Kulasingam Shalini L, Myers Evan R
Department of Obstetrics and Gynecology and Center for Clinical Health Policy Research, Duke University, Durham, NC 27705, USA.
JAMA. 2003 Aug 13;290(6):781-9. doi: 10.1001/jama.290.6.781.
Recently published results suggest that effective vaccines against cervical cancer-associated human papillomavirus (HPV) may become available within the next decade.
To examine the potential health and economic effects of an HPV vaccine in a setting of existing screening.
DESIGN, SETTING, AND POPULATION: A Markov model was used to estimate the lifetime (age 12-85 years) costs and life expectancy of a hypothetical cohort of women screened for cervical cancer in the United States. Three strategies were compared: (1) vaccination only; (2) conventional cytological screening only; and (3) vaccination followed by screening. Two of the strategies incorporated a vaccine targeted against a defined proportion of high-risk (oncogenic) HPV types. Screening intervals of 1, 2, 3, and 5 years and starting ages for screening of 18, 22, 24, 26, and 30 years were chosen for 2 of the strategies (conventional cytological screening only and vaccination followed by screening).
Incremental cost per life-year gained.
Vaccination only or adding vaccination to screening conducted every 3 and 5 years was not cost-effective. However, at more frequent screening intervals, strategies combining vaccination and screening were preferred. Vaccination plus biennial screening delayed until age 24 years had the most attractive cost-effectiveness ratio (44 889 dollars) compared with screening only beginning at age 18 years and conducted every 3 years. However, the strategy of vaccination with annual screening beginning at age 18 years had the largest overall reduction in cancer incidence and mortality at a cost of 236 250 dollars per life-year gained compared with vaccination and annual screening beginning at age 22 years. The cost-effectiveness of vaccination plus delayed screening was highly sensitive to age of vaccination, duration of vaccine efficacy, and cost of vaccination.
Vaccination for HPV in combination with screening can be a cost-effective health intervention, but it depends on maintaining effectiveness during the ages of peak oncogenic HPV incidence. Identifying the optimal age for vaccination should be a top research priority.
最近公布的结果表明，在未来十年内可能会有针对宫颈癌相关人乳头瘤病毒（HPV）的有效疫苗。
研究在现有筛查背景下HPV疫苗的潜在健康和经济影响。
设计、地点和人群：采用马尔可夫模型估计美国一个假设的宫颈癌筛查女性队列的终生（12至85岁）成本和预期寿命。比较了三种策略：（1）仅接种疫苗；（2）仅进行传统细胞学筛查；（3）接种疫苗后进行筛查。其中两种策略采用了针对特定比例高危（致癌）HPV类型的疫苗。为其中两种策略（仅传统细胞学筛查和接种疫苗后进行筛查）选择了1、2、3和5年的筛查间隔以及18、22、24、26和30岁的筛查起始年龄。
每获得一个生命年的增量成本。
仅接种疫苗或在每3年和5年进行的筛查中增加接种疫苗不具有成本效益。然而，在更频繁的筛查间隔下，结合接种疫苗和筛查的策略更受青睐。与仅从18岁开始每3年进行一次筛查相比，接种疫苗加每两年一次筛查并推迟到24岁的成本效益比最具吸引力（44889美元）。然而，从18岁开始每年进行筛查的接种疫苗策略在癌症发病率和死亡率方面的总体降低幅度最大，每获得一个生命年的成本为236250美元，而从22岁开始进行接种疫苗和每年筛查。接种疫苗加延迟筛查的成本效益对疫苗接种年龄、疫苗效力持续时间和疫苗接种成本高度敏感。
HPV疫苗接种与筛查相结合可以是一种具有成本效益的健康干预措施，但这取决于在致癌HPV发病率高峰期保持有效性。确定最佳疫苗接种年龄应是首要研究重点。
