Goldhaber-Fiebert Jeremy D, Stout Natasha K, Salomon Joshua A, Kuntz Karen M, Goldie Sue J
Doctoral Program in Health Policy, Decision Science Concentration, Harvard University, Cambridge, MA, USA.
J Natl Cancer Inst. 2008 Mar 5;100(5):308-20. doi: 10.1093/jnci/djn019. Epub 2008 Feb 26.
The availability of human papillomavirus (HPV) DNA testing and vaccination against HPV types 16 and 18 (HPV-16,18) motivates questions about the cost-effectiveness of cervical cancer prevention in the United States for unvaccinated older women and for girls eligible for vaccination.
An empirically calibrated model was used to assess the quality-adjusted life years (QALYs), lifetime costs, and incremental cost-effectiveness ratios (2004 US dollars per QALY) of screening, vaccination of preadolescent girls, and vaccination combined with screening. Screening varied by initiation age (18, 21, or 25 years), interval (every 1, 2, 3, or 5 years), and test (HPV DNA testing of cervical specimens or cytologic evaluation of cervical cells with a Pap test). Testing strategies included: 1) cytology followed by HPV DNA testing for equivocal cytologic results (cytology with HPV test triage); 2) HPV DNA testing followed by cytology for positive HPV DNA results (HPV test with cytology triage); and 3) combined HPV DNA testing and cytology. Strategies were permitted to switch once at age 25, 30, or 35 years.
For unvaccinated women, triennial cytology with HPV test triage, beginning by age 21 years and switching to HPV testing with cytology triage at age 30 years, cost $78,000 per QALY compared with the next best strategy. For girls vaccinated before age 12 years, this same strategy, beginning at age 25 years and switching at age 35 years, cost $41,000 per QALY with screening every 5 years and $188,000 per QALY screening triennially, each compared with the next best strategy. These strategies were more effective and cost-effective than screening women of all ages with cytology alone or cytology with HPV triage annually or biennially.
For both vaccinated and unvaccinated women, age-based screening by use of HPV DNA testing as a triage test for equivocal results in younger women and as a primary screening test in older women is expected to be more cost-effective than current screening recommendations.
人乳头瘤病毒（HPV）DNA检测的可及性以及针对16型和18型HPV（HPV-16,18）的疫苗接种引发了关于美国未接种疫苗的老年女性以及符合疫苗接种条件的女孩预防宫颈癌成本效益的问题。
使用经验校准模型评估筛查、青春期前女孩接种疫苗以及接种疫苗与筛查相结合的质量调整生命年（QALY）、终身成本和增量成本效益比（每QALY的2004年美元）。筛查因起始年龄（18、21或25岁）、间隔时间（每1、2、3或5年）和检测方法（宫颈标本的HPV DNA检测或巴氏试验对宫颈细胞进行细胞学评估）而异。检测策略包括：1）细胞学检查，对于可疑细胞学结果进行HPV DNA检测（细胞学检查加HPV检测分流）；2）HPV DNA检测结果为阳性时进行细胞学检查（HPV检测加细胞学分流）；3）HPV DNA检测与细胞学检查相结合。策略允许在25、30或35岁时切换一次。
对于未接种疫苗的女性，从21岁开始每三年进行一次细胞学检查并进行HPV检测分流，在30岁时切换为HPV检测加细胞学分流，与次优策略相比，每QALY成本为78,000美元。对于12岁前接种疫苗的女孩，同样的策略，从25岁开始，在35岁时切换，每5年筛查一次时每QALY成本为41,000美元，每三年筛查一次时每QALY成本为188,000美元，与次优策略相比。这些策略比仅对所有年龄段女性进行年度或两年一次的细胞学筛查或细胞学加HPV分流筛查更有效且更具成本效益。
对于接种疫苗和未接种疫苗的女性，使用HPV DNA检测作为年轻女性可疑结果的分流检测以及老年女性的主要筛查检测的基于年龄的筛查预计比当前的筛查建议更具成本效益。
