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Kim JJ, Wright TC, Goldie SJ. Cost-effectiveness of Alternative Triage Strategies for Atypical Squamous Cells of Undetermined Significance. JAMA. 2002;287(18):2382–2390. doi:10.1001/jama.287.18.2382
Author Affiliations: Department of Health Policy and Management, Harvard Center for Risk Analysis, Harvard School of Public Health, Boston, Mass (Ms Kim and Dr Goldie) and the Department of Pathology, College of Physicians and Surgeons of Columbia University, New York, NY (Dr Wright).
Context Every year approximately 2 million US women are diagnosed as having
a cervical cytological result of atypical squamous cells of undetermined significance
Objective To determine the most efficient and cost-effective management strategy
for women in the United States diagnosed as having ASC-US.
Design and Setting Cost-effectiveness analysis of data from clinical trials, prospective
studies, and other published literature. A computer-based model was used to
compare 4 management strategies for a cytological result of ASC-US: immediate
colposcopy; human papillomavirus (HPV) triage, which includes colposcopy if
high-risk HPV types are detected; repeat cytology, which includes follow-up
cytology at 6 and 12 months and referral for colposcopy if a repeat abnormal
result occurs; and reclassifying ASC-US as normal in which a cytological result
of ASC-US is ignored. Reflex HPV DNA testing uses either residual liquid-based
cytological specimens or samples co-collected at the time of the initial screening
for conventional cytology. Another method, referred to as the 2-visit HPV
DNA triage, requires a woman with an ASC-US result to return within 1 month
to provide another speciman sample.
Main Outcome Measures Years of life saved (YLS), quality-adjusted life-years (QALYs), and
incremental cost-effectiveness ratios.
Results The least costly strategy for biennial screening was to reclassify ASC-US
as normal, resulting in a reduction in total cancer incidence of 75% for conventional
cytology and 84% for liquid-based cytology compared with no screening. The
next least costly strategy was HPV DNA testing resulting in a reduction in
total cancer incidence of 86% for conventional cytology and 90% for liquid-based
cytology, followed by immediate colposcopy with a reduction of 87% and 91%,
respectively. Compared with reflex HPV DNA testing, a strategy of repeat cervical
cytology or delayed HPV testing costs more but is less effective. When all
strategies were compared simultaneously, varying frequency and type of cytological
test, biennial (vs every 3 years) liquid-based cytology with reflex HPV testing
had a cost of $174 200 per YLS. In a similar comparison, liquid-based
cytology with reflex HPV testing conducted every 3 years (vs every 5 years)
had a cost of $59 600 per YLS and was more effective and less costly
than a strategy of conventional cytology incorporating repeat cytology or
immediate colposcopy conducted biennially.
Conclusion Reflex HPV DNA testing provides the same or greater life expectancy
benefits and is more cost-effective than other management strategies for women
diagnosed as having ASC-US.
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