The clinical effectiveness and cost-effectiveness of primary human papillomavirus cervical screening in England: extended follow-up of the ARTISTIC randomised trial cohort through three screening rounds

INTRODUCTION:The cost-effectiveness of Human papillomavirus (HPV)-based primary cervical screening in the Irish healthcare setting is assessed using a decision-analysis approach to inform a decision around changes to the national screening program. Current practices comprises primary screening with liquid-based cytology (LBC) followed by HPV triage, at 3-yearly intervals for ages 25 to 45 years and 5-yearly until age 60 years.METHODS:This study assessed changing the primary screening test from LBC to HPV testing, in both an unvaccinated and a vaccinated (against HPV 16/18) cohort. It considered extending the screening interval (to 5-yearly for all), the upper age limit (from 60 to 65 years) and different test sequences (four possible tests were included: HPV, LBC, partial genotyping for HPV16 or HPV 18 and the molecular biomarker p16INK4a/Ki67). A Markov-model for HPV-infection and cervical cancer was developed based on a German cervical screening model (1). The perspective of the healthcare system was adopted and a 5 percent discount rate used.RESULTS:Strategies using HPV as the primary screening test are more effective than LBC-based strategies. The optimal strategy, at a willingness-to-pay threshold of EUR45,000 per quality-adjusted life year (QALY), for the unvaccinated cohort was HPV-based primary screening with a LBC triage test, at five-yearly intervals from age 25 to 60 years. This strategy is cost saving compared with current practice and cost effective when compared to no screening, with an Incremental cost-effectiveness ratio (ICER) of EUR18,164 per QALY. The optimal strategy for the vaccinated cohort was also HPV primary screening with a LBC triage test, at five-yearly intervals from age 25 to 60 years. While more effective and cost saving compared with current practice, it would not be considered cost effective compared with no screening (ICER of EUR58,745/QALY).CONCLUSIONS:Based on our analyses, HPV-based cervical screening is more effective and cost saving compared with LBC-based screening for both vaccinated and unvaccinated cohorts in an Irish setting.

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Baseline Human Papillomavirus Status of Women With Abnormal Smears in Cervical Screening: A 5-Year Follow-up Study in the Netherlands

Obstetrical & Gynecological Survey ◽

10.1097/01.ogx.0000291683.58373.68 ◽

2007 ◽

Vol 62 (12) ◽

pp. 783-784

Author(s):

C F.M. Prinsen ◽

R Fles ◽

C W. Wijnen-Dubbers ◽

H A. de Valk ◽

C H.W. Klaassen ◽

...

Keyword(s):

Human Papillomavirus ◽

The Netherlands ◽

Cervical Screening ◽

Follow Up Study ◽

Status Of Women

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Comparative clinical effectiveness and cost effectiveness of endovascular strategy v open repair for ruptured abdominal aortic aneurysm: three year results of the IMPROVE randomised trial

BMJ ◽

10.1136/bmj.j4859 ◽

2017 ◽

pp. j4859 ◽

Cited By ~ 36

Author(s):

Keyword(s):

Abdominal Aortic Aneurysm ◽

Cost Effectiveness ◽

Aortic Aneurysm ◽

Open Repair ◽

Randomised Trial ◽

Clinical Effectiveness ◽

Ruptured Abdominal Aortic Aneurysm ◽

Abdominal Aortic

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Individualised screening for diabetic retinopathy: the ISDR study—rationale, design and methodology for a randomised controlled trial comparing annual and individualised risk-based variable-interval screening

BMJ Open ◽

10.1136/bmjopen-2018-025788 ◽

2019 ◽

Vol 9 (6) ◽

pp. e025788 ◽

Cited By ~ 9

Author(s):

Deborah M Broadbent ◽

Christopher J Sampson ◽

Amu Wang ◽

Lola Howard ◽

Abigail E Williams ◽

...

Keyword(s):

Diabetic Retinopathy ◽

Cost Effectiveness ◽

Randomised Controlled Trial ◽

Screening Programme ◽

Controlled Trial ◽

Randomised Trial ◽

Variable Interval ◽

Randomised Controlled ◽

The Uk

IntroductionCurrently, all people with diabetes (PWD) aged 12 years and over in the UK are invited for screening for diabetic retinopathy (DR) annually. Resources are not increasing despite a 5% increase in the numbers of PWD nationwide each year. We describe the rationale, design and methodology for a randomised controlled trial (RCT) evaluating the safety, acceptability and cost-effectiveness of personalised variable-interval risk-based screening for DR. This is the first randomised trial of personalised screening for DR and the largest ophthalmic RCT in the UK.Methods and analysisPWD attending seven screening clinics in the Liverpool Diabetic Eye Screening Programme were recruited into a single site RCT with a 1:1 allocation to individualised risk-based variable-interval or annual screening intervals. A risk calculation engine developed for the trial estimates the probability that an individual will develop referable disease (screen positive DR) within the next 6, 12 or 24 months using demographic, retinopathy and systemic risk factor data from primary care and screening programme records. Dynamic, secure, real-time data connections have been developed. The primary outcome is attendance for follow-up screening. We will test for equivalence in attendance rates between the two arms. Secondary outcomes are rates and severity of DR, visual outcomes, cost-effectiveness and health-related quality of life. The required sample size was 4460 PWD. Recruitment is complete, and the trial is in follow-up.Ethics and disseminationEthical approval was obtained from National Research Ethics Service Committee North West – Preston, reference 14/NW/0034. Results will be presented at international meetings and published in peer-reviewed journals. This pragmatic RCT will inform screening policy in the UK and elsewhere.Trial registration numberISRCTN87561257; Pre-results.

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Clinical impact and cost-effectiveness of primary cytology versus human papillomavirus testing for cervical cancer screening in England

International Journal of Gynecological Cancer ◽

10.1136/ijgc-2018-000161 ◽

2019 ◽

Vol 29 (4) ◽

pp. 669-675

Author(s):

Irenjeet Bains ◽

Yoon Hong Choi ◽

Kate Soldan ◽

Mark Jit

Keyword(s):

Cervical Cancer ◽

Human Papillomavirus ◽

Cost Effectiveness ◽

Cancer Screening ◽

Cervical Cancer Screening ◽

Cervical Screening ◽

Clinical Impact ◽

Hpv Testing ◽

Life Years ◽

The Impact

ObjectivesIn England, human papillomavirus (HPV) testing is to replace cytological screening by 2019–2020. We conducted a model-based economic evaluation to project the long-term clinical impact and cost-effectiveness of routine cytology versus HPV testing.MethodsAn individual-based model of HPV acquisition, natural history, and cervical cancer screening was used to compare cytological screening and HPV testing with cytology triage for women aged 25–64 years (with either 3- or 5-year screening intervals for women aged under 50 years). The model was fitted to data from England's National Health Service Cervical Screening Programme. Both clinical and economic outcomes were projected to inform cost-effectiveness analyses.ResultsHPV testing is likely to decrease annual cytology testing (by 2.76 million), cervical cancer incidence (by 290 cases), and health system costs (by £13 million). It may increase the number of colposcopies, although this could be reduced without leading to more cancers compared with primary cytology by increasing the interval between screens to 5 years. The impact in terms of quality-adjusted life-years (QALYs) depends on the quality of life weight given to colposcopies versus cancer.ConclusionsEngland's move from cytology to HPV screening may potentially be life-saving and cost-effective. Cost-effectiveness can be improved further by extending the interval between screens or using alternative triage methods such as partial or full genotyping.

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Promising strategies for cervical cancer screening in the post-human papillomavirus vaccination era

Sexual Health ◽

10.1071/sh10022 ◽

2010 ◽

Vol 7 (3) ◽

pp. 376 ◽

Cited By ~ 20

Author(s):

Joseph Tota ◽

Salaheddin M. Mahmud ◽

Alex Ferenczy ◽

François Coutlée ◽

Eduardo L. Franco

Keyword(s):

Cervical Cancer ◽

Human Papillomavirus ◽

Human Error ◽

Pap Smear ◽

Cervical Screening ◽

Screening Tests ◽

Hpv Testing ◽

Human Papillomavirus Vaccination ◽

Screening Programs

Human papillomavirus (HPV) vaccination is expected to reduce the burden of cervical cancer in most settings; however, it is also expected to interfere with the effectiveness of screening. In the future, maintaining Pap cytology as the primary cervical screening test may become too costly. As the prevalence of cervical dysplasias decreases, the positive predictive value of the Pap test will also decrease, and, as a result, more women will be referred for unnecessary diagnostic procedures and follow-up. HPV DNA testing has recently emerged as the most likely candidate to replace cytology for primary screening. It is less prone to human error and much more sensitive than the Pap smear in detecting high-grade cervical lesions. Incorporating this test would improve the overall quality of screening programs and allow spacing out screening tests, while maintaining safety and lowering costs. Although HPV testing is less specific than Pap cytology, this issue could be resolved by reserving the latter for the more labour-efficient task of triaging HPV-positive cases. Because most HPV-positive smears would contain relevant abnormalities, Pap cytology would be expected to perform with sufficient accuracy under these circumstances. HPV Pap triage would also provide a low-cost strategy to monitor long-term vaccine efficacy. Although demonstration projects could start implementing HPV testing as a population screening tool, more research is needed to determine the optimal age to initiate screening, the role of HPV typing and other markers of disease progression, and appropriate follow-up algorithms for HPV-positive and Pap-negative women.

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