Estimated Quality of Life and Economic Outcomes Associated With 12 Cervical Cancer Screening Strategies

Abstract

IMPORTANCE Many cervical cancer screening strategies are now recommended in the United States, but the benefits, harms, and costs of each option are unclear. OBJECTIVE To estimate the cost-effectiveness of 12 cervical cancer screening strategies. DESIGN, SETTING, AND PARTICIPANTS The cross-sectional portion of this study enrolled a convenience sample of 451 English-speaking or Spanish-speaking women aged 21 to 65 years from September 22, 2014, to June 16, 2016, identified at women's health clinics in San Francisco. In this group, utilities (preferences) were measured for 23 cervical cancer screening-associated health states and were applied to a decision model of type-specific high-risk human papillomavirus (hrHPV)-induced cervical carcinogenesis. Test accuracy estimates were abstracted from systematic reviews. The evaluated strategies were cytologic testing every 3 years for women aged 21 to 65 years with either repeat cytologic testing in 1 year or immediate hrHPV triage for atypical squamous cells of undetermined significance (ASC-US), cytologic testing every 3 years for women age 21 to 29 years followed by cytologic testing plus hrHPV testing (cotesting), or primary hrHPV testing alone for women aged 30 to 65 years. Screening frequency, abnormal test result management, and the age to switch from cytologic testing to hrHPV testing (25 or 30 years) were varied. Analyses were conducted from both the societal and health care sector perspectives. MAIN OUTCOMES AND MEASURES Utilities for 23 cervical cancer screening-associated health states (cross-sectional study) and quality-adjusted life-years (QALYs) and total costs for each strategy. RESULTS Utilities were measured in a sociodemographically diverse group of 451 women (mean [SD] age, 38.2 [10.7] years; 258 nonwhite [57.2%]). Cytologic testing every 3 years with repeat cytologic testing for ASC-US yielded the most lifetime QALYs and conferred more QALYs at higher costs ($2166 per QALY) than the lowest-cost strategy (cytologic testing every 3 years with hrHPV triage of ASC-US). All cytologic testing plus hrHPV testing (cotesting) and primary hrHPV testing strategies provided fewer QALYs at higher costs. Adding indirect costs did not change the conclusions. In sensitivity analyses, hrHPV testing every 5 years with genotyping triage beginning at age 30 years was the lowest-cost strategy when hrHPV test sensitivity was markedly higher than cytologic test sensitivity or when hrHPV test cost was equated to the lowest reported cytologic test cost ($14). CONCLUSIONS AND RELEVANCE Cytologic testing every 3 years for women aged 21 to 29 years with either continued cytologic testing every 3 years or switching to a low-cost hrHPV test every 5 years confers a reasonable balance of benefits, harms, and costs. Comparative modeling is needed to confirm the association of these novel utilities with cost-effectiveness.

Discussing Cervical Cancer Screening Options: Outcomes to Guide Conversations Between Patients and Providers

“…21 Our parent study found that a normal cytologic test result conferred a higher mean utility for women compared with a negative hrHPV test alone. 7 In addition, other studies have found that women prefer shorter time intervals for cervical cancer screening rather than longer intervals. [21][22][23] Given the outcomes presented in our study, women can make decisions based on forecasted benefits and harms related to cervical cancer screening strategies they personally prefer and decide what frequency of screening would allow them to feel secure that the risk of cervical cancer is minimal while balancing the harms of possible false-positive tests and treatments.…”

“…Our methods have previously been described. 7 Briefly, we constructed a type-specific HPV Markov decision model using estimates of the natural history of HPV, cervical precancerous lesions, and cancer. The model was validated using outcomes from a randomized trial of hrHPV testing compared with cytology as well as data from the Surveillance, Epidemiology and End Results (SEER) program.…”

“…6 We previously reported cost-effectiveness analyses of various cervical cancer screening strategies over a lifetime of screening. 7 In this study, we use decision analysis to estimate outcomes of screening strategies recommended for women at age 30, expressed per 10,000 women over a shorter-than-lifetime (15-year) horizon, similar to that used in shared decision making for breast cancer screening. 8 Our overarching objective was to provide evidencebased information in a familiar format to guide conversations and improve shared decision making between patients and providers about various cervical cancer screening options, as recommended by the USPSTF and ACOG.…”

Cervical Cancer Screening

“…Recent cost-effectiveness analyses suggest that cytology every 3 years for women ages 21 to 29 years with either continued triennial cytology or switching to a low-cost hrHPV test every 5 years from ages 30 to 65 years confers a reasonable balance of benefits, harms, and costs from both a societal and health care sector perspective. 10…”

High-risk HPV test in cervical cancer prevention – present and future

“…In the USA, due to USPSTF guidelines, for women aged 21-29, it is suggested that they should undergo a cervical smear test every three years. Co-testing with cervical smear and the hrHPV test is recommended in women aged 30-65, at five year intervals [12,23,24]. As mentioned, in The Netherlands, the screening policy was changed in 2017.…”