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Original Research |

Inefficiencies and High-Value Improvements in U.S. Cervical Cancer Screening Practice: A Cost-Effectiveness AnalysisImproving U.S. Cervical Cancer Screening Practice

Jane J. Kim, PhD; Nicole G. Campos, PhD; Stephen Sy, MS; Emily A. Burger, PhD; Jack Cuzick, PhD; Philip E. Castle, PhD, MPH; William C. Hunt, MS; Alan Waxman, MD, MPH; Cosette M. Wheeler, PhD, on behalf of the New Mexico HPV Pap Registry Steering Committee*
[+] Article, Author, and Disclosure Information

*For a list of members of the New Mexico HPV Pap Registry Steering Committee, see the Appendix.

This article was published online first at www.annals.org on 29 September 2015.


From Harvard T.H. Chan School of Public Health, Boston, Massachusetts; University of Oslo, Oslo, Norway; Queen Mary University of London, London, United Kingdom; Albert Einstein College of Medicine, Bronx, New York; Global Coalition Against Cervical Cancer, Arlington, Virginia; University of New Mexico Health Sciences Center, Albuquerque, New Mexico.

Grant Support: By the U.S. National Cancer Institute through a cooperative agreement (U54 CA164336; principal investigator, Cosette Wheeler, University of New Mexico), part of the Population-Based Research Optimizing Screening through Personalized Regimens (PROSPR) consortium. The overall aim of PROSPR is to conduct multisite, coordinated, transdisciplinary research to evaluate and improve cancer screening processes.

Disclosures: Drs. Kim and Campos report grants from U.S. National Cancer Institute during the conduct of the study. Dr. Cuzick reports grants from Qiagen, OncoHealth, and Genera and grants and other from Beckton Dickinson, Abbott, Hologic, Trovagene, and Cepheid during the conduct of the study. Dr. Castle reports personal fees from Guided Therapeutics, Inovio, Merck, Hologic, GE Healthcare, Cepheid, and ClearPath; personal fees and nonfinancial support from Roche and BD; and nonfinancial support from mtm and Qiagen outside the submitted work. Dr. Waxman reports grants from National Cancer Institute and grants to his institution (University of New Mexico) during the conduct of the study and personal fees from American College of Obstetricians and Gynecologists, American College of Osteopathic Obstetricians and Gynecologists, and American Society for Colposcopy and Cervical Pathology outside the submitted work. Dr. Wheeler reports grants from U.S. National Cancer Institute during the conduct of the study and other fees from GSK, Merck, and Roche Molecular Systems outside the submitted work. Authors not named here have disclosed no conflicts of interest. Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictsOfInterestForms.do?msNum=M15-0420.

Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that she has no financial relationships or interests to disclose. Darren B. Taichman, MD, PhD, Executive Deputy Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Deborah Cotton, MD, MPH, Deputy Editor, reports that she has no financial relationships or interest to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Catharine B. Stack, PhD, MS, Deputy Editor for Statistics, reports that she has stock holdings in Pfizer.

Reproducible Research Statement:Study protocol: Not applicable. Statistical code: Not available. Data set: Requests to the NMHPVPR must be made in writing and approved by the NMHPVPR Steering Committee; proposal submission instructions are available from the New Mexico HPV Pap Registry (email, nmhpvpr@salud.unm.edu).

Requests for Single Reprints: Jane J. Kim, PhD, Harvard T.H. Chan School of Public Health, Center for Health Decision Science, 718 Huntington Avenue, Boston, MA 02115; email, jkim@hsph.harvard.edu.

Current Author Addresses: Drs. Kim, Campos, and Burger and Mr. Sy: Harvard T.H. Chan School of Public Health, Center for Health Decision Science, 718 Huntington Avenue, Boston, MA 02115.

Dr. Cuzick: Queen Mary, University of London, Wolfson Institute of Preventive Medicine, Charterhouse Square, London, EC1M 6BQ, United Kingdom.

Dr. Castle: 3800 Fairfax Drive, Suite 5, Arlington, VA 22203.

Mr. Hunt: Departments of Pathology and Obstetrics and Gynecology, University of New Mexico Health Sciences Center, MSC02-1670 Building 191, House of Prevention Epidemiology, 1 University of New Mexico, Albuquerque, NM 87131.

Dr. Waxman: Department of Obstetrics and Gynecology, University of New Mexico Health Sciences Center, MSC10-5580, 1 University of New Mexico, Albuquerque, NM 87131.

Dr. Wheeler: Departments of Pathology and Obstetrics and Gynecology, University of New Mexico Health Sciences Center, MSC02-1670 Building 191, House of Prevention Epidemiology, 1 University of New Mexico, Albuquerque, NM 87131.

Author Contributions: Conception and design: J.J. Kim.

Analysis and interpretation of the data: J.J. Kim, N.G. Campos, S. Sy, E.A. Burger, J. Cuzick, P.E. Castle, W.C. Hunt, C.M. Wheeler.

Drafting of the article: J.J. Kim.

Critical revision of the article for important intellectual content: E.A. Burger, J. Cuzick, P.E. Castle, A. Waxman, C.M. Wheeler.

Final approval of the article: J.J. Kim, N.G. Campos, S. Sy, E.A. Burger, J. Cuzick, P.E. Castle, W.C. Hunt, A. Waxman, C.M. Wheeler.

Provision of study materials or patients: C.M. Wheeler.

Statistical expertise: J.J. Kim, J. Cuzick, W.C. Hunt.

Obtaining of funding: J.J. Kim, P.E. Castle, C.M. Wheeler.

Administrative, technical, or logistic support: S. Sy, E.A. Burger, C.M. Wheeler.

Collection and assembly of data: J.J. Kim, N.G. Campos, S. Sy, W.C. Hunt, C.M. Wheeler.


Ann Intern Med. 2015;163(8):589-597. doi:10.7326/M15-0420
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Background: Studies suggest that cervical cancer screening practice in the United States is inefficient. The cost and health implications of nonadherence in the screening process compared with recommended guidelines are uncertain.

Objective: To estimate the benefits, costs, and cost-effectiveness of current cervical cancer screening practice and assess the value of screening improvements.

Design: Model-based cost-effectiveness analysis.

Data Sources: New Mexico HPV Pap Registry; medical literature.

Target Population: Cohort of women eligible for routine screening.

Time Horizon: Lifetime.

Perspective: Societal.

Intervention: Current cervical cancer screening practice; improved adherence to guidelines-based screening interval, triage testing, diagnostic referrals, and precancer treatment referrals.

Outcome Measures: Reductions in lifetime cervical cancer risk, quality-adjusted life-years (QALYs), lifetime costs, incremental cost-effectiveness ratios, and incremental net monetary benefits (INMBs).

Results of Base-Case Analysis: Current screening practice was associated with lower health benefit and was not cost-effective relative to guidelines-based strategies. Improvements in the screening process were associated with higher QALYs and small changes in costs. Perfect adherence to screening every 3 years with cytologic testing and adherence to colposcopy/biopsy referrals were associated with the highest INMBs ($759 and $741, respectively, at a willingness-to-pay threshold of $100 000 per QALY gained); together, the INMB increased to $1645.

Results of Sensitivity Analysis: Current screening practice was inefficient in 100% of simulations. The rank ordering of screening improvements according to INMBs was stable over a range of screening inputs and willingness-to-pay thresholds.

Limitation: The effect of human papillomavirus vaccination was not considered.

Conclusions: The added health benefit of improving adherence to guidelines, especially the 3-year interval for cytologic screening and diagnostic follow-up, may justify additional investments in interventions to improve U.S. cervical cancer screening practice.

Primary Funding Source: U.S. National Cancer Institute.

Figures

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Appendix Figure 1.

Validation of model-predicted 3-y cumulative risk for CIN2+ (top) and CIN3+ (bottom), by baseline cytologic result in women aged 30 y or older against empirical data (10, 35).

ASC-H = atypical squamous cells, cannot exclude high-grade squamous intraepithelial lesion; ASCUS = atypical squamous cells of undetermined significance; CIN2+ = cervical intraepithelial neoplasia, grade 2 or worse; CIN3+ = cervical intraepithelial neoplasia, grade 3 or worse; HSIL = high-grade squamous intraepithelial lesion; LSIL = low-grade squamous intraepithelial lesion; NMHPVPR = New Mexico HPV Pap Registry; Pap = Papanicolaou.

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Figure.

Health benefits and costs of current and improved cervical cancer screening.

Tradeoff of QALYs (left y-axis) and reductions in lifetime cervical cancer incidence (right y-axis) against lifetime costs (x-axis) for each of the screening scenarios. The circle represents no screening; diamonds represent cytologic testing only; and the triangle represents cytologic testing every 3 years from ages 21 to 29 years, switching to cotesting every 5 years from age 30 years. Green symbols indicate current U.S. guideline–based strategies; the blue square represents current screening practice. Red squares represent scenarios in which screening improvements are assumed (i.e., full adherence to the indicated screening measures); for example, the red square labeled “HPV triage” represents the scenario in which inappropriate HPV triage testing is eliminated from current screening practice. For all scenarios, screening begins at age 21 years and ends at age 65 years. The curve indicates the strategies that are efficient; the incremental cost-effectiveness ratios of strategies on the curve represent the increase in lifetime cost divided by the increase in QALYs compared with the next less-costly strategy. Both QALYs and lifetime costs are discounted at 3% per year. HPV = human papillomavirus; QALY = quality-adjusted life-year.

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Appendix Figure 2.

Effect of screening parameter uncertainty on incremental net monetary benefits at a willingness-to-pay threshold of $100000 per quality-adjusted life-year.

HPV = human papillomavirus.

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Appendix Figure 3.

Comparison of age-specific cervical cancer incidence (top) and mortality (bottom) rates between United States and New Mexico from the Surveillance, Epidemiology, and End Results Program, 2000–2012 (1).

NM = New Mexico; SEER = Surveillance, Epidemiology, and End Results Program.

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