Cost-Effectiveness of Primary HPV Testing, Cytology and Co-testing as Cervical Cancer Screening for Women Above Age 30 Years

Abstract

BACKGROUND: Cervical cancer screening guidelines for women aged ≥30 years allow for co-testing or primary cytology testing. Our objective was to determine the test characteristics and costs associated with Cytology, HPV and Co-testing screening strategies. MAIN METHODS: Retrospective cohort study of women undergoing cervical cancer screening with both cytology and HPV (Hybrid Capture 2) testing from 2004 to 2010 in an integrated health system. The electronic health record was used to identify women aged ≥30 years who had cotesting. Unsatisfactory or unavailable test results and incorrectly ordered tests were excluded. The main outcome was biopsy-proven cervical intraepithelial neoplasia grade 3 or higher (CIN3+). KEY RESULTS: The final cohort consisted of 99,549 women. Subjects were mostly white (78.4 %), married (70.7 %), never smokers (61.3 %) and with private insurance (86.1 %). Overall, 5121 (5.1 %) tested positive for HPV and 6115 (6.1 %) had cytology ≥ ASCUS; 1681 had both and underwent colposcopy and 310 (0.3 %) had CIN3+. Sensitivity for CIN3+ was 91.9 % for Primary Cytology, 99.4 % for Co-testing, and 94.8 % for Primary HPV; specificity was 97.3 % for Co-testing and Primary Cytology and 97.9 % for Primary HPV. Over a 3-year screening interval, Primary HPV detected more cases of CIN3+ and was less expensive than Primary Cytology. Co-testing detected 14 more cases of CIN3+ than Primary HPV, but required an additional 100,277 cytology tests and 566 colposcopies at an added cost of $2.38 million, or $170,096 per additional case detected. CONCLUSIONS: Primary HPV was more effective and less expensive than Primary Cytology. Primary HPV screening appears to represent a cost-effective alternative to Co-testing.

Implementation of Multicolor Melt Curve Analysis for High-Risk Human Papilloma Virus Detection in Low- and Middle-Income Countries: A Pilot Study for Expanded Cervical Cancer Screening in Honduras

“…The cost of current cervical screening methods, including cytologic and molecular cotesting, are prohibitively expensive for public health applications in LMICs. 6 , 7 It has been estimated that, globally, 75 LMICs have fewer than 2.5 health-care workers per 1,000 people, which fails to reach the minimum number needed to deliver basic health-care services. 8 , 9 In addition, accurate screening results may take days to weeks to complete, by which time many of these patients can be lost to follow-up care.…”

“…hrHPV testing has been shown to be more cost-effective than traditional screening by Pap and offers the potential for expanding cervical cancer screening in LMICs by substituting device-based testing for traditional cytology that requires trained cytologists, who are scarce in LMICs. 7 …”

The use of HPV-DNA testing combined with Pap smear in detection of pre-invasive disease of the cervix

“…9 Screening is done through cytologybased screening (Pap test), HPV based screening, visual inspection of aceto-white cervix (VIA), colposcopic examination. 10,11 According to the American Cancer Society (ACS), before 1980, a Pap smear was recommended as part of a regular check-up. From 1980 to 1987, pap smears with cervical cytology were recommended yearly for women over the age 20.…”

Controlling Human Papilloma Virus: A Public Health Perspective of Treatment of Anogenital Warts

“…The role of HPV testing in cervical screening is firmly established. Combined HPV and cervical smear screening (also called HPV cotesting) and the role of primary HPV testing as the sole modality of screening are being investigated [7]. HPV cotesting can increase the interval period for cervical screening to 5 years under the current guidelines.…”