Cost-effectiveness of HPV-based cervical cancer screening in the public health system in Nicaragua.

Abstract

OBJECTIVES:

To evaluate the cost-effectiveness of human papillomavirus (HPV) DNA testing (versus Papanicolaou (Pap)-based screening) for cervical cancer screening in Nicaragua.

DESIGN:

A previously developed Monte Carlo simulation model of the natural history of HPV infection and cervical cancer was calibrated to epidemiological data from Nicaragua. Cost data inputs were derived using a micro-costing approach in Carazo, Chontales and Chinandega departments; test performance data were from a demonstration project in Masaya department.

SETTING:

Nicaragua's public health sector facilities.

PARTICIPANTS:

Women aged 30-59 years.

INTERVENTIONS:

Screening strategies included (1) Pap testing every 3 years, with referral to colposcopy for women with an atypical squamous cells of undetermined significance or worse result ('Pap'); (2) HPV testing every 5 years, with referral to cryotherapy for HPV-positive eligible women (HPV cryotherapy or 'HPV-Cryo'); (3) HPV testing every 5 years, with referral to triage with visual inspection with acetic acid (VIA) for HPV-positive women ('HPV-VIA'); and (4) HPV testing every 5 years, with referral to Pap testing for HPV-positive women ('HPV-Pap').

OUTCOME MEASURES:

Reduction in lifetime risk of cancer and incremental cost-effectiveness ratios (ICER; 2015 US$ per year of life saved (YLS)).

RESULTS:

HPV-based screening strategies were more effective than Pap testing. HPV-Cryo was the least costly and most effective strategy, reducing lifetime cancer risk by 29.5% and outperforming HPV-VIA, HPV-Pap and Pap only, which reduced cancer risk by 19.4%, 12.2% and 10.8%, respectively. With an ICER of US$320/YLS, HPV-Cryo every 5 years would be very cost-effective using a threshold based on Nicaragua's per capita gross domestic product of US$2090. Findings were robust across sensitivity analyses on test performance, coverage, compliance and cost parameters.

CONCLUSIONS:

HPV testing is very cost-effective compared with Pap testing in Nicaragua, due to higher test sensitivity and the relatively lower number of visits required. Increasing compliance with recommended follow-up will further improve the health benefits and value for public health dollars.

• Authors: Nicole G Campos, Mercy Mvundura, Jose Jeronimo, Francesca Holme, Elisabeth Vodicka, Jane J Kim
• Journal: BMJ open (BMJ Open) Vol. 7 Issue 6 Pg. e015048 (06 15 2017) ISSN: 2044-6055 [Electronic] England
• PMID: 28619772 (Publication Type: Journal Article)
• Copyright: © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Topics

• Adult
• Colposcopy (economics, statistics & numerical data)
• Cost-Benefit Analysis
• Early Detection of Cancer (economics, instrumentation, standards)
• Female
• Health Care Surveys
• Health Knowledge, Attitudes, Practice
• Humans
• Mass Screening (economics)
• Middle Aged
• Nicaragua (epidemiology)
• Papanicolaou Test (economics, statistics & numerical data)
• Papillomavirus Infections (diagnosis, economics)
• Public Health (economics)
• Uterine Cervical Neoplasms (diagnosis, prevention & control)
• Vaginal Smears (economics, statistics & numerical data)
• Uterine Cervical Dysplasia (diagnosis, prevention & control)