Policy analysis of cervical cancer screening strategies in low-resource settings - Clinical benefits and cost-effectiveness

Context Cervical cancer is a leading cause of cancer-related death among wo men in developing countries. In such low-resource settings, cytology-based screening is difficult to implement, and less complex strategies may offer additional options. Objective To assess the cost-effectiveness of several cervical cancer scree ning strategies using population-specific data. Design and Setting Cost-effectiveness analysis using a mathematical model a nd a hypothetical cohort of previously unscreened 30-year-old black South A frican women. Screening tests included direct visual inspection (DVI) of th e cervix, cytologic methods, and testing for high-risk types of human papil lomavirus (HPV) DNA, Strategies differed by number of clinical visits, scre ening frequency, and response to a positive test result. Data sources inclu ded a South African screening study, national surveys and fee schedules, an d published literature. Main Outcome Measures Years of life saved (YLS), lifetime costs in US dolla rs, and incremental cost-effectiveness ratios (cost per YLS). Results When analyzing all strategies performed as a single lifetime screen at age 35 years compared with no screening, HPV testing followed by treatm ent of screen-positive women at a second visit, cost $39/YLS (27% cancer in cidence reduction); DVI, coupled with immediate treatment of screen-positiv e women at the first visit was next most effective (26% cancer incidence re duction) and was cost saving; cytology, followed by treatment of screen-pos itive women at a second visit was least effective (19% cancer incidence red uction) at a cost of $81/YLS, For any given screening frequency, when strat egies were compared incrementally, HPV DNA testing generally was more effec tive but also more costly than DVI, and always was more effective and less costly than cytology. When comparing all strategies simultaneously across s creening frequencies, DVI was the nondominated strategy up to a frequency o f every 3 years (incremental cost-effectiveness ratio, $460/YLS), and HPV t esting every 3 years (incremental cost-effectiveness ratio, $11 500/YLS) wa s the most effective strategy. Conclusion Cervical cancer screening strategies that incorporate DVI or HPV DNA testing and eliminate colposcopy may offer attractive alternatives to cytology-based screening programs in low-resource settings.