Cancer Center; University of Maryland School of Medicine, Baltimore, MD, United States
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD, United States
| | - Brian Befano
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD, United States
- Information Management Services Inc, Information Management, Calverton, NY, United States
| | - Li C. Cheung
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD, United States
| | - Ana Cecilia Rodriguez
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD, United States
| | - Maria Demarco
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD, United States
| | - Greg Rydzak
- Information Management Services Inc, Information Management, Calverton, NY, United States
| | - Xiaojian Chen
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD, United States
| | - Carolina Porras
- Agencia Costarricense de Investigaciones Biomédicas, Fundación INCIENSA, San José, Costa Rica
| | - Rolando Herrero
- Agencia Costarricense de Investigaciones Biomédicas, Fundación INCIENSA, San José, Costa Rica
- Prevention and Implementation Group, International Agency for Research on Cancer, Lyon, France
| | - Jane J. Kim
- Center for Health Decision Science, Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, United States
| | - Philip E. Castle
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD, United States
- Division of Cancer Prevention, National Cancer Institute, Rockville, MD, United States
| | - Nicolas Wentzensen
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD, United States
| | - Aimée R. Kreimer
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD, United States
| | - Mark Schiffman
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD, United States
| | - Nicole G. Campos
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD, United States
- Center for Health Decision Science, Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, United States
| |
Collapse
|
8
|
Shastri SS, Temin S, Almonte M, Basu P, Campos NG, Gravitt PE, Gupta V, Lombe DC, Murillo R, Nakisige C, Ogilvie G, Pinder LF, Poli UR, Qiao Y, Woo YL, Jeronimo J. Secondary Prevention of Cervical Cancer: ASCO Resource-Stratified Guideline Update. JCO Glob Oncol 2022; 8:e2200217. [PMID: 36162041 PMCID: PMC9812449 DOI: 10.1200/go.22.00217] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 08/02/2022] [Accepted: 08/17/2022] [Indexed: 01/07/2023] Open
Abstract
PURPOSE To update resource-stratified, evidence-based recommendations on secondary prevention of cervical cancer globally. METHODS American Society of Clinical Oncology convened a multidisciplinary, multinational Expert Panel to produce recommendations reflecting four resource-tiered settings. A review of existing guidelines, formal consensus-based process, and modified ADAPTE process to adapt existing guidelines was conducted. Other experts participated in formal consensus. RESULTS This guideline update reflects changes in evidence since the previous update. Five existing guidelines were identified and reviewed, and adapted recommendations form the evidence base. Cost-effectiveness analyses provided indirect evidence to inform consensus, which resulted in ≥ 75% agreement. RECOMMENDATIONS Human papillomavirus (HPV) DNA testing is recommended in all resource settings; visual inspection with acetic acid may be used in basic settings. Recommended age ranges and frequencies vary by the following setting: maximal: age 25-65 years, every 5 years; enhanced: age 30-65 years, if two consecutive negative tests at 5-year intervals, then every 10 years; limited: age 30-49 years, every 10 years; basic: age 30-49 years, one to three times per lifetime. For basic settings, visual assessment is used to determine treatment eligibility; in other settings, genotyping with cytology or cytology alone is used to determine treatment. For basic settings, treatment is recommended if abnormal triage results are obtained; in other settings, abnormal triage results followed by colposcopy is recommended. For basic settings, treatment options are thermal ablation or loop electrosurgical excision procedure; for other settings, loop electrosurgical excision procedure or ablation is recommended; with a 12-month follow-up in all settings. Women who are HIV-positive should be screened with HPV testing after diagnosis, twice as many times per lifetime as the general population. Screening is recommended at 6 weeks postpartum in basic settings; in other settings, screening is recommended at 6 months. In basic settings without mass screening, infrastructure for HPV testing, diagnosis, and treatment should be developed.Additional information is available at www.asco.org/resource-stratified-guidelines.
Collapse
Affiliation(s)
| | - Sarah Temin
- American Society of Clinical Oncology, Alexandria, VA
| | | | | | - Nicole G Campos
- Harvard University T.H. Chan School of Public Health, Boston, MA
| | | | | | - Dorothy C Lombe
- Regional Cancer Treatment Services, MidCentral District Health Board, Palmerston North, New Zealand
| | | | | | | | | | - Usha R Poli
- India Institute of Public Health, Hyderabad, India
| | - Youlin Qiao
- Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | | | | |
Collapse
|
9
|
Barnard-Mayers R, Kouser H, Cohen JA, Tassiopoulos K, Caniglia EC, Moscicki AB, Campos NG, Caunca MR, Iii GRS, Murray EJ. A case study and proposal for publishing directed acyclic graphs: The effectiveness of the quadrivalent human papillomavirus vaccine in perinatally HIV Infected girls. J Clin Epidemiol 2022; 144:127-135. [PMID: 34998951 PMCID: PMC8977269 DOI: 10.1016/j.jclinepi.2021.12.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 12/22/2021] [Accepted: 12/29/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Developing a causal graph is an important step in etiologic research planning and can be used to highlight data flaws and irreparable bias and confounding. As a case study, we consider recent findings that suggest human papillomavirus (HPV) vaccine is less effective against HPV-associated disease among girls living with HIV compared to girls without HIV. OBJECTIVES To understand the relationship between HIV status and HPV vaccine effectiveness, it is important to outline the key assumptions of the causal mechanisms before designing a study to investigate the effect of the HPV vaccine in girls living with HIV infection. METHODS We present a causal graph to describe our assumptions and proposed approach to explore this relationship. We hope to obtain feedback on our assumptions prior to data analysis and exemplify the process for designing causal graphs to inform an etiologic study. CONCLUSION The approach we lay out in this paper may be useful for other researchers who have an interest in using causal graphs to describe and assess assumptions in their own research prior to undergoing data collection and/or analysis.
Collapse
Affiliation(s)
| | - Hiba Kouser
- Department of Epidemiology, Boston University, Boston, MA, USA; Breast Oncology Center, Dana Farber Cancer Institute, Boston, MA, USA
| | - Jamie A Cohen
- Health Policy PhD Program, Harvard University, Cambridge, MA, USA
| | | | - Ellen C Caniglia
- Department of Population Health, NYU School of Medicine, New York, NY, USA
| | - Anna-Barbara Moscicki
- Department of Pediatrics, Division of Adolescent Medicine, University of California, Los Angeles, CA, USA
| | - Nicole G Campos
- Center for Health Decision Science, Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Michelle R Caunca
- Medical Scientist Training Program, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - George R Seage Iii
- Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, MA
| | | |
Collapse
|
10
|
Porras C, Sampson JN, Herrero R, Gail MH, Cortés B, Hildesheim A, Cyr J, Romero B, Schiller JT, Montero C, Pinto LA, Schussler J, Coronado K, Sierra MS, Kim JJ, Torres CM, Carvajal L, Wagner S, Campos NG, Ocampo R, Kemp TJ, Zuniga M, Lowy DR, Avila C, Chanock S, Castrillo A, Estrada Y, Barrientos G, Monge C, Oconitrillo MY, Kreimer AR. Rationale and design of a double-blind randomized non-inferiority clinical trial to evaluate one or two doses of vaccine against human papillomavirus including an epidemiologic survey to estimate vaccine efficacy: The Costa Rica ESCUDDO trial. Vaccine 2022; 40:76-88. [PMID: 34857420 PMCID: PMC8759448 DOI: 10.1016/j.vaccine.2021.11.041] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 11/12/2021] [Accepted: 11/14/2021] [Indexed: 01/05/2023]
Abstract
HPV vaccination of adolescent girls is the most effective measure to prevent cervical cancer. The World Health Organization recommends that adolescent girls receive two doses of vaccine but only a small proportion of girls from regions with the highest disease burden are vaccinated because of cost and logistical considerations. Our Costa Rica HPV Vaccine trial suggested that one dose of the bivalent HPV vaccine provides robust and lasting protection against persistent HPV infections for over a decade. Data from a post-licensure trial of the quadrivalent vaccine in India also suggested that a single dose may be effective in reducing cervical cancer risk. To formally compare one versus two doses of the bivalent and nonavalent HPV vaccines, we implemented a large, randomized, double-blind trial to investigate the non-inferiority of one compared to two vaccine doses in the prevention of new HPV16/18 infections that persist 6 or more months. Bivalent and nonavalent vaccines will be evaluated separately. The trial enrolled and randomized (1:1:1:1 to 1- and 2-dose arms of the bivalent and nonavalent vaccines) 20,330 girls 12 to 16 years old residing in Costa Rica. Trial participants are followed every 6 months for up to 5 years. We also aim to estimate vaccine efficacy by comparing the rates of 6 month persistent infection in unvaccinated women with the rates in the follow-up visits of trial participants. We included one survey of unvaccinated women at the start of the study (N = 4452) and will include another survey concomitant with follow up visits of trial participants at year 4.5 (planned N = 3000). Survey participants attend two visits 6 months appart. Herein, we present the rationale, design, and enrolled study population of the ESCUDDO trial. ClinicalTrials.gov Identifier: NCT03180034.
Collapse
Affiliation(s)
- Carolina Porras
- Agencia Costarricense de Investigaciones Biomédicas (ACIB)-Fundación INCIENSA, San José, Costa Rica.
| | - Joshua N Sampson
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Rolando Herrero
- Agencia Costarricense de Investigaciones Biomédicas (ACIB)-Fundación INCIENSA, San José, Costa Rica
| | - Mitchell H Gail
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Bernal Cortés
- Agencia Costarricense de Investigaciones Biomédicas (ACIB)-Fundación INCIENSA, San José, Costa Rica
| | - Allan Hildesheim
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Jean Cyr
- Information Management Services, Silver Spring, MD, USA
| | - Byron Romero
- Agencia Costarricense de Investigaciones Biomédicas (ACIB)-Fundación INCIENSA, San José, Costa Rica
| | - John T Schiller
- Laboratory of Cellular Oncology, Center for Cancer Research, National Cancer Institute, Bethesda, MD, USA
| | - Christian Montero
- Agencia Costarricense de Investigaciones Biomédicas (ACIB)-Fundación INCIENSA, San José, Costa Rica
| | - Ligia A Pinto
- HPV Serology Laboratory, Leidos Biomedical Research, Inc., Frederick National Laboratory for Cancer Research, Frederick, MD, USA
| | | | - Karla Coronado
- Agencia Costarricense de Investigaciones Biomédicas (ACIB)-Fundación INCIENSA, San José, Costa Rica
| | - Mónica S Sierra
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Jane J Kim
- Center for Health Decision Science, Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | | | - Loretto Carvajal
- Agencia Costarricense de Investigaciones Biomédicas (ACIB)-Fundación INCIENSA, San José, Costa Rica
| | - Sarah Wagner
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA; Cancer Genomics Research Laboratory, Frederick National Laboratory for Cancer Research, Leidos Biomedical Research Inc., Frederick, MD, USA
| | - Nicole G Campos
- Center for Health Decision Science, Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Rebecca Ocampo
- Agencia Costarricense de Investigaciones Biomédicas (ACIB)-Fundación INCIENSA, San José, Costa Rica
| | - Troy J Kemp
- HPV Serology Laboratory, Leidos Biomedical Research, Inc., Frederick National Laboratory for Cancer Research, Frederick, MD, USA
| | - Michael Zuniga
- Agencia Costarricense de Investigaciones Biomédicas (ACIB)-Fundación INCIENSA, San José, Costa Rica
| | - Douglas R Lowy
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA; Laboratory of Cellular Oncology, Center for Cancer Research, National Cancer Institute, Bethesda, MD, USA
| | - Carlos Avila
- Agencia Costarricense de Investigaciones Biomédicas (ACIB)-Fundación INCIENSA, San José, Costa Rica
| | - Stephen Chanock
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Ariane Castrillo
- Agencia Costarricense de Investigaciones Biomédicas (ACIB)-Fundación INCIENSA, San José, Costa Rica
| | - Yenory Estrada
- Agencia Costarricense de Investigaciones Biomédicas (ACIB)-Fundación INCIENSA, San José, Costa Rica
| | - Gloriana Barrientos
- Agencia Costarricense de Investigaciones Biomédicas (ACIB)-Fundación INCIENSA, San José, Costa Rica
| | - Cindy Monge
- Agencia Costarricense de Investigaciones Biomédicas (ACIB)-Fundación INCIENSA, San José, Costa Rica
| | - María Y Oconitrillo
- Agencia Costarricense de Investigaciones Biomédicas (ACIB)-Fundación INCIENSA, San José, Costa Rica
| | - Aimée R Kreimer
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA.
| |
Collapse
|
11
|
Desai KT, Befano B, Xue Z, Kelly H, Campos NG, Egemen D, Gage JC, Rodriguez AC, Sahasrabuddhe V, Levitz D, Pearlman P, Jeronimo J, Antani S, Schiffman M, de Sanjosé S. The development of "automated visual evaluation" for cervical cancer screening: The promise and challenges in adapting deep-learning for clinical testing. Int J Cancer 2021; 150:741-752. [PMID: 34800038 PMCID: PMC8732320 DOI: 10.1002/ijc.33879] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 09/24/2021] [Accepted: 10/15/2021] [Indexed: 12/22/2022]
Abstract
There is limited access to effective cervical cancer screening programs in many resource‐limited settings, resulting in continued high cervical cancer burden. Human papillomavirus (HPV) testing is increasingly recognized to be the preferable primary screening approach if affordable due to superior long‐term reassurance when negative and adaptability to self‐sampling. Visual inspection with acetic acid (VIA) is an inexpensive but subjective and inaccurate method widely used in resource‐limited settings, either for primary screening or for triage of HPV‐positive individuals. A deep learning (DL)‐based automated visual evaluation (AVE) of cervical images has been developed to help improve the accuracy and reproducibility of VIA as assistive technology. However, like any new clinical technology, rigorous evaluation and proof of clinical effectiveness are required before AVE is implemented widely. In the current article, we outline essential clinical and technical considerations involved in building a validated DL‐based AVE tool for broad use as a clinical test.
Collapse
Affiliation(s)
- Kanan T Desai
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, Maryland, USA
| | - Brian Befano
- Information Management Services Inc., Calverton, Maryland, USA.,Department of Epidemiology, University of Washington School of Public Health, Seattle, Washington, USA
| | - Zhiyun Xue
- US National Library of Medicine, Bethesda, Maryland, USA
| | - Helen Kelly
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, Maryland, USA
| | - Nicole G Campos
- Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Didem Egemen
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, Maryland, USA
| | - Julia C Gage
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, Maryland, USA
| | - Ana-Cecilia Rodriguez
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, Maryland, USA
| | | | - David Levitz
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, Maryland, USA
| | - Paul Pearlman
- Center for Global Health, National Cancer Institute, Rockville, Maryland, USA
| | - Jose Jeronimo
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, Maryland, USA
| | - Sameer Antani
- US National Library of Medicine, Bethesda, Maryland, USA
| | - Mark Schiffman
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, Maryland, USA
| | - Silvia de Sanjosé
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, Maryland, USA.,ISGlobal, Barcelona, Spain
| |
Collapse
|
12
|
Spencer JC, Campos NG, Burger EA, Sy S, Kim JJ. Potential effectiveness of a therapeutic HPV intervention campaign in Uganda. Int J Cancer 2021; 150:847-855. [PMID: 34741526 PMCID: PMC8732308 DOI: 10.1002/ijc.33867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 10/05/2021] [Accepted: 10/19/2021] [Indexed: 12/24/2022]
Abstract
Cervical cancer is a major source of morbidity and mortality in Uganda. In addition to prophylactic HPV vaccination, secondary prevention strategies are needed to reduce cancer burden. We evaluated the potential cancer reductions associated with a hypothetical single-contact therapeutic HPV intervention-with 70% coverage and variable efficacy [30%-100%]-using a three-stage HPV modeling framework reflecting HPV and cervical cancer burden in Uganda. In the reference case, we assumed prophylactic preadolescent HPV vaccination starting in 2020 with 70% coverage. A one-time therapeutic intervention targeting 35-year-old women in 2025 (not age-eligible for prophylactic vaccination) averted 1801 cervical cancers per 100 000 women over their lifetime (100% efficacy) or 533 cancers per 100 000 (30% efficacy). Benefits were considerably smaller in birth cohorts eligible for prophylactic HPV vaccination (768 cases averted per 100 000 at 100% efficacy). Evaluating the population-level impact over 40 years, we found introduction of a therapeutic intervention in 2025 with 100% efficacy targeted annually to 30-year-old women averted 139 000 incident cervical cancers in Uganda. This benefit was greatly reduced if efficacy was lower (30% efficacy; 41 000 cases averted), introduction was delayed (2040 introduction; 72 000 cases averted) or both (22 000 cases averted). We demonstrate the potential benefits of a single-contact HPV therapeutic intervention in a low-income setting, but show the importance of high therapeutic efficacy and early introduction timing relative to existing prophylactic programs. Reduced benefits from a less efficacious intervention may be somewhat offset if available within a shorter time frame.
Collapse
Affiliation(s)
- Jennifer C Spencer
- Department of Population Health, Dell Medical School, University of Texas at Austin, Austin, Texas, USA.,Department of Internal Medicine, Dell Medical School, University of Texas at Austin, Austin, Texas, USA
| | - Nicole G Campos
- Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Emily A Burger
- Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA.,Department of Health Management and Health Economics, University of Oslo, Oslo, Norway
| | - Stephen Sy
- Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Jane J Kim
- Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| |
Collapse
|
13
|
Portnoy A, Campos NG, Sy S, Burger EA, Cohen J, Regan C, Kim JJ. Retraction: Impact and Cost-effectiveness of Human Papillomavirus Vaccination Campaigns. Cancer Epidemiol Biomarkers Prev 2021; 30:1283. [PMID: 34074734 DOI: 10.1158/1055-9965.epi-21-0455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
|
14
|
Campos NG, Chaturvedi AK, Kreimer AR. Real-World HPV Vaccine Effectiveness Studies: Guideposts for Interpretation of Current and Future Studies. J Natl Cancer Inst 2021; 113:1270-1271. [PMID: 33876237 DOI: 10.1093/jnci/djab081] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 04/09/2021] [Indexed: 01/30/2023] Open
Affiliation(s)
- Nicole G Campos
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA 02115, USA
| | - Anil K Chaturvedi
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD 20892, USA
| | - Aimée R Kreimer
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD 20892, USA
| |
Collapse
|
15
|
Campos NG, Scarinci IC, Tucker L, Peral S, Li Y, Regan MC, Sy S, Castle PE, Kim JJ. Cost-Effectiveness of Offering Cervical Cancer Screening with HPV Self-Sampling among African-American Women in the Mississippi Delta. Cancer Epidemiol Biomarkers Prev 2021; 30:1114-1121. [PMID: 33771846 DOI: 10.1158/1055-9965.epi-20-1673] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 02/08/2021] [Accepted: 03/22/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND African-American women in the United States have an elevated risk of cervical cancer incidence and mortality. In the Mississippi Delta, cervical cancer disparities are particularly stark. METHODS We conducted a micro-costing study alongside a group randomized trial that evaluated the efficacy of a patient-centered approach ("Choice" between self-collection at home for HPV testing or current standard of care within the public health system in Mississippi) versus the current standard of care ["Standard-of-care screening," involving cytology (i.e., Pap) and HPV co-testing at the Health Department clinics]. The interventions in both study arms were delivered by community health workers (CHW). Using cost, screening uptake, and colposcopy adherence data from the trial, we informed a mathematical model of HPV infection and cervical carcinogenesis to conduct a cost-effectiveness analysis comparing the "Choice" and "Standard-of-care screening" interventions among un/underscreened African-American women in the Mississippi Delta. RESULTS When each intervention was simulated every 5 years from ages 25 to 65 years, the "Standard-of-care screening" strategy reduced cancer risk by 6.4% and was not an efficient strategy; "Choice" was more effective and efficient, reducing lifetime risk of cervical cancer by 14.8% and costing $62,720 per year of life saved (YLS). Screening uptake and colposcopy adherence were key drivers of intervention cost-effectiveness. CONCLUSIONS Offering "Choice" to un/underscreened African-American women in the Mississippi Delta led to greater uptake than CHW-facilitated screening at the Health Department, and may be cost-effective. IMPACT We evaluated the cost-effectiveness of an HPV self-collection intervention to reduce disparities.
Collapse
Affiliation(s)
- Nicole G Campos
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.
| | - Isabel C Scarinci
- Division of Preventive Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Laura Tucker
- Mississippi State Department of Health, Jackson, Mississippi
| | - Sylvia Peral
- Division of Preventive Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Yufeng Li
- Division of Preventive Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Mary Caroline Regan
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Stephen Sy
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Philip E Castle
- Division of Cancer Prevention, National Cancer Institute, National Institutes of Health, Rockville, Maryland
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Rockville, Maryland
| | - Jane J Kim
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| |
Collapse
|
16
|
Burger EA, Jansen EE, Killen J, Kok IMD, Smith MA, Sy S, Dunnewind N, G Campos N, Haas JS, Kobrin S, Kamineni A, Canfell K, Kim JJ. Impact of COVID-19-related care disruptions on cervical cancer screening in the United States. J Med Screen 2021; 28:213-216. [PMID: 33730899 DOI: 10.1177/09691413211001097] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVES To quantify the secondary impacts of the COVID-19 pandemic disruptions to cervical cancer screening in the United States, stratified by step in the screening process and primary test modality, on cervical cancer burden. METHODS We conducted a comparative model-based analysis using three independent NCI Cancer Intervention and Surveillance Modeling Network cervical models to quantify the impact of eight alternative COVID-19-related screening disruption scenarios compared to a scenario of no disruptions. Scenarios varied by the duration of the disruption (6 or 24 months), steps in the screening process being disrupted (primary screening, surveillance, colposcopy, excisional treatment), and primary screening modality (cytology alone or cytology plus human papillomavirus "cotesting"). RESULTS The models consistently showed that COVID-19-related disruptions yield small net increases in cervical cancer cases by 2027, which are greater for women previously screened with cytology compared with cotesting. When disruptions affected all four steps in the screening process under cytology-based screening, there were an additional 5-7 and 38-45 cases per one million screened for 6- and 24-month disruptions, respectively. In contrast, under cotesting, there were additional 4-5 and 35-45 cases per one million screened for 6- and 24-month disruptions, respectively. The majority (58-79%) of the projected increases in cases under cotesting were due to disruptions to surveillance, colposcopies, or excisional treatment, rather than to primary screening. CONCLUSIONS Women in need of surveillance, colposcopies, or excisional treatment, or whose last primary screen did not involve human papillomavirus testing, may comprise priority groups for reintroductions.
Collapse
Affiliation(s)
- Emily A Burger
- Harvard T. H. Chan School of Public Health, Boston, MA, USA.,Department of Health Management and Health Economics, University of Oslo, Oslo, Norway
| | - Erik El Jansen
- Erasmus MC, University Medical Center Rotterdam, Department of Public Health, Rotterdam, Netherlands
| | - James Killen
- Cancer Research Division, Cancer Council NSW, Sydney, Australia
| | - Inge McM de Kok
- Erasmus MC, University Medical Center Rotterdam, Department of Public Health, Rotterdam, Netherlands
| | - Megan A Smith
- Cancer Research Division, Cancer Council NSW, Sydney, Australia.,School of Public Health, University of Sydney, Sydney, Australia
| | - Stephen Sy
- Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - Niels Dunnewind
- Erasmus MC, University Medical Center Rotterdam, Department of Public Health, Rotterdam, Netherlands
| | | | | | - Sarah Kobrin
- National Cancer Institute, Division of Cancer Control and Population Sciences, Rockville, MD, USA
| | - Aruna Kamineni
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Karen Canfell
- Cancer Research Division, Cancer Council NSW, Sydney, Australia.,School of Public Health, University of Sydney, Sydney, Australia
| | - Jane J Kim
- Harvard T. H. Chan School of Public Health, Boston, MA, USA
| |
Collapse
|
17
|
Scarinci IC, Li Y, Tucker L, Campos NG, Kim JJ, Peral S, Castle PE. Given a choice between self-sampling at home for HPV testing and standard of care screening at the clinic, what do African American women choose? Findings from a group randomized controlled trial. Prev Med 2021; 142:106358. [PMID: 33338505 DOI: 10.1016/j.ypmed.2020.106358] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 11/30/2020] [Accepted: 12/04/2020] [Indexed: 10/22/2022]
Abstract
The goals of this study were to: (1) evaluate adherence to cervical cancer screening using a patient-centered approach that provided a choice of self-sampling at home for human papillomavirus (HPV) testing or standard of care screening at the local health department ('Choice') versus only standard of care screening at the local health department ('SCS') among un/under-screened African-American women; and (2) examine whether women given a choice were more likely to choose and adhere to self-sampling for HPV testing. We conducted a group randomized trial among un/under-screened African-American women in the Mississippi Delta, with "town" as the unit of randomization (12 towns). Both interventions (i.e., 'Choice' versus 'SCS') were delivered by Community Health Workers (CHWs) through a door-to-door approach. A total of 335 women were enrolled in the study from 2016 to 2019. The 'Choice' arm had a significantly (p = 0.005) higher adherence to screening compared to the 'SCS' arm after adjusting for the cluster effect and other relevant behavioral variables. Participants in the 'Choice' arm were 5.62 (95% CI 1.71-18.44) times more likely to adhere to cervical cancer screening compared to participants in the 'SCS' arm. Women in the 'Choice' arm were significantly more likely to choose (76%) and adhere to self-sampling at home for HPV testing (48% adherence) compared to standard of care screening at the local health department (7.5% adherence). A theory-driven, CHW-led intervention can effectively promote cervical cancer screening among un/under-screened African-American women in a rural setting when women are provided with a choice between two screening modalities. Clinical Trials Registration: NCT03713710.
Collapse
Affiliation(s)
- Isabel C Scarinci
- Division of Preventive Medicine, University of Alabama at Birmingham, MT 609, 1717 11(th) Ave South, Birmingham, AL 35205, United States of America.
| | - Yufeng Li
- Division of Preventive Medicine, University of Alabama at Birmingham, MT 644, 1717 11(th) Ave South, Birmingham, AL 35205, United States of America.
| | - Laura Tucker
- Mississippi State Department of Health, 570 E Woodrow Wilson Ave, Jackson, MS 39216, United States of America.
| | - Nicole G Campos
- Harvard T.H. Chan School of Public Health, Harvard University, 718 Huntington Ave, Boston, MA 02138, United States of America.
| | - Jane J Kim
- Harvard T.H. Chan School of Public Health, Center for Health Decision Science, 718 Huntington Ave, Boston, MA 02115, United States of America.
| | - Sylvia Peral
- Division of Preventive Medicine, University of Alabama at Birmingham, MT 101D, 1717 11(th) Ave South, Birmingham, AL 35205, United States of America.
| | - Philip E Castle
- Albert Einstein College of Medicine, New York, NY, United States of America; National Cancer Institute, Bethesda, MD, United States of America.
| |
Collapse
|
18
|
Burger EA, Portnoy A, Campos NG, Sy S, Regan C, Kim JJ. Choosing the optimal HPV vaccine: The health impact and economic value of the nonavalent and bivalent HPV vaccines in 48 Gavi-eligible countries. Int J Cancer 2020; 148:932-940. [PMID: 32706907 DOI: 10.1002/ijc.33233] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 07/06/2020] [Accepted: 07/15/2020] [Indexed: 01/03/2023]
Abstract
The human papillomavirus (HPV) vaccines may provide some level of cross-protection against high-risk HPV genotypes not directly targeted by the vaccines. We evaluated the long-term health and economic impacts of routine HPV vaccination using either the nonavalent HPV vaccine or the bivalent HPV vaccine in the context of 48 Gavi-eligible countries. We used a multi-modeling approach to compare the bivalent with or without cross-protection and the nonavalent HPV vaccine. The optimal, that is, most cost-effective, vaccine was the vaccine with an incremental cost-effectiveness ratio below the per-capita gross domestic product (GDP) for each country. By 2100 and assuming 70% HPV vaccination coverage, a bivalent vaccine without cross-protection, a bivalent vaccine with favorable cross-protection and the nonavalent vaccine were projected to avert 14.9, 17.2 and 18.5 million cumulative cases of cervical cancer across all 48 Gavi-eligible countries, respectively. The relative value of the bivalent vaccine compared to the nonavalent vaccine increased assuming a bivalent vaccine conferred high cross-protection. For example, assuming a cost-effectiveness threshold of per-capita GDP, the nonavalent vaccine was optimal in 83% (n = 40) of countries if the bivalent vaccine did not confer cross-protection; however, the proportion of countries decreased to 63% (n = 30) if the bivalent vaccine conferred high cross-protection. For lower cost-effectiveness thresholds, the bivalent vaccine was optimal in a greater proportion of countries, under both cross-protection assumptions. Although the nonavalent vaccine is projected to avert more cases of cervical cancer, the bivalent vaccine with favorable cross-protection can prevent a considerable number of cases and would be considered a high-value vaccine for many Gavi-eligible countries.
Collapse
Affiliation(s)
- Emily A Burger
- Harvard T.H. Chan School of Public Health, Center for Health Decision Science, Boston, Massachusetts, USA.,Department of Health Management and Health Economics, University of Oslo, Oslo, Norway
| | - Allison Portnoy
- Harvard T.H. Chan School of Public Health, Center for Health Decision Science, Boston, Massachusetts, USA
| | - Nicole G Campos
- Harvard T.H. Chan School of Public Health, Center for Health Decision Science, Boston, Massachusetts, USA
| | - Stephen Sy
- Harvard T.H. Chan School of Public Health, Center for Health Decision Science, Boston, Massachusetts, USA
| | - Catherine Regan
- Harvard T.H. Chan School of Public Health, Center for Health Decision Science, Boston, Massachusetts, USA
| | - Jane J Kim
- Harvard T.H. Chan School of Public Health, Center for Health Decision Science, Boston, Massachusetts, USA
| |
Collapse
|
19
|
Campos NG, Alfaro K, Maza M, Sy S, Melendez M, Masch R, Soler M, Conzuelo-Rodriguez G, Gage JC, Alonzo TA, Castle PE, Felix JC, Cremer M, Kim JJ. The cost-effectiveness of human papillomavirus self-collection among cervical cancer screening non-attenders in El Salvador. Prev Med 2020; 131:105931. [PMID: 31765712 DOI: 10.1016/j.ypmed.2019.105931] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Revised: 11/19/2019] [Accepted: 11/21/2019] [Indexed: 01/17/2023]
Abstract
Cervical cancer screening with human papillomavirus (HPV) DNA testing has been incorporated into El Salvador's national guidelines. The feasibility of home-based HPV self-collection among women who do not attend screening at the clinic (i.e., non-attenders) has been demonstrated, but cost-effectiveness has not been evaluated. Using cost and compliance data from El Salvador, we informed a mathematical microsimulation model of HPV infection and cervical carcinogenesis to conduct a cost-effectiveness analysis from the societal perspective. We estimated the reduction in cervical cancer risk, lifetime cost per woman (2017 US$), life expectancy, and incremental cost-effectiveness ratio (ICER, 2017 US$ per year of life saved [YLS]) of a program with home-based self-collection of HPV (facilitated by health promoters) for the 18% of women reluctant to screen at the clinic. The model was calibrated to epidemiologic data from El Salvador. We evaluated health and economic outcomes of the self-collection intervention for women aged 30 to 59 years, alone and in concert with clinic-based HPV provider-collection. Home-based self-collection of HPV was projected to reduce population cervical cancer risk by 14% and cost $1210 per YLS compared to no screening. An integrated program reaching 99% coverage with both provider- and home-based self-collection of HPV reduced cancer risk by 74% (compared to no screening), and cost $1210 per YLS compared to provider-collection alone. Self-collection facilitated by health promoters is a cost-effective strategy for increasing screening uptake in El Salvador.
Collapse
Affiliation(s)
- Nicole G Campos
- Center for Health Decision Science, Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, 718 Huntington Avenue, Boston, MA, USA.
| | - Karla Alfaro
- Basic Health International, Colonia San Francisco, Avenido Las Camelias 14, San Salvador, El Salvador; Basic Health International, 25 Broadway, 9th Floor, New York, NY 10004, USA
| | - Mauricio Maza
- Basic Health International, Colonia San Francisco, Avenido Las Camelias 14, San Salvador, El Salvador; Basic Health International, 25 Broadway, 9th Floor, New York, NY 10004, USA
| | - Stephen Sy
- Center for Health Decision Science, Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, 718 Huntington Avenue, Boston, MA, USA
| | - Mario Melendez
- Basic Health International, Colonia San Francisco, Avenido Las Camelias 14, San Salvador, El Salvador; Basic Health International, 25 Broadway, 9th Floor, New York, NY 10004, USA
| | - Rachel Masch
- Basic Health International, Colonia San Francisco, Avenido Las Camelias 14, San Salvador, El Salvador; Basic Health International, 25 Broadway, 9th Floor, New York, NY 10004, USA
| | - Montserrat Soler
- Obstetrics, Gynecology & Women's Health Institute, Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA
| | | | - Julia C Gage
- Department of Cancer Epidemiology and Genetics, National Cancer Institute, 9609 Medical Center Drive, Rockville, MD, USA
| | - Todd A Alonzo
- University of Southern California, 222 East Huntington Drive, Suite 100, Monrovia, CA 91016, USA
| | | | - Juan C Felix
- Department of Pathology, Medical College of Wisconsin, 9200 W Wisconsin Avenue, Milwaukee, WI, USA
| | - Miriam Cremer
- Basic Health International, Colonia San Francisco, Avenido Las Camelias 14, San Salvador, El Salvador; Basic Health International, 25 Broadway, 9th Floor, New York, NY 10004, USA; Obstetrics, Gynecology & Women's Health Institute, Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA
| | - Jane J Kim
- Center for Health Decision Science, Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, 718 Huntington Avenue, Boston, MA, USA
| |
Collapse
|
20
|
Portnoy A, Campos NG, Sy S, Burger EA, Cohen J, Regan C, Kim JJ. Impact and Cost-Effectiveness of Human Papillomavirus Vaccination Campaigns. Cancer Epidemiol Biomarkers Prev 2019; 29:22-30. [DOI: 10.1158/1055-9965.epi-19-0767] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Revised: 09/13/2019] [Accepted: 10/23/2019] [Indexed: 11/16/2022] Open
|
21
|
Campos NG, Maza M, Alfaro K, Gage JC, Castle PE, Felix JC, Masch R, Cremer M, Kim JJ. The cost-effectiveness of implementing HPV testing for cervical cancer screening in El Salvador. Int J Gynaecol Obstet 2019; 145:40-46. [PMID: 30702142 PMCID: PMC6988124 DOI: 10.1002/ijgo.12773] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Revised: 09/06/2018] [Accepted: 01/29/2019] [Indexed: 01/13/2023]
Abstract
Objective To assess the cost-effectiveness of HPV-based screening and management algorithms for HPV-positive women in phase 2 of the Cervical Cancer Prevention in El Salvador (CAPE) demonstration, relative to the status quo of Pap-based screening. Methods Data from phase 2 of the CAPE demonstration (n=8000 women) were used to inform a mathematical model of HPV infection and cervical cancer. The model was used to project the lifetime health and economic outcomes of HPV testing every 5 years (age 30–65 years), with referral to colposcopy for HPV-positive women; HPV testing every 5 years (age 30-65 years), with immediate cryotherapy for eligible HPV-positive women; and Pap testing every 2 years (age 20–65 years), with referral to colposcopy for Pap-positive women. Results Despite slight decreases in the proportion of HPV-positive women who received treatment relative to phase 1, the health impact of screening in phase 2 remained stable, reducing cancer risk by 58.5%. As in phase 1, HPV testing followed by cryotherapy for eligible HPV-positive women remained the least costly and most effective strategy (US$490 per year of life saved). Conclusion HPV-based screening followed by immediate cryotherapy in all eligible women would be very cost-effective in El Salvador.
Collapse
Affiliation(s)
- Nicole G Campos
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Center for Health Decision Science, Boston, MA, USA
| | - Mauricio Maza
- Basic Health International, Colonia San Francisco, San Salvador, El Salvador
| | - Karla Alfaro
- Basic Health International, Colonia San Francisco, San Salvador, El Salvador
| | - Julia C Gage
- Department of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD, USA
| | - Philip E Castle
- Albert Einstein College of Medicine, Bronx, New York, NY, USA
| | - Juan C Felix
- Department of Pathology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Rachel Masch
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Miriam Cremer
- Obstetrics, Gynecology & Women's Health Institute, Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA
| | - Jane J Kim
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Center for Health Decision Science, Boston, MA, USA
| |
Collapse
|
22
|
Campos NG, Tsu V, Jeronimo J, Regan C, Resch S, Clark A, Sy S, Kim JJ. Health impact of delayed implementation of cervical cancer screening programs in India: A modeling analysis. Int J Cancer 2018; 144:687-696. [PMID: 30132850 PMCID: PMC6519250 DOI: 10.1002/ijc.31823] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Revised: 07/27/2018] [Accepted: 08/01/2018] [Indexed: 11/22/2022]
Abstract
India has the highest burden of cervical cancer in the world. To estimate the consequences of delaying implementation of organized cervical cancer screening, we projected the avertable burden of disease under different implementation scenarios of a screening program. We used an individual‐based microsimulation model of human papillomavirus (HPV) infection and cervical cancer calibrated to epidemiologic data from India to project age‐specific cancer incidence and mortality reductions associated with screening (once‐in‐a‐lifetime among women aged 30–34 years) with one‐visit visual inspection with acetic acid (VIA) and one‐ and two‐visit HPV DNA testing. We then applied these reductions to a population model to project the lifetime cervical cancer cases and deaths averted under different implementation scenarios taking place from 2017 to 2026: (1) immediate implementation of screening with currently available screening tests (one‐visit VIA, two‐visit HPV testing); (2) immediate implementation of screening with currently available screening tests, with a switch to point‐of‐care one‐visit HPV testing in 5 years; and (3) 5‐year delayed implementation of screening with current screening tests or point‐of‐care HPV testing. Immediate implementation of two‐visit HPV testing with a switch to one‐visit HPV testing averted 574,100 cases and 382,500 deaths over the lifetimes of 81.4 million 30‐ to 34‐year‐old women screened once between 2017 and 2026. Delayed implementation with a one‐visit HPV test averted 209,300 cases and 139,100 deaths. Delaying implementation of screening programs in high‐burden settings will result in substantial morbidity and mortality among women beyond the age for adolescent HPV vaccination. What's new? Nearly one‐quarter of cervical cancer cases worldwide occur in India. Nonetheless, while the disease can be prevented through screening for precancerous lesions, very few Indian women receive Pap tests. Here, the authors estimated cervical cancer burden in India assuming different screening program implementation scenarios, including immediate implementation with both one‐visit VIA and two‐visit human papillomavirus (HPV) testing and delayed implementation with a one‐visit HPV test. Models showed that immediate implementation of two‐visit HPV testing averted more than double the number of cases and deaths from cervical cancer among 30‐ to 34‐year‐old women compared with delayed implementation with one‐visit HPV testing.
Collapse
Affiliation(s)
- Nicole G. Campos
- Center for Health Decision ScienceHarvard T.H. Chan School of Public HealthBostonMA
| | - Vivien Tsu
- PATH, Reproductive Health Global ProgramWashingtonDC
| | - Jose Jeronimo
- PATH, Reproductive Health Global ProgramWashingtonDC
- Global Coalition against Cervical CancerArligtonVA
| | - Catherine Regan
- Center for Health Decision ScienceHarvard T.H. Chan School of Public HealthBostonMA
| | - Stephen Resch
- Center for Health Decision ScienceHarvard T.H. Chan School of Public HealthBostonMA
| | - Andrew Clark
- Department of Health Services Research and PolicyLondon School of Hygiene & Tropical MedicineLondonUnited Kingdom
| | - Stephen Sy
- Center for Health Decision ScienceHarvard T.H. Chan School of Public HealthBostonMA
| | - Jane J. Kim
- Center for Health Decision ScienceHarvard T.H. Chan School of Public HealthBostonMA
| |
Collapse
|
23
|
Campos NG, Lince-Deroche N, Chibwesha CJ, Firnhaber C, Smith JS, Michelow P, Meyer-Rath G, Jamieson L, Jordaan S, Sharma M, Regan C, Sy S, Liu G, Tsu V, Jeronimo J, Kim JJ. Cost-Effectiveness of Cervical Cancer Screening in Women Living With HIV in South Africa: A Mathematical Modeling Study. J Acquir Immune Defic Syndr 2018; 79:195-205. [PMID: 29916959 PMCID: PMC6143200 DOI: 10.1097/qai.0000000000001778] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Accepted: 06/13/2018] [Indexed: 01/25/2023]
Abstract
BACKGROUND Women with HIV face an increased risk of human papillomavirus (HPV) acquisition and persistence, cervical intraepithelial neoplasia, and invasive cervical cancer. Our objective was to determine the cost-effectiveness of different cervical cancer screening strategies among women with HIV in South Africa. METHODS We modified a mathematical model of HPV infection and cervical disease to reflect coinfection with HIV. The model was calibrated to epidemiologic data from HIV-infected women in South Africa. Clinical and economic data were drawn from in-country data sources. The model was used to project reductions in the lifetime risk of cervical cancer and incremental cost-effectiveness ratios (ICERs) of Pap and HPV DNA screening and management algorithms beginning at HIV diagnosis, at 1-, 2-, or 3-year intervals. Strategies with an ICER below South Africa's 2016 per capita gross domestic product (US$5270) were considered "cost-effective." RESULTS HPV testing followed by treatment (test-and-treat) at 2-year intervals was the most effective strategy that was also cost-effective, reducing lifetime cancer risk by 56.6% with an ICER of US$3010 per year of life saved. Other cost-effective strategies included Pap (referral threshold: HSIL+) at 1-, 2-, and 3-year intervals, and HPV test-and-treat at 3-year intervals. Pap (ASCUS+), HPV testing with 16/18 genotyping, and HPV testing with Pap or visual triage of HPV-positive women were less effective and more costly than alternatives. CONCLUSIONS Considering per capita gross domestic product as the benchmark for cost-effectiveness, HPV test-and-treat is optimal in South Africa. At lower cost-effectiveness benchmarks, Pap (HSIL+) would be optimal.
Collapse
Affiliation(s)
- Nicole G. Campos
- Harvard T.H. Chan School of Public Health, Department of Health Policy and Management, Boston, MA
| | - Naomi Lince-Deroche
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Carla J. Chibwesha
- Division of Global Women's Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Clinical HIV Research Unit, Helen Joseph Hospital, Johannesburg, South Africa
| | - Cynthia Firnhaber
- Clinical HIV Research Unit, Helen Joseph Hospital, Johannesburg, South Africa
- Right to Care, Helen Joseph Hospital, Johannesburg, South Africa
| | - Jennifer S. Smith
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC
| | - Pam Michelow
- National Health Laboratory Service, Johannesburg, South Africa
- Anatomical Pathology Department, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Gesine Meyer-Rath
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Global Health and Development, School of Public Health, Boston University, Boston, MA
| | - Lise Jamieson
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Suzette Jordaan
- National Health Laboratory Service, Johannesburg, South Africa
| | - Monisha Sharma
- Harvard T.H. Chan School of Public Health, Department of Health Policy and Management, Boston, MA
- Department of Epidemiology, University of Washington, Seattle, WA
| | - Catherine Regan
- Harvard T.H. Chan School of Public Health, Department of Health Policy and Management, Boston, MA
| | - Stephen Sy
- Harvard T.H. Chan School of Public Health, Department of Health Policy and Management, Boston, MA
| | - Gui Liu
- Department of Epidemiology, University of Washington, Seattle, WA
| | | | - Jose Jeronimo
- Global Coalition Against Cervical Cancer, Arlington, VA
| | - Jane J. Kim
- Harvard T.H. Chan School of Public Health, Department of Health Policy and Management, Boston, MA
| |
Collapse
|
24
|
Mezei AK, Pedersen HN, Sy S, Regan C, Mitchell-Foster SM, Byamugisha J, Sekikubo M, Armstrong H, Rawat A, Singer J, Ogilvie GS, Kim JJ, Campos NG. Community-based HPV self-collection versus visual inspection with acetic acid in Uganda: a cost-effectiveness analysis of the ASPIRE trial. BMJ Open 2018; 8:e020484. [PMID: 29895648 PMCID: PMC6009460 DOI: 10.1136/bmjopen-2017-020484] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Cervical cancer is the leading cause of cancer death for women in Uganda, despite the potential for prevention through organised screening. Community-based self-collected human papillomavirus (HPV) testing has been proposed to reduce barriers to screening. OBJECTIVE Our objective was to evaluate the cost-effectiveness of the Advances in Screening and Prevention of Reproductive Cancers (ASPIRE) trial, conducted in Kisenyi, Uganda in April 2014 (n=500). The trial compared screening uptake and compliance with follow-up in two arms: (1) community-based (ie, home or workplace) self-collected HPV testing (facilitated by community health workers) with clinic-based visual inspection with acetic acid (VIA) triage of HPV-positive women ('HPV-VIA') and (2) clinic-based VIA ('VIA'). In both arms, VIA was performed at the local health unit by midwives with VIA-positive women receiving immediate treatment with cryotherapy. DESIGN We informed a Monte Carlo simulation model of HPV infection and cervical cancer with screening uptake, compliance and retrospective cost data from the ASPIRE trial; additional cost, test performance and treatment effectiveness data were drawn from observational studies. The model was used to assess the cost-effectiveness of each arm of ASPIRE, as well as an HPV screen-and-treat strategy ('HPV-ST') involving community-based self-collected HPV testing followed by treatment for all HPV-positive women at the clinic. OUTCOME MEASURES The primary outcomes were reductions in cervical cancer risk and incremental cost-effectiveness ratios (ICERs), expressed in dollars per year of life saved (YLS). RESULTS HPV-ST was the most effective and cost-effective screening strategy, reducing the lifetime absolute risk of cervical cancer from 4.2% (range: 3.8%-4.7%) to 3.5% (range: 3.2%-4%), 2.8% (range: 2.4%-3.1%) and 2.4% (range: 2.1%-2.7%) with ICERs of US$130 (US$110-US$150) per YLS, US$240 (US$210-US$280) per YLS, and US$470 (US$410-US$550) per YLS when performed one, three and five times per lifetime, respectively. Findings were robust across sensitivity analyses, unless HPV costs were more than quadrupled. CONCLUSIONS Community-based self-collected HPV testing followed by treatment for HPV-positive women has the potential to be an effective and cost-effective screening strategy.
Collapse
Affiliation(s)
- Alex K Mezei
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Heather N Pedersen
- Women's Health Research Institute, British Columbia Women's Hospital and Health Centre, Vancouver, British Columbia, Canada
| | - Stephen Sy
- Department of Health Policy and Management, Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Catherine Regan
- Department of Health Policy and Management, Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Sheona M Mitchell-Foster
- Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Josaphat Byamugisha
- Department of Obstetrics and Gynecology, Makerere University, Kampala, Uganda
- Department of Obstetrics and Gynecology, Mulago National Referral Hospital, Kampala, Uganda
| | - Musa Sekikubo
- Department of Obstetrics and Gynecology, Makerere University, Kampala, Uganda
- Department of Obstetrics and Gynecology, Mulago National Referral Hospital, Kampala, Uganda
| | - Heather Armstrong
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Angeli Rawat
- Women's Health Research Institute, British Columbia Women's Hospital and Health Centre, Vancouver, British Columbia, Canada
| | - Joel Singer
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
- Centre for Health Evaluation and Outcome Sciences, St. Paul's Hospital, Vancouver, British Columbia, Canada
| | - Gina S Ogilvie
- Women's Health Research Institute, British Columbia Women's Hospital and Health Centre, Vancouver, British Columbia, Canada
| | - Jane J Kim
- Department of Health Policy and Management, Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Nicole G Campos
- Department of Health Policy and Management, Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| |
Collapse
|
25
|
Castle PE, Wheeler CM, Campos NG, Sy S, Burger EA, Kim JJ. Inefficiencies of over-screening and under-screening for cervical cancer prevention in the U.S. Prev Med 2018; 111:177-179. [PMID: 29548787 PMCID: PMC5930058 DOI: 10.1016/j.ypmed.2018.03.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Revised: 02/09/2018] [Accepted: 03/09/2018] [Indexed: 11/28/2022]
Abstract
There is limited information on the cost-inefficiencies of non-adherence to recommended cervical cancer screening or the potential value for improving non-adherence. We estimated the incremental value of adhering to recommended screening every three years with cytology, using a disease simulation model that integrated real-world screening practice data from New Mexico. The amount that can be spent to improve adherence was estimated by calculating the incremental net monetary benefit (INMB) under scenarios of Current Practice (assuming a population of mixed adherence) and Uniformly Non-Adherent populations with imperfect or perfect adherence to follow-up of screen-positive women. Getting unscreened women screened every three years by cytology was a better value than increasing screening in the under-screened or reducing screening in the over-screened. For example, INMBs were $3998 for screening previously unscreened women versus $136 for eliminating annual screening at a willingness-to-pay threshold of $100,000 per quality-adjusted life-year gained. Strategies to reach unscreened women are potentially high-value investments.
Collapse
Affiliation(s)
- Philip E Castle
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY, USA.
| | - Cosette M Wheeler
- Departments of Pathology and Obstetrics and Gynecology, University of New Mexico, Albuquerque, NM, USA
| | - Nicole G Campos
- Department of Health Policy and Management, Harvard University, Boston, MA, USA
| | - Stephen Sy
- Department of Health Policy and Management, Harvard University, Boston, MA, USA
| | | | - Jane J Kim
- Department of Health Policy and Management, Harvard University, Boston, MA, USA
| | | |
Collapse
|
26
|
Burger EA, Campos NG, Sy S, Regan C, Kim JJ. Health and economic benefits of single-dose HPV vaccination in a Gavi-eligible country. Vaccine 2018; 36:4823-4829. [PMID: 29807710 PMCID: PMC6066173 DOI: 10.1016/j.vaccine.2018.04.061] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Revised: 04/13/2018] [Accepted: 04/20/2018] [Indexed: 11/02/2022]
Abstract
BACKGROUND Although guidelines for prophylactic human papillomavirus (HPV) vaccination recommend two doses for girls ages 9-14 years, several studies have demonstrated similar protection with one dose. Our objective was to evaluate the long-term health and economic impacts of routine one-dose HPV vaccination compared to (1) no vaccination and (2) two-dose HPV vaccination in a low-income country. METHODS We used a three-tiered hybrid modeling approach that captured HPV transmission, cervical carcinogenesis, and population demographics to project long-term health and economic outcomes associated with one-dose HPV vaccination (assuming 80% efficacy against HPV-16/18 infections under three waning scenarios) and two-dose HPV vaccination (assuming 100% efficacy over the lifetime) in Uganda. Costs included the vaccine program (dosage and delivery) costs over a 10-year period and cervical cancer costs over the lifetimes of the current population of Ugandan women. Health outcomes included number of cervical cancer cases and disability-adjusted life years (DALYs). Incremental cost-effectiveness ratios (i.e., cost per DALY averted) were calculated and compared against the Ugandan per-capita gross domestic product. RESULTS Routine one-dose HPV vaccination of 9-year-old girls required substantial upfront investment but was cost-saving compared to no vaccination when accounting for the cost-offsets from future cancers averted. Forty years after initiating routine vaccination and depending on assumptions of vaccine waning, one-dose HPV vaccination with equivalent coverage (70%) averted 15-16% of cervical cancer cases versus 21% with two-dose vaccination but required only half the upfront economic investment. Vaccination with two doses had an attractive cost-effectiveness profile except if one-dose vaccination enabled higher coverage (90% vs. 70%) and did not wane. CONCLUSIONS One-dose HPV vaccination resulted in cost-savings compared to no vaccination and could be cost-effective compared to two-dose vaccination if protection is longstanding and higher coverage can be achieved.
Collapse
Affiliation(s)
- Emily A Burger
- Harvard T.H. Chan School of Public Health, Center for Health Decision Science, 718 Huntington Ave, 2ndFloor, Boston, MA 02117, USA; University of Oslo, Department of Health Management and Health Economics, Postboks 1089, Blindern, 0317 Oslo, Norway.
| | - Nicole G Campos
- Harvard T.H. Chan School of Public Health, Center for Health Decision Science, 718 Huntington Ave, 2ndFloor, Boston, MA 02117, USA
| | - Stephen Sy
- Harvard T.H. Chan School of Public Health, Center for Health Decision Science, 718 Huntington Ave, 2ndFloor, Boston, MA 02117, USA
| | - Catherine Regan
- Harvard T.H. Chan School of Public Health, Center for Health Decision Science, 718 Huntington Ave, 2ndFloor, Boston, MA 02117, USA
| | - Jane J Kim
- Harvard T.H. Chan School of Public Health, Center for Health Decision Science, 718 Huntington Ave, 2ndFloor, Boston, MA 02117, USA
| |
Collapse
|
27
|
Campos NG, Tsu V, Jeronimo J, Njama-Meya D, Mvundura M, Kim JJ. Cost-effectiveness of an HPV self-collection campaign in Uganda: comparing models for delivery of cervical cancer screening in a low-income setting. Health Policy Plan 2018; 32:956-968. [PMID: 28369405 PMCID: PMC5886074 DOI: 10.1093/heapol/czw182] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/23/2016] [Indexed: 12/26/2022] Open
Abstract
With the availability of a low-cost HPV DNA test that can be administered by either a healthcare provider or a woman herself, programme planners require information on the costs and cost-effectiveness of implementing cervical cancer screening programmes in low-resource settings under different models of healthcare delivery. Using data from the START-UP demonstration project and a micro-costing approach, we estimated the health and economic impact of once-in-a-lifetime HPV self-collection campaign relative to clinic-based provider-collection of HPV specimens in Uganda. We used an individual-based Monte Carlo simulation model of the natural history of HPV and cervical cancer to estimate lifetime health and economic outcomes associated with screening with HPV DNA testing once in a lifetime (clinic-based provider-collection vs a self-collection campaign). Test performance and cost data were obtained from the START-UP demonstration project using a micro-costing approach. Model outcomes included lifetime risk of cervical cancer, total lifetime costs (in 2011 international dollars [I$]), and life expectancy. Cost-effectiveness ratios were expressed using incremental cost-effectiveness ratios (ICERs). When both strategies achieved 75% population coverage, ICERs were below Uganda's per capita GDP (self-collection: I$80 per year of life saved [YLS]; provider-collection: I$120 per YLS). When the self-collection campaign achieved coverage gains of 15-20%, it was more effective than provider-collection, and had a lower ICER unless coverage with both strategies was 50% or less. Findings were sensitive to cryotherapy compliance among screen-positive women and relative HPV test performance. The primary limitation of this analysis is that self-collection costs are based on a hypothetical campaign but are based on unit costs from Uganda. Once-in-a-lifetime screening with HPV self-collection may be very cost-effective and reduce cervical cancer risk by > 20% if coverage is high. Demonstration projects will be needed to confirm the validity of our logistical, costing and compliance assumptions.
Collapse
Affiliation(s)
- Nicole G Campos
- Center for Health Decision Science, Harvard T.H. Chan School of Public Health, 718 Huntington Avenue, Boston, MA, USA
| | - Vivien Tsu
- PATH, Reproductive Health Global Program, P.O. Box 900922, Seattle, WA, USA
| | - Jose Jeronimo
- PATH, Reproductive Health Global Program, P.O. Box 900922, Seattle, WA, USA
| | | | - Mercy Mvundura
- PATH, Devices and Tools Program, P.O. Box 900922, Seattle, WA, USA
| | - Jane J Kim
- Center for Health Decision Science, Harvard T.H. Chan School of Public Health, 718 Huntington Avenue, Boston, MA, USA
| |
Collapse
|
28
|
Rutter CM, Kim JJ, Meester RGS, Sprague BL, Burger EA, Zauber AG, Ergun MA, Campos NG, Doubeni CA, Trentham-Dietz A, Sy S, Alagoz O, Stout N, Lansdorp-Vogelaar I, Corley DA, Tosteson ANA. Effect of Time to Diagnostic Testing for Breast, Cervical, and Colorectal Cancer Screening Abnormalities on Screening Efficacy: A Modeling Study. Cancer Epidemiol Biomarkers Prev 2018; 27:158-164. [PMID: 29150480 PMCID: PMC5809257 DOI: 10.1158/1055-9965.epi-17-0378] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Revised: 09/25/2017] [Accepted: 11/09/2017] [Indexed: 01/02/2023] Open
Abstract
Background: Patients who receive an abnormal cancer screening result require follow-up for diagnostic testing, but the time to follow-up varies across patients and practices.Methods: We used a simulation study to estimate the change in lifetime screening benefits when time to follow-up for breast, cervical, and colorectal cancers was increased. Estimates were based on four independently developed microsimulation models that each simulated the life course of adults eligible for breast (women ages 50-74 years), cervical (women ages 21-65 years), or colorectal (adults ages 50-75 years) cancer screening. We assumed screening based on biennial mammography for breast cancer, triennial Papanicolaou testing for cervical cancer, and annual fecal immunochemical testing for colorectal cancer. For each cancer type, we simulated diagnostic testing immediately and at 3, 6, and 12 months after an abnormal screening exam.Results: We found declines in screening benefit with longer times to diagnostic testing, particularly for breast cancer screening. Compared to immediate diagnostic testing, testing at 3 months resulted in reduced screening benefit, with fewer undiscounted life years gained per 1,000 screened (breast: 17.3%, cervical: 0.8%, colorectal: 2.0% and 2.7%, from two colorectal cancer models), fewer cancers prevented (cervical: 1.4% fewer, colorectal: 0.5% and 1.7% fewer, respectively), and, for breast and colorectal cancer, a less favorable stage distribution.Conclusions: Longer times to diagnostic testing after an abnormal screening test can decrease screening effectiveness, but the impact varies substantially by cancer type.Impact: Understanding the impact of time to diagnostic testing on screening effectiveness can help inform quality improvement efforts. Cancer Epidemiol Biomarkers Prev; 27(2); 158-64. ©2017 AACR.
Collapse
Affiliation(s)
| | - Jane J Kim
- Department of Health Policy and Management, Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Reinier G S Meester
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Brian L Sprague
- Departments of Surgery and Radiology, University of Vermont Cancer Center, Burlington, Vermont
| | - Emily A Burger
- Department of Health Policy and Management, Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Ann G Zauber
- Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Mehmet Ali Ergun
- Department of Industrial and Systems Engineering, University of Wisconsin-Madison, Madison, Wisconsin
| | - Nicole G Campos
- Department of Health Policy and Management, Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Chyke A Doubeni
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Amy Trentham-Dietz
- Department of Population Health Sciences and Carbone Cancer Center, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin
| | - Stephen Sy
- Department of Health Policy and Management, Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Oguzhan Alagoz
- Department of Industrial and Systems Engineering, University of Wisconsin-Madison, Madison, Wisconsin
| | - Natasha Stout
- Department of Health Policy and Management, Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Iris Lansdorp-Vogelaar
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | | | - Anna N A Tosteson
- Norris Cotton Cancer Center, Lebanon, New Hampshire
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon New Hampshire
| |
Collapse
|
29
|
Campos NG, Tsu V, Jeronimo J, Njama-Meya D, Mvundura M, Kim JJ. Cost-effectiveness of an HPV self-collection campaign in Uganda: comparing models for delivery of cervical cancer screening in a low-income setting. Health Policy Plan 2017; 32:1491. [PMID: 28973511 PMCID: PMC5886202 DOI: 10.1093/heapol/czx076] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
|
30
|
Campos NG, Tsu V, Jeronimo J, Mvundura M, Kim JJ. Estimating the value of point-of-care HPV testing in three low- and middle-income countries: a modeling study. BMC Cancer 2017; 17:791. [PMID: 29178896 PMCID: PMC5702206 DOI: 10.1186/s12885-017-3786-3] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Accepted: 11/14/2017] [Indexed: 12/30/2022] Open
Abstract
Background Where resources are available, the World Health Organization recommends cervical cancer screening with human papillomavirus (HPV) DNA testing and subsequent treatment of HPV-positive women with timely cryotherapy. Newer technologies may facilitate a same-day screen-and-treat approach, but these testing systems are generally too expensive for widespread use in low-resource settings. Methods To assess the value of a hypothetical point-of-care HPV test, we used a mathematical simulation model of the natural history of HPV and data from the START-UP multi-site demonstration project to estimate the health benefits and costs associated with a shift from a 2-visit approach (requiring a return visit for treatment) to 1-visit HPV testing (i.e., screen-and-treat). We estimated the incremental net monetary benefit (INMB), which represents the maximum additional lifetime cost per woman that could be incurred for a new point-of-care HPV test to be cost-effective, depending on expected loss to follow-up between visits (LTFU) in a given setting. Results For screening three times in a lifetime at 100% coverage of the target population, when LTFU was 10%, the INMB of the 1-visit relative to the 2-visit approach was I$13 in India, I$36 in Nicaragua, and I$17 in Uganda. If LTFU was 30% or greater, the INMB values for the 1-visit approach in all countries was equivalent to or exceeded total lifetime costs associated with screening three times in a lifetime. At a LTFU level of 70%, the INMB of the 1-visit approach was I$127 in India, I$399 in Nicaragua, and I$121 in Uganda. Conclusions These findings indicate that point-of-care technology for cervical cancer screening may be worthy of high investment if linkage to treatment can be assured, particularly in settings where LTFU is high. Electronic supplementary material The online version of this article (10.1186/s12885-017-3786-3) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Nicole G Campos
- Center for Health Decision Science, Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, 718 Huntington Avenue, 2nd Floor, Boston, Massachusetts, 02115, USA.
| | - Vivien Tsu
- PATH, Reproductive Health Global Program, P.O. Box 900922, Seattle, Washington, USA
| | - Jose Jeronimo
- Global Coalition against Cervical Cancer, Arlington, Virginia, USA
| | - Mercy Mvundura
- PATH, Devices and Tools Program, P.O. Box 90922, Seattle, Washington, USA
| | - Jane J Kim
- Center for Health Decision Science, Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, 718 Huntington Avenue, 2nd Floor, Boston, Massachusetts, 02115, USA
| |
Collapse
|
31
|
Campos NG, Jeronimo J, Tsu V, Castle PE, Mvundura M, Kim JJ. The Cost-Effectiveness of Visual Triage of Human Papillomavirus-Positive Women in Three Low- and Middle-Income Countries. Cancer Epidemiol Biomarkers Prev 2017. [PMID: 28710075 DOI: 10.1158/1055‐9965.epi‐16‐0787] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: World Health Organization guidelines support human papillomavirus (HPV) testing alone (followed by treatment with cryotherapy) or in conjunction with visual inspection with acetic acid (VIA) triage testing. Our objective was to determine the cost-effectiveness of VIA triage for HPV-positive women in low-resource settings.Methods: We calibrated mathematical simulation models of HPV infection and cervical cancer to epidemiologic data from India, Nicaragua, and Uganda. Using cost and test performance data from the START-UP demonstration projects, we assumed screening took place either once or three times in a lifetime between ages 30 and 40 years. Strategies included (i) HPV alone, followed by cryotherapy for all eligible HPV-positive women; and (ii) HPV testing with VIA triage for HPV-positive women, followed by cryotherapy for eligible women who were also VIA-positive (HPV-VIA). Model outcomes included lifetime risk of cervical cancer and incremental cost-effectiveness ratios (ICERs; international dollars/year of life saved).Results: In all three countries, HPV alone was more effective than HPV-VIA. In Nicaragua and Uganda, HPV alone was also less costly than HPV-VIA; ICERs associated with screening three times in a lifetime (HPV alone) were below per capita GDP. In India, both HPV alone and HPV-VIA had ICERs below per capita GDP.Conclusions: VIA triage of HPV-positive women is not likely to be cost-effective in settings with high cervical cancer burden. HPV alone followed by treatment may achieve greater health benefits and value for public health dollars.Impact: This study provides early evidence on the cost-effectiveness of HPV testing followed by VIA triage versus an HPV screen-and-treat strategy. Cancer Epidemiol Biomarkers Prev; 26(10); 1500-10. ©2017 AACR.
Collapse
Affiliation(s)
- Nicole G Campos
- Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.
| | - Jose Jeronimo
- PATH, Reproductive Health Program, Seattle, Washington
| | - Vivien Tsu
- PATH, Reproductive Health Program, Seattle, Washington
| | - Philip E Castle
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York.,Global Coalition Against Cervical Cancer, Arlington, Virginia
| | | | - Jane J Kim
- Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| |
Collapse
|
32
|
Campos NG, Jeronimo J, Tsu V, Castle PE, Mvundura M, Kim JJ. The Cost-Effectiveness of Visual Triage of Human Papillomavirus-Positive Women in Three Low- and Middle-Income Countries. Cancer Epidemiol Biomarkers Prev 2017; 26:1500-1510. [PMID: 28710075 DOI: 10.1158/1055-9965.epi-16-0787] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Revised: 05/11/2017] [Accepted: 07/05/2017] [Indexed: 11/16/2022] Open
Abstract
Background: World Health Organization guidelines support human papillomavirus (HPV) testing alone (followed by treatment with cryotherapy) or in conjunction with visual inspection with acetic acid (VIA) triage testing. Our objective was to determine the cost-effectiveness of VIA triage for HPV-positive women in low-resource settings.Methods: We calibrated mathematical simulation models of HPV infection and cervical cancer to epidemiologic data from India, Nicaragua, and Uganda. Using cost and test performance data from the START-UP demonstration projects, we assumed screening took place either once or three times in a lifetime between ages 30 and 40 years. Strategies included (i) HPV alone, followed by cryotherapy for all eligible HPV-positive women; and (ii) HPV testing with VIA triage for HPV-positive women, followed by cryotherapy for eligible women who were also VIA-positive (HPV-VIA). Model outcomes included lifetime risk of cervical cancer and incremental cost-effectiveness ratios (ICERs; international dollars/year of life saved).Results: In all three countries, HPV alone was more effective than HPV-VIA. In Nicaragua and Uganda, HPV alone was also less costly than HPV-VIA; ICERs associated with screening three times in a lifetime (HPV alone) were below per capita GDP. In India, both HPV alone and HPV-VIA had ICERs below per capita GDP.Conclusions: VIA triage of HPV-positive women is not likely to be cost-effective in settings with high cervical cancer burden. HPV alone followed by treatment may achieve greater health benefits and value for public health dollars.Impact: This study provides early evidence on the cost-effectiveness of HPV testing followed by VIA triage versus an HPV screen-and-treat strategy. Cancer Epidemiol Biomarkers Prev; 26(10); 1500-10. ©2017 AACR.
Collapse
Affiliation(s)
- Nicole G Campos
- Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.
| | - Jose Jeronimo
- PATH, Reproductive Health Program, Seattle, Washington
| | - Vivien Tsu
- PATH, Reproductive Health Program, Seattle, Washington
| | - Philip E Castle
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York
- Global Coalition Against Cervical Cancer, Arlington, Virginia
| | | | - Jane J Kim
- Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| |
Collapse
|
33
|
Campos NG, Tsu V, Jeronimo J, Mvundura M, Kim JJ. Evidence-based policy choices for efficient and equitable cervical cancer screening programs in low-resource settings. Cancer Med 2017; 6:2008-2014. [PMID: 28707435 PMCID: PMC5548874 DOI: 10.1002/cam4.1123] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Accepted: 05/25/2017] [Indexed: 01/25/2023] Open
Abstract
Women in developing countries disproportionately bear the burden of cervical cancer. The availability of prophylactic vaccines against human papillomavirus (HPV) types 16 and 18, which cause approximately 70% of cervical cancers, provides reason for optimism as roll‐out begins with support from Gavi, the Vaccine Alliance. However, for the hundreds of millions of women beyond the target age for HPV vaccination, cervical cancer screening to detect and treat precancerous lesions remains the only form of prevention. Here we describe the challenges that confront screening programs in low‐resource settings, including (1) optimizing screening test effectiveness; (2) achieving high screening coverage of the target population; and (3) managing screen‐positive women. For each of these challenges, we summarize the tradeoffs between resource utilization and programmatic attributes. We then highlight opportunities for efficient and equitable programming, with supporting evidence from recent mathematical modeling analyses informed by data from the PATH demonstration projects in India, Nicaragua, and Uganda.
Collapse
Affiliation(s)
- Nicole G. Campos
- Center for Health Decision ScienceHarvard T.H. Chan School of Public Health718 Huntington AvenueBostonMassachusetts
| | - Vivien Tsu
- PATHReproductive Health ProgramSeattleWashington
| | | | | | - Jane J. Kim
- Center for Health Decision ScienceHarvard T.H. Chan School of Public Health718 Huntington AvenueBostonMassachusetts
| |
Collapse
|
34
|
Campos NG, Sharma M, Clark A, Lee K, Geng F, Regan C, Kim J, Resch S. The health and economic impact of scaling cervical cancer prevention in 50 low- and lower-middle-income countries. Int J Gynaecol Obstet 2017; 138 Suppl 1:47-56. [DOI: 10.1002/ijgo.12184] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Affiliation(s)
- Nicole G. Campos
- Department of Health Policy and Management; Center for Health Decision Science; Harvard T.H. Chan School of Public Health; Boston MA USA
| | - Monisha Sharma
- Department of Epidemiology; School of Public Health; University of Washington Seattle; Seattle WA USA
| | - Andrew Clark
- Department of Health Services Research and Policy; London School of Hygiene and Tropical Medicine; London UK
| | - Kyueun Lee
- Department of Health Research and Policy; Stanford University; Stanford CA USA
| | - Fangli Geng
- Department of Health Policy and Management; Center for Health Decision Science; Harvard T.H. Chan School of Public Health; Boston MA USA
| | - Catherine Regan
- Department of Health Policy and Management; Center for Health Decision Science; Harvard T.H. Chan School of Public Health; Boston MA USA
| | - Jane Kim
- Department of Health Policy and Management; Center for Health Decision Science; Harvard T.H. Chan School of Public Health; Boston MA USA
| | - Stephen Resch
- Department of Health Policy and Management; Center for Health Decision Science; Harvard T.H. Chan School of Public Health; Boston MA USA
| |
Collapse
|
35
|
Campos NG, Tsu V, Jeronimo J, Mvundura M, Lee K, Kim JJ. To expand coverage, or increase frequency: Quantifying the tradeoffs between equity and efficiency facing cervical cancer screening programs in low-resource settings. Int J Cancer 2017; 140:1293-1305. [PMID: 27925175 PMCID: PMC5516173 DOI: 10.1002/ijc.30551] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Accepted: 11/15/2016] [Indexed: 01/09/2023]
Abstract
Cervical cancer is a leading cause of cancer death worldwide, with 85% of the disease burden residing in less developed regions. To inform evidence‐based decision‐making as cervical cancer screening programs are planned, implemented, and scaled in low‐ and middle‐income countries, we used cost and test performance data from the START‐UP demonstration project in Uganda and a microsimulation model of HPV infection and cervical carcinogenesis to quantify the health benefits, distributional equity, cost‐effectiveness, and financial impact of either (1) improving access to cervical cancer screening or (2) increasing the number of lifetime screening opportunities for women who already have access. We found that when baseline screening coverage was low (i.e., 30%), expanding coverage of screening once in a lifetime to 50% can yield comparable reductions in cancer risk to screening two or three times in a lifetime at 30% coverage, lead to greater reductions in health disparities, and cost 150 international dollars (I$) per year of life saved (YLS). At higher baseline screening coverage levels (i.e., 70%), screening three times in a lifetime yielded greater health benefits than expanding screening once in a lifetime to 90% coverage, and would have a cost‐effectiveness ratio (I$590 per YLS) below Uganda's per capita GDP. Given very low baseline coverage at present, we conclude that a policy focus on increasing access for previously unscreened women appears to be more compatible with improving both equity and efficiency than a focus on increasing frequency for a small subset of women. What's new? Most cervical cancer cases and deaths occur in less‐developed countries, where resource constraints challenge the planning and implementation of screening programs. The present report examines tradeoffs between equity and efficiency in cervical cancer screening approaches specifically in Uganda, where current baseline screening coverage is low. Analyses indicate that the expansion of access to once‐in‐a lifetime cervical cancer screening in areas with initially low baseline coverage is likely to yield greater benefits for health, distributional equity and cost‐effectiveness than increasing the number of screening opportunities per woman in low‐resource settings. Improving access for previously unscreened women should be a priority in such areas.
Collapse
Affiliation(s)
- Nicole G Campos
- Harvard T.H. Chan School of Public Health, Center for Health Decision Science, 718 Huntington Avenue, Boston, MA
| | - Vivien Tsu
- PATH, Reproductive Health Program, P.O. Box 900922, Seattle, WA
| | - Jose Jeronimo
- PATH, Reproductive Health Program, P.O. Box 900922, Seattle, WA
| | - Mercy Mvundura
- Devices and Tools Program, PATH, P.O. Box 900922, Seattle, WA
| | - Kyueun Lee
- Harvard T.H. Chan School of Public Health, Center for Health Decision Science, 718 Huntington Avenue, Boston, MA.,Department of Health Research and Policy, Stanford University, Stanford, CA
| | - Jane J Kim
- Harvard T.H. Chan School of Public Health, Center for Health Decision Science, 718 Huntington Avenue, Boston, MA
| |
Collapse
|
36
|
Abstract
OBJECTIVES To evaluate the cost-effectiveness of human papillomavirus (HPV) DNA testing (versus Papanicolaou (Pap)-based screening) for cervical cancer screening in Nicaragua. DESIGN A previously developed Monte Carlo simulation model of the natural history of HPV infection and cervical cancer was calibrated to epidemiological data from Nicaragua. Cost data inputs were derived using a micro-costing approach in Carazo, Chontales and Chinandega departments; test performance data were from a demonstration project in Masaya department. SETTING Nicaragua's public health sector facilities. PARTICIPANTS Women aged 30-59 years. INTERVENTIONS Screening strategies included (1) Pap testing every 3 years, with referral to colposcopy for women with an atypical squamous cells of undetermined significance or worse result ('Pap'); (2) HPV testing every 5 years, with referral to cryotherapy for HPV-positive eligible women (HPV cryotherapy or 'HPV-Cryo'); (3) HPV testing every 5 years, with referral to triage with visual inspection with acetic acid (VIA) for HPV-positive women ('HPV-VIA'); and (4) HPV testing every 5 years, with referral to Pap testing for HPV-positive women ('HPV-Pap'). OUTCOME MEASURES Reduction in lifetime risk of cancer and incremental cost-effectiveness ratios (ICER; 2015 US$ per year of life saved (YLS)). RESULTS HPV-based screening strategies were more effective than Pap testing. HPV-Cryo was the least costly and most effective strategy, reducing lifetime cancer risk by 29.5% and outperforming HPV-VIA, HPV-Pap and Pap only, which reduced cancer risk by 19.4%, 12.2% and 10.8%, respectively. With an ICER of US$320/YLS, HPV-Cryo every 5 years would be very cost-effective using a threshold based on Nicaragua's per capita gross domestic product of US$2090. Findings were robust across sensitivity analyses on test performance, coverage, compliance and cost parameters. CONCLUSIONS HPV testing is very cost-effective compared with Pap testing in Nicaragua, due to higher test sensitivity and the relatively lower number of visits required. Increasing compliance with recommended follow-up will further improve the health benefits and value for public health dollars.
Collapse
Affiliation(s)
- Nicole G Campos
- Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Mercy Mvundura
- PATH, Devices and Tools Program, Seattle, Washington, USA
| | - Jose Jeronimo
- PATH, Reproductive Health Global Program, Seattle, Washington, USA
| | - Francesca Holme
- PATH, Reproductive Health Global Program, Seattle, Washington, USA
| | - Elisabeth Vodicka
- University of Washington, School of Pharmacy, Seattle, Washington, USA
| | - Jane J Kim
- Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| |
Collapse
|
37
|
Kim JJ, Burger EA, Sy S, Campos NG. Optimal Cervical Cancer Screening in Women Vaccinated Against Human Papillomavirus. J Natl Cancer Inst 2016; 109:djw216. [PMID: 27754955 DOI: 10.1093/jnci/djw216] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Accepted: 08/24/2016] [Indexed: 01/10/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Jane J Kim
- Center for Health Decision Science, Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - Emily A Burger
- Center for Health Decision Science, Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, MA, USA.,Department of Health Management and Health Economics, University of Oslo, Oslo, Norway
| | - Stephen Sy
- Center for Health Decision Science, Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - Nicole G Campos
- Center for Health Decision Science, Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, MA, USA
| |
Collapse
|
38
|
Campos NG, Sharma M, Clark A, Kim JJ, Resch SC. Resources Required for Cervical Cancer Prevention in Low- and Middle-Income Countries. PLoS One 2016; 11:e0164000. [PMID: 27711124 PMCID: PMC5053484 DOI: 10.1371/journal.pone.0164000] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Accepted: 09/19/2016] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Cervical cancer is the fourth leading cause of cancer death in women, with 85% of cases and deaths occurring in developing countries. While organized screening programs have reduced cervical cancer incidence in high-income countries through detection and treatment of precancerous lesions, the implementation of organized screening has not been effective in low-resource settings due to lack of infrastructure and limited budgets. Our objective was to estimate the cost of comprehensive primary and secondary cervical cancer prevention in low- and middle-income countries. METHODS AND FINDINGS We performed a modeling analysis to estimate 1) for girls aged 10 years, the cost of 2-dose human papillomavirus (HPV) vaccination; and 2) for women aged 30 to 49 years, the cost of cervical cancer screening (with visual inspection with acetic acid (VIA), HPV testing, or cytology) and preventive treatment in 102 low- and middle-income countries from 2015 to 2024. We used an Excel-based costing and service utilization model to estimate financial costs (2013 US$) based on prevalence of HPV, prevalence of precancerous lesions, and screening test performance. Where epidemiologic data were unavailable, we extrapolated from settings with data using an individual-based microsimulation model of cervical carcinogenesis (calibrated to 20 settings) and multivariate regression. Total HPV vaccination costs ranged from US$8.6 billion to US$24.2 billion for all scenarios considered (immediate, 5-year, or 10-year roll-out; price per dose US$4.55-US$70 by country income level). The total cost of screening and preventive treatment ranged from US$5.1 billion (10-year roll-out, screening once at age 35 years) to US$42.3 billion (immediate roll-out, high intensity screening). Limitations of this analysis include the assumption of standardized protocols by country income level that did not account for the potential presence of multiple screening modalities or management strategies within a country, and extrapolation of cost and epidemiologic data to settings where data were limited. CONCLUSIONS The estimated cost of comprehensive cervical cancer prevention with 2-dose HPV vaccination of 10-year-old girls and screening of women aged 30 to 49 years ranges from US$13.7 billion to US$66.5 billion, depending on speed of roll-out, vaccine price per dose, and screening test and frequency. Findings demonstrate the substantial impact of vaccine price in middle-income countries that are not eligible for assistance from Gavi, the Vaccine Alliance. Replacing routine cytology with HPV-based screening may reduce total costs. Data on the health impact and relative cost-effectiveness of strategies are needed to determine the best value for public health dollars.
Collapse
Affiliation(s)
- Nicole G. Campos
- Center for Health Decision Science, Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, 718 Huntington Avenue, Boston, Massachusetts, 02115, United States of America
| | - Monisha Sharma
- International Clinical Research Center, Department of Global Health, University of Washington, 908 Jefferson Street, Seattle, Washington, 98104, United States of America
| | - Andrew Clark
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London, WC1H9SH, United Kingdom
| | - Jane J. Kim
- Center for Health Decision Science, Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, 718 Huntington Avenue, Boston, Massachusetts, 02115, United States of America
| | - Stephen C. Resch
- Center for Health Decision Science, Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, 718 Huntington Avenue, Boston, Massachusetts, 02115, United States of America
| |
Collapse
|
39
|
Campos NG, Tsu V, Jeronimo J, Mvundura M, Lee K, Kim JJ. When and how often to screen for cervical cancer in three low- and middle-income countries: A cost-effectiveness analysis. Papillomavirus Research 2015. [PMCID: PMC5886851 DOI: 10.1016/j.pvr.2015.05.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
|
40
|
Kim JJ, Campos NG, Sy S, Burger EA, Cuzick J, Castle PE, Hunt WC, Waxman A, Wheeler CM. Inefficiencies and High-Value Improvements in U.S. Cervical Cancer Screening Practice: A Cost-Effectiveness Analysis. Ann Intern Med 2015; 163:589-97. [PMID: 26414147 PMCID: PMC5104349 DOI: 10.7326/m15-0420] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Studies suggest that cervical cancer screening practice in the United States is inefficient. The cost and health implications of nonadherence in the screening process compared with recommended guidelines are uncertain. OBJECTIVE To estimate the benefits, costs, and cost-effectiveness of current cervical cancer screening practice and assess the value of screening improvements. DESIGN Model-based cost-effectiveness analysis. DATA SOURCES New Mexico HPV Pap Registry; medical literature. TARGET POPULATION Cohort of women eligible for routine screening. TIME HORIZON Lifetime. PERSPECTIVE Societal. INTERVENTION Current cervical cancer screening practice; improved adherence to guidelines-based screening interval, triage testing, diagnostic referrals, and precancer treatment referrals. OUTCOME MEASURES Reductions in lifetime cervical cancer risk, quality-adjusted life-years (QALYs), lifetime costs, incremental cost-effectiveness ratios, and incremental net monetary benefits (INMBs). RESULTS OF BASE-CASE ANALYSIS Current screening practice was associated with lower health benefit and was not cost-effective relative to guidelines-based strategies. Improvements in the screening process were associated with higher QALYs and small changes in costs. Perfect adherence to screening every 3 years with cytologic testing and adherence to colposcopy/biopsy referrals were associated with the highest INMBs ($759 and $741, respectively, at a willingness-to-pay threshold of $100,000 per QALY gained); together, the INMB increased to $1645. RESULTS OF SENSITIVITY ANALYSIS Current screening practice was inefficient in 100% of simulations. The rank ordering of screening improvements according to INMBs was stable over a range of screening inputs and willingness-to-pay thresholds. LIMITATION The effect of human papillomavirus vaccination was not considered. CONCLUSIONS The added health benefit of improving adherence to guidelines, especially the 3-year interval for cytologic screening and diagnostic follow-up, may justify additional investments in interventions to improve U.S. cervical cancer screening practice. PRIMARY FUNDING SOURCE U.S. National Cancer Institute.
Collapse
Affiliation(s)
- Jane J. Kim
- From Harvard T.H. Chan School of Public Health, Boston, Massachusetts; University of Oslo, Oslo, Norway; Queen Mary University of London, London, United Kingdom; Albert Einstein College of Medicine, Bronx, New York; Global Coalition Against Cervical Cancer, Arlington, Virginia; University of New Mexico Health Sciences Center, Albuquerque, New Mexico
| | - Nicole G. Campos
- From Harvard T.H. Chan School of Public Health, Boston, Massachusetts; University of Oslo, Oslo, Norway; Queen Mary University of London, London, United Kingdom; Albert Einstein College of Medicine, Bronx, New York; Global Coalition Against Cervical Cancer, Arlington, Virginia; University of New Mexico Health Sciences Center, Albuquerque, New Mexico
| | - Stephen Sy
- From Harvard T.H. Chan School of Public Health, Boston, Massachusetts; University of Oslo, Oslo, Norway; Queen Mary University of London, London, United Kingdom; Albert Einstein College of Medicine, Bronx, New York; Global Coalition Against Cervical Cancer, Arlington, Virginia; University of New Mexico Health Sciences Center, Albuquerque, New Mexico
| | - Emily A. Burger
- From Harvard T.H. Chan School of Public Health, Boston, Massachusetts; University of Oslo, Oslo, Norway; Queen Mary University of London, London, United Kingdom; Albert Einstein College of Medicine, Bronx, New York; Global Coalition Against Cervical Cancer, Arlington, Virginia; University of New Mexico Health Sciences Center, Albuquerque, New Mexico
| | - Jack Cuzick
- From Harvard T.H. Chan School of Public Health, Boston, Massachusetts; University of Oslo, Oslo, Norway; Queen Mary University of London, London, United Kingdom; Albert Einstein College of Medicine, Bronx, New York; Global Coalition Against Cervical Cancer, Arlington, Virginia; University of New Mexico Health Sciences Center, Albuquerque, New Mexico
| | - Philip E. Castle
- From Harvard T.H. Chan School of Public Health, Boston, Massachusetts; University of Oslo, Oslo, Norway; Queen Mary University of London, London, United Kingdom; Albert Einstein College of Medicine, Bronx, New York; Global Coalition Against Cervical Cancer, Arlington, Virginia; University of New Mexico Health Sciences Center, Albuquerque, New Mexico
| | - William C. Hunt
- From Harvard T.H. Chan School of Public Health, Boston, Massachusetts; University of Oslo, Oslo, Norway; Queen Mary University of London, London, United Kingdom; Albert Einstein College of Medicine, Bronx, New York; Global Coalition Against Cervical Cancer, Arlington, Virginia; University of New Mexico Health Sciences Center, Albuquerque, New Mexico
| | - Alan Waxman
- From Harvard T.H. Chan School of Public Health, Boston, Massachusetts; University of Oslo, Oslo, Norway; Queen Mary University of London, London, United Kingdom; Albert Einstein College of Medicine, Bronx, New York; Global Coalition Against Cervical Cancer, Arlington, Virginia; University of New Mexico Health Sciences Center, Albuquerque, New Mexico
| | - Cosette M. Wheeler
- From Harvard T.H. Chan School of Public Health, Boston, Massachusetts; University of Oslo, Oslo, Norway; Queen Mary University of London, London, United Kingdom; Albert Einstein College of Medicine, Bronx, New York; Global Coalition Against Cervical Cancer, Arlington, Virginia; University of New Mexico Health Sciences Center, Albuquerque, New Mexico
| | | |
Collapse
|
41
|
Campos NG, Castle PE, Wright TC, Kim JJ. Cervical cancer screening in low-resource settings: A cost-effectiveness framework for valuing tradeoffs between test performance and program coverage. Int J Cancer 2015; 137:2208-19. [PMID: 25943074 DOI: 10.1002/ijc.29594] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2014] [Revised: 03/20/2015] [Accepted: 04/21/2015] [Indexed: 12/16/2022]
Abstract
As cervical cancer screening programs are implemented in low-resource settings, protocols are needed to maximize health benefits under operational constraints. Our objective was to develop a framework for examining health and economic tradeoffs between screening test sensitivity, population coverage and follow-up of screen-positive women, to help decision makers identify where program investments yield the greatest value. As an illustrative example, we used an individual-based Monte Carlo simulation model of the natural history of human papillomavirus (HPV) and cervical cancer calibrated to epidemiologic data from Uganda. We assumed once in a lifetime screening at age 35 with two-visit HPV DNA testing or one-visit visual inspection with acetic acid (VIA). We assessed the health and economic tradeoffs that arise between (i) test sensitivity and screening coverage; (ii) test sensitivity and loss to follow-up (LTFU) of screen-positive women; and (iii) test sensitivity, screening coverage and LTFU simultaneously. The decline in health benefits associated with sacrificing HPV DNA test sensitivity by 20% (e.g., shifting from provider- to self-collection of specimens) could be offset by gains in coverage if coverage increased by at least 20%. When LTFU was 10%, two-visit HPV DNA testing with 80-90% sensitivity was more effective and more cost-effective than one-visit VIA with 40% sensitivity and yielded greater health benefits than VIA even as VIA sensitivity increased to 60% and HPV test sensitivity declined to 70%. As LTFU increased, two-visit HPV DNA testing became more costly and less effective than one-visit VIA. Setting-specific data on achievable test sensitivity, coverage, follow-up rates and programmatic costs are needed to guide decision making for cervical cancer screening.
Collapse
Affiliation(s)
- Nicole G Campos
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Center for Health Decision Science, Boston, MA
| | - Philip E Castle
- Global Coalition against Cervical Cancer, Arlington, VA.,Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY
| | - Thomas C Wright
- Department of Pathology and Cell Biology, Columbia University Medical Center, NY
| | - Jane J Kim
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Center for Health Decision Science, Boston, MA
| |
Collapse
|
42
|
Campos NG, Maza M, Alfaro K, Gage JC, Castle PE, Felix JC, Cremer ML, Kim JJ. The comparative and cost-effectiveness of HPV-based cervical cancer screening algorithms in El Salvador. Int J Cancer 2015; 137:893-902. [DOI: 10.1002/ijc.29438] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2014] [Revised: 12/12/2014] [Accepted: 12/17/2014] [Indexed: 12/22/2022]
Affiliation(s)
- Nicole G. Campos
- Center for Health Decision Science; Department of Health Policy and Management; Harvard T.H. Chan School of Public Health; Boston MA
| | - Mauricio Maza
- Basic Health International; San Salvador El Salvador
| | - Karla Alfaro
- Basic Health International; San Salvador El Salvador
| | - Julia C. Gage
- Department of Cancer Epidemiology and Genetics; National Cancer Institute; Rockville MD
| | - Philip E. Castle
- Global Coalition against Cervical Cancer; Arlington VA
- Department of Epidemiology & Population Health; Albert Einstein College of Medicine; Bronx NY
| | - Juan C. Felix
- Department of Pathology; Keck School of Medicine of University of Southern California; Los Angeles CA
| | - Miriam L. Cremer
- Basic Health International; San Salvador El Salvador
- Obstetrics, Gynecology & Women's Health Institute, Cleveland Clinic; Cleveland OH
| | - Jane J. Kim
- Center for Health Decision Science; Department of Health Policy and Management; Harvard T.H. Chan School of Public Health; Boston MA
| |
Collapse
|
43
|
Campos NG, Burger EA, Sy S, Sharma M, Schiffman M, Rodriguez AC, Hildesheim A, Herrero R, Kim JJ. An updated natural history model of cervical cancer: derivation of model parameters. Am J Epidemiol 2014; 180:545-55. [PMID: 25081182 DOI: 10.1093/aje/kwu159] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Mathematical models of cervical cancer have been widely used to evaluate the comparative effectiveness and cost-effectiveness of preventive strategies. Major advances in the understanding of cervical carcinogenesis motivate the creation of a new disease paradigm in such models. To keep pace with the most recent evidence, we updated a previously developed microsimulation model of human papillomavirus (HPV) infection and cervical cancer to reflect 1) a shift towards health states based on HPV rather than poorly reproducible histological diagnoses and 2) HPV clearance and progression to precancer as a function of infection duration and genotype, as derived from the control arm of the Costa Rica Vaccine Trial (2004-2010). The model was calibrated leveraging empirical data from the New Mexico Surveillance, Epidemiology, and End Results Registry (1980-1999) and a state-of-the-art cervical cancer screening registry in New Mexico (2007-2009). The calibrated model had good correspondence with data on genotype- and age-specific HPV prevalence, genotype frequency in precancer and cancer, and age-specific cancer incidence. We present this model in response to a call for new natural history models of cervical cancer intended for decision analysis and economic evaluation at a time when global cervical cancer prevention policy continues to evolve and evidence of the long-term health effects of cervical interventions remains critical.
Collapse
|
44
|
Kim JJ, Campos NG, O'Shea M, Diaz M, Mutyaba I. Model-Based Impact and Cost-Effectiveness of Cervical Cancer Prevention in Sub-Saharan Africa. Vaccine 2013; 31 Suppl 5:F60-72. [DOI: 10.1016/j.vaccine.2012.07.093] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2012] [Revised: 07/02/2012] [Accepted: 07/11/2012] [Indexed: 12/01/2022]
|
45
|
Campos NG, Castle PE, Schiffman M, Kim JJ. Policy implications of adjusting randomized trial data for economic evaluations: a demonstration from the ASCUS-LSIL Triage Study. Med Decis Making 2011; 32:400-27. [PMID: 22147881 DOI: 10.1177/0272989x11428516] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Although the randomized controlled trial (RCT) is widely considered the most reliable method for evaluation of health care interventions, challenges to both internal and external validity exist. Thus, the efficacy of an intervention in a trial setting does not necessarily represent the real-world performance that decision makers seek to inform comparative effectiveness studies and economic evaluations. METHODS Using data from the ASCUS-LSIL Triage Study (ALTS), we performed a simplified economic evaluation of age-based management strategies to detect cervical intraepithelial neoplasia grade 3 (CIN3) among women who were referred to the study with low-grade squamous intraepithelial lesions (LSIL). We used data from the trial itself to adjust for 1) potential lead time bias and random error that led to variation in the observed prevalence of CIN3 by study arm and 2) potential ascertainment bias among providers in the most aggressive management arm. RESULTS We found that using unadjusted RCT data may result in counterintuitive cost-effectiveness results when random error and/or bias are present. Following adjustment, the rank order of management strategies changed for 2 of the 3 age groups we considered. CONCLUSIONS Decision analysts need to examine study design, available trial data, and cost-effectiveness results closely in order to detect evidence of potential bias. Adjustment for random error and bias in RCTs may yield different policy conclusions relative to unadjusted trial data.
Collapse
Affiliation(s)
- Nicole G Campos
- Center for Health Decision Science, Harvard School of Public Health, Boston, MA (NGC, JJK),Center of Excellence for Health Disparities Research–El Centro, School of Nursing and Health Studies, University of Miami, Coral Gables, FL (NGC)
| | - Philip E Castle
- American Society for Clinical Pathology Institute, Washington, DC (PEC)
| | - Mark Schiffman
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Rockville, MD (MS)
| | - Jane J Kim
- Center for Health Decision Science, Harvard School of Public Health, Boston, MA (NGC, JJK)
| |
Collapse
|
46
|
Campos NG, Kim JJ, Castle PE, Ortendahl JD, O'Shea M, Diaz M, Goldie SJ. Health and economic impact of HPV 16/18 vaccination and cervical cancer screening in Eastern Africa. Int J Cancer 2011; 130:2672-84. [PMID: 21717458 DOI: 10.1002/ijc.26269] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2011] [Revised: 05/23/2011] [Accepted: 06/16/2011] [Indexed: 11/08/2022]
Abstract
Eastern Africa has the world's highest cervical cancer incidence and mortality rates. We used epidemiologic data from Kenya, Mozambique, Tanzania, Uganda, and Zimbabwe to develop models of HPV-related infection and disease. For each country, we assessed HPV vaccination of girls before age 12 followed by screening with HPV DNA testing once, twice, or three times per lifetime (at ages 35, 40, 45). For women over age 30, we assessed only screening (with HPV DNA testing up to three times per lifetime or VIA at age 35). Assuming no waning immunity, mean reduction in lifetime cancer risk associated with vaccination ranged from 36 to 45%, and vaccination followed by screening once per lifetime at age 35 with HPV DNA testing ranged from 43 to 51%. For both younger and older women, the most effective screening strategy was HPV DNA testing three times per lifetime. Provided the cost per vaccinated girl was less than I$10 (I$2 per dose), vaccination had an incremental cost-effectiveness ratio [I$ (international dollars)/year of life saved (YLS)] less than the country-specific per capita GDP, a commonly cited heuristic for "very cost-effective" interventions. If the cost per vaccinated girl was between I$10 (I$2 per dose) and I$25 (I$5 per dose), vaccination followed by HPV DNA testing would save the most lives and would be considered good value for public health dollars. These results should be used to catalyze design and evaluation of HPV vaccine delivery and screening programs, and contribute to a dialogue on financing HPV vaccination in poor countries.
Collapse
Affiliation(s)
- Nicole G Campos
- Center for Health Decision Science, Department of Health Policy and Management, Harvard School of Public Health, Boston, MA, USA.
| | | | | | | | | | | | | |
Collapse
|
47
|
Campos NG, Rodriguez AC, Castle PE, Herrero R, Hildesheim A, Katki H, Kim JJ, Wacholder S, Morales J, Burk RD, Schiffman M. Persistence of concurrent infections with multiple human papillomavirus types: a population-based cohort study. J Infect Dis 2011; 203:823-7. [PMID: 21257737 DOI: 10.1093/infdis/jiq131] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
The presence of more than one human papillomavirus (HPV) genotype may influence the duration of prevalently detected infections. This analysis included 1,646 infections detected at enrollment in 980 women from the Guanacaste, Costa Rica, cohort who were actively followed up every 6-12 months for up to 8 years. We categorized HPV infections as single or multiple types. Persistence of infections was estimated using discrete-time survival analysis. The difference between the duration of single and that of concurrent multiple type-specific prevalent HPV infections was not significant (P = .9; log-rank test). Concurrent, prevalent detection of additional HPV types did not change the likelihood of viral persistence.
Collapse
Affiliation(s)
- Nicole G Campos
- Center for Health Decision Science, Harvard School of Public Health, Boston, Massachusetts, USA.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
48
|
Campos NG, Salomon JA, Servoss JC, Nunes DP, Samet JH, Freedberg KA, Goldie SJ. Cost-effectiveness of treatment for hepatitis C in an urban cohort co-infected with HIV. Am J Med 2007; 120:272-9. [PMID: 17349451 PMCID: PMC2034752 DOI: 10.1016/j.amjmed.2006.06.036] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2006] [Revised: 06/16/2006] [Accepted: 06/23/2006] [Indexed: 11/21/2022]
Abstract
PURPOSE Recent clinical trials have evaluated treatment strategies for chronic infection with hepatitis C virus (HCV) in patients co-infected with human immunodeficiency virus (HIV). Our objective was to use these data to examine the cost-effectiveness of treating HCV in an urban cohort of co-infected patients. METHODS A computer-based model, together with available published data, was used to estimate lifetime costs (2004 US dollars), life expectancy, and incremental cost per year of life saved (YLS) associated with 3 treatment strategies: (1) interferon-alfa and ribavirin; (2) pegylated interferon-alfa; and (3) pegylated interferon-alfa and ribavirin. The target population included treatment-eligible patients, based on an actual urban cohort of HIV-HCV co-infected subjects, with a mean age of 44 years, of whom 66% had genotype 1 HCV, 16% had cirrhosis, and 98% had CD4 cell counts >200 cells/mm3. RESULTS Pegylated interferon-alfa and ribavirin was consistently more effective and cost-effective than other treatment strategies, particularly in patients with non-genotype 1 HCV. For patients with CD4 counts between 200 and 500 cells/mm3, survival benefits ranged from 5 to 11 months, and incremental cost-effectiveness ratios were consistently less than $75,000 per YLS for men and women of both genotypes. Due to better treatment efficacy in non-genotype 1 HCV patients, this group experienced greater life expectancy gains and lower incremental cost-effectiveness ratios. CONCLUSIONS Combination therapy with pegylated interferon-alfa and ribavirin for HCV in eligible co-infected patients with stable HIV disease provides substantial life-expectancy benefits and appears to be cost-effective. Overcoming barriers to HCV treatment eligibility among urban co-infected patients remains a critical priority.
Collapse
Affiliation(s)
- Nicole G Campos
- Program in Health Policy, Harvard University, Cambridge, Mass, USA.
| | | | | | | | | | | | | |
Collapse
|