Maximizing the cost-effectiveness of cervical screening in the context of routine HPV vaccination by optimizing screening strategies with respect to vaccine uptake: a modeling analysis

Abstract

Background Regarding primary and secondary cervical cancer prevention, the World Health Organization proposed the cervical cancer elimination strategy that requires countries to achieve 90% uptake of human papillomavirus (HPV) vaccines and 70% screening uptake. The optimal cervical screening strategy is likely different for unvaccinated and vaccinated cohorts upon national HPV immunization. However, health authorities typically only provide a one-size-fits-all recommendation for the general population. We aimed to evaluate the cost-effectiveness for determining the optimal screening strategies for vaccinated and unvaccinated cohorts. Methods We considered the women population in Hong Kong which has a unique HPV infection and cervical cancer epidemiology compared to other regions in China and Asia. We used mathematical models which comprise a deterministic age-structured compartmental dynamic component and a stochastic individual-based cohort component to evaluate the cost-effectiveness of screening strategies for cervical screening. Following the recommendations in local guidelines in Hong Kong, we considered strategies that involved cytology, HPV testing, or co-testing as primary cervical screening. We also explored the impacts of adopting alternative de-intensified strategies for vaccinated cohorts. The 3-year cytology screening was used as the base comparator while no screening was also considered for vaccinated cohorts. Women’s lifetime life years, quality-adjusted life years, and costs of screening and treatment were estimated from the societal perspective based on the year 2022 and were discounted by 3% annually. Incremental cost-effectiveness ratios (ICERs) were compared to a willingness to pay (WTP) threshold of one gross domestic product per capita (US $47,792). Probabilistic and one-way sensitivity analyses were conducted. Results Among unvaccinated cohorts, the strategy that adds reflex HPV to triage mild cytology abnormality generated more life years saved than cytology-only screening and could be a cost-effective alternative. Among vaccinated cohorts, when vaccine uptake was 85% (based on the uptake in 2022), all guideline-based strategies (including the cytology-only screening) had ICERs above the WTP threshold when compared with no screening if the vaccine-induced protection duration was 20 years or longer. Under the same conditions, HPV testing with genotyping triage had ICERs (compared with no screening) below the WTP threshold if the routine screening interval was lengthened to 10 and 15 years or screening was initiated at ages 30 and 35 years. Conclusions HPV testing is a cost-effective alternative to cytology for vaccinated cohorts, and the associated optimal screening frequency depends on vaccine uptake. Health authorities should optimize screening recommendations by accounting for population vaccine uptake.

Cervical screening among Chinese females in the era of HPV vaccination: a population-based survey on screening uptake and regular screening following an 18-year organized screening program

“…Our survey found that vaccinated women were more likely to have attended cervical screening and screened regularly than unvaccinated women. As illustrated in our recent cost-effectiveness study, the optimal screening strategies were likely different by vaccination coverage in the age cohort [ 30 ]. Among women who have received HPV vaccines, a longer screening interval following negative screening results would likely remain cost-effective on top of HPV vaccination in the vaccinated cohort.…”

“…The optimal cervical screening strategy likely correlated with HPV vaccination uptake among screening females. Specifically, a longer screening interval may be preferred in cohorts with high HPV vaccine uptake [ 30 32 ]. Our findings provide information for policymakers to consider when updating switching screening recommendations.…”

The awareness and acceptance of HPV vaccines among parents of primary and junior high school students in China: a meta-analysis

“…Cervical cancer is the only cancer in the world that can be prevented by HPV vaccination [30 , 31] . Studies have shown that persistent infection with HR-HPV is the main cause of cervical cancer [32 , 33] .…”

Cervical cancer: Challenges and prevention strategies: A narrative review

“…Visual inspection with acetic acid may also be cost-effective in certain settings, such as rural areas. 91 Another study carried out in Sweden and Australia also showed that primary screening for HPV is better than both cytology-based methods and primary HPV screening followed by cytology. 92,93 A study conducted in Nicaragua also has found that HPV testing is a more cost-effective option than Pap testing.…”

“…[75][76][77][78] Age in years ACS (2012) USPSTF ( 2018 screening can be a cost-effective approach, but only if routine vaccination rates reach 75% or higher. 91 A systematic review of economic evaluations of CC screening methods showed that primary HPV DNA testing strategies are cost-effective in several settings.…”