COST-EFFECTIVE POLICIES FOR CERVICAL-CANCER SCREENING - AN INTERNATIONAL REVIEW

Screening programmes for cervical cancer have been credited with reduc ing the incidence of and mortality from cervical cancer. The main comp onents of these screening programmes are: (i) their level of organisat ion; (ii) the age at which women begin screening; (iii) the age at whi ch women discontinue screening; (iv) the interval between repeat scree ns; (v) the frequency at which the programmes provide screening; and ( vi) the response to an abnormal screening test. However, not all scree ning programmes are equally efficient and differences in programme com ponents can result in big differences in their cost effectiveness. Stu dies that employ cost-effectiveness analysis (CEA) to examine the effi ciency of different programme components can inform the development of cost-effective programmes. This article presents findings of an inter national review of cost-effectiveness studies of cervical cancer scree ning. These studies consistently find that certain types of programmes are more cost effective than others. Programmes that are centrally or ganised and implemented by the public sector are reported to be more c ost effective than those that use public funds for screening at other medical visits (convenience screening), or those that provide guidelin es for healthcare professionals and the public to promote spontaneous discretionary screening. There is also substantial agreement about the cost effectiveness of other programme components. When multiple scree nings are possible, studies report that they should generally begin at age 25 to 35 years and end at age 65 to 70 years, although it is impo rtant that older women have 3 normal Papanicolaou (Pap) smears before the discontinuation of screening, The interval for repeat screens that is reported to provide the best balance between cost and life-years s aved is between 3 and 5 years. However, when a choice must be made bet ween screening more women fewer times, or screening fewer women more t imes, most studies indicate that it is more cost effective to prioriti se resources to obtain at least one screening for each woman. The scre ening of previously unscreened and high-risk populations has been show n to be especially cost effective. Despite this agreement, many studie s report that models of the cost effectiveness of scorning for cervica l cancer are sensitive to a number of parameters. Changes in the atten dance rate of the programme, the quality of the Pap smear, and the cos t of the Pap smear can markedly change the cost effectiveness of a scr eening programme. Finally, this review discusses different perspective s of social choice analysis (e.g. CEA and cost-benefit analysis), when the objective is to prevent cervical cancer and the options are to sc reen, detect and treat, to reduce behavioural risk factors, and/or to pursue promising biological research.