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Goldie SJ, Kuhn L, Denny L, Pollack A, Wright TC. Policy Analysis of Cervical Cancer Screening Strategies in Low-Resource Settings: Clinical Benefits and Cost-effectiveness. JAMA. 2001;285(24):3107–3115. doi:10.1001/jama.285.24.3107
Author Affiliations: From the Department of Health Policy and Management Harvard School of Public Health, Boston, Mass (Dr Goldie); Department of Obstetrics and Gynecology, University of Cape Town, South Africa (Dr Denny); Gertrude H. Sergievsky Center, College of Physicians and Surgeons, and Division of Epidemiology, Joseph L. Mailman School of Public Health, Columbia University, New York, NY (Dr Kuhn); EngenderHealth, New York, NY, (Dr Pollack); Department of Pathology, College of Physicians and Surgeons of Columbia University, New York, NY, (Dr Wright).
Context Cervical cancer is a leading cause of cancer-related death among women
in developing countries. In such low-resource settings, cytology-based screening
is difficult to implement, and less complex strategies may offer additional
Objective To assess the cost-effectiveness of several cervical cancer screening
strategies using population-specific data.
Design and Setting Cost-effectiveness analysis using a mathematical model and a hypothetical
cohort of previously unscreened 30-year-old black South African women. Screening
tests included direct visual inspection (DVI) of the cervix, cytologic methods,
and testing for high-risk types of human papillomavirus (HPV) DNA. Strategies
differed by number of clinical visits, screening frequency, and response to
a positive test result. Data sources included a South African screening study,
national surveys and fee schedules, and published literature.
Main Outcome Measures Years of life saved (YLS), lifetime costs in US dollars, and incremental
cost-effectiveness ratios (cost per YLS).
Results When analyzing all strategies performed as a single lifetime screen
at age 35 years compared with no screening, HPV testing followed by treatment
of screen-positive women at a second visit, cost $39/YLS (27% cancer incidence
reduction); DVI, coupled with immediate treatment of screen-positive women
at the first visit was next most effective (26% cancer incidence reduction)
and was cost saving; cytology, followed by treatment of screen-positive women
at a second visit was least effective (19% cancer incidence reduction) at
a cost of $81/YLS. For any given screening frequency, when strategies were
compared incrementally, HPV DNA testing generally was more effective but also
more costly than DVI, and always was more effective and less costly than cytology.
When comparing all strategies simultaneously across screening frequencies,
DVI was the nondominated strategy up to a frequency of every 3 years (incremental
cost-effectiveness ratio, $460/YLS), and HPV testing every 3 years (incremental
cost-effectiveness ratio, $11 500/YLS) was the most effective strategy.
Conclusion Cervical cancer screening strategies that incorporate DVI or HPV DNA
testing and eliminate colposcopy may offer attractive alternatives to cytology-based
screening programs in low-resource settings.
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