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Original Investigation
Less Is More
May 13, 2019

Estimated Quality of Life and Economic Outcomes Associated With 12 Cervical Cancer Screening Strategies: A Cost-effectiveness Analysis

Author Affiliations
  • 1Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco
  • 2University of California, San Francisco Center for Healthcare Value, San Francisco
  • 3Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis
  • 4Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis
  • 5now at Drug Policy Program, Center for Research and Teaching in Economics, Aguascalientes, Aguascalientes, Mexico
  • 6Department of Medicine, University of California, San Francisco
  • 7Division of Research, Kaiser Permanente, Oakland, California
  • 8Department of Obstetrics and Gynecology, Global Health Institute, Duke University, Durham, North Carolina
JAMA Intern Med. 2019;179(7):867-878. doi:10.1001/jamainternmed.2019.0299
Key Points

Question  After incorporating women’s preferences into a cost-effectiveness analysis, what are the estimated quality of life and economic outcomes associated with cervical cancer screening strategies currently recommended in the United States?

Findings  Of 12 strategies evaluated in a cost-effectiveness model, cytologic testing every 3 years for women aged 21 to 29 years with either continued triennial cytologic testing or switching to a low-cost high-risk human papillomavirus test every 5 years from age 30 to 65 years conferred a reasonable balance of benefits, harms, and costs from both a societal and health care sector perspective.

Meaning  Cytologic testing every 3 years and low-cost high-risk human papillomavirus testing every 5 years both may be considered reasonable cervical cancer screening options for women aged 30 to 65 years.

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.

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