Fahs M C, Plichta S B, Mandelblatt J S
Department of Community Medicine, Mount Sinai Medical Center, New York City, New York, USA.
Pharmacoeconomics. 1996 Mar;9(3):211-30. doi: 10.2165/00019053-199609030-00004.
Screening programmes for cervical cancer have been credited with reducing the incidence of and mortality from cervical cancer. The main components of these screening programmes are: (i) their level of organisation; (ii) the age at which women begin screening; (iii) the age at which women discontinue screening; (iv) the interval between repeat screens; (v) the frequency at which the programmes provide screening; and (vi) the response to an abnormal screening test. However, not all screening programmes are equally efficient and differences in programme components can result in big differences in their cost effectiveness. Studies that employ cost-effectiveness analysis (CEA) to examine the efficiency of different programme components can inform the development of cost-effective programmes. This article presents findings of an international review of cost-effectiveness studies of cervical cancer screening. These studies consistently find that certain types of programmes are more cost effective than others. Programmes that are centrally organised and implemented by the public sector are reported to be more cost effective than those that use public funds for screening at other medical visits (convenience screening), or those that provide guidelines 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 screenings 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 important 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 saved is between 3 and 5 years. However, when a choice must be made between screening more women fewer times, or screening fewer women more times, most studies indicate that it is more cost effective to prioritize resources to obtain at least one screening for each woman. The screening of previously unscreened and high-risk populations has been shown to be especially cost effective. Despite this agreement, many studies report that models of the cost effectiveness of screening for cervical cancer are sensitive to a number of parameters. Changes in the attendance rate of the programme, the quality of the Pap smear, and the cost of the Pap smear can markedly change the cost effectiveness of a screening programme. Finally, this review discusses different perspectives of social choice analysis (e.g. CEA and cost-benefit analysis), when the objective is to prevent cervical cancer and the options are to screen, detect and treat, to reduce behavioural risk factors, and/or to pursue promising biological research.
宫颈癌筛查项目被认为降低了宫颈癌的发病率和死亡率。这些筛查项目的主要组成部分包括：（i）组织水平；（ii）女性开始筛查的年龄；（iii）女性停止筛查的年龄；（iv）重复筛查之间的间隔；（v）项目提供筛查的频率；以及（vi）对异常筛查结果的应对措施。然而，并非所有筛查项目都同样有效，项目组成部分的差异可能导致其成本效益存在巨大差异。采用成本效益分析（CEA）来检验不同项目组成部分效率的研究可为具有成本效益的项目的开发提供参考。本文介绍了一项关于宫颈癌筛查成本效益研究的国际综述的结果。这些研究一致发现，某些类型的项目比其他项目更具成本效益。据报道，由公共部门集中组织和实施的项目比那些在其他医疗就诊时使用公共资金进行筛查（便利筛查）的项目，或那些为医疗保健专业人员和公众提供指导以促进自发自愿筛查的项目更具成本效益。对于其他项目组成部分的成本效益也有大量共识。当可以进行多次筛查时，研究报告称，筛查通常应在25至35岁开始，在65至70岁结束，不过重要的是老年女性在停止筛查前要有3次正常的巴氏涂片检查结果。据报道，在成本和挽救的生命年之间提供最佳平衡的重复筛查间隔为3至5年。然而，当必须在对更多女性进行较少次数的筛查或对较少女性进行较多次数的筛查之间做出选择时，大多数研究表明，优先分配资源为每位女性至少进行一次筛查更具成本效益。对以前未筛查过的人群和高危人群进行筛查已被证明特别具有成本效益。尽管存在这些共识，但许多研究报告称，宫颈癌筛查成本效益模型对一些参数很敏感。项目的参与率、巴氏涂片检查的质量以及巴氏涂片检查的成本的变化都可能显著改变筛查项目的成本效益。最后，当目标是预防宫颈癌且选择包括筛查、检测和治疗、降低行为风险因素以及/或者开展有前景的生物学研究时，本综述讨论了社会选择分析的不同视角（例如CEA和成本效益分析）。
