Grand Rounds

Cervical Cancer Screening Strategies and Cost-Effectiveness: Which is the Best?

BACKGROUND AND PURPOSE:

There are multiple different strategies available for cervical cancer screening
Sawaya et al. (JAMA Intern Med., 2019) estimated the cost-effectiveness as well as the quality of life outcomes of 12 cervical cancer screening strategies

Cross-sectional study and cost-effectiveness analysis
Participants
- 4 focus groups
- English or Spanish-speaking women aged 21-65 years
- Sociodemographically diverse
- Preferences elicited via interview and questionnaire
- Natural history and test accuracy determined using model-predicted outcomes based on literature
Overall 12 strategies were evaluated including currently recommended ACOG / USPSTF guidance
Measures
- Utilities (preferences) for 23 cervical cancer screening associated health states
Data analysis
- Analyses were conducted from both the societal and health care sector perspectives
- Costs included screening, diagnosis and treatment, including cancer
Primary outcomes
- Quality-adjusted life-years (QALYs) and total costs for each strategy

451 women helped to determine utilities
- Mean [SD] age: 38.2 [10.7] years; 258 nonwhite [57.2%]
Screening was cost-saving ($1267-$2577 per woman) vs no screening ($2891 per woman)
Lowest cost strategy
- Cytologic testing every 3 years with hrHPV triage of ASC-US
Higher cost strategy
- Cytologic testing every 3 years with repeat cytologic testing for ASC-US
Fewer QALYs at higher costs
- Cotesting and primary hrHPV testing
Most costly strategy
- Annual cytologic testing
- Fewer QALYs than cytologic testing every 3 years
Not cost-effective to
- Perform cytologic testing plus hrHPV testing (cotesting) under any condition
- To start primary hrHPV testing prior to age 30 years
- To perform hrHPV testing every 3 years
- To perform cytologic testing annually

Superior strategy when considering benefits, harms, and costs were
- Cytologic testing every 3 years for women aged 21 to 29 years with either
  - Continued cytologic testing every 3 years
  - Switching to a low-cost hrHPV test every 5 years

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