Shepherd Jonathan P, Guido Richard, Lowder Jerry L
Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh Medical Center, Pittsburgh, PA.
J Low Genit Tract Dis. 2014 Apr;18(2):101-8. doi: 10.1097/LGT.0b013e3182a0b572.
Endocervical curettage (ECC) has been used with colposcopy-directed biopsy to increase diagnostic sensitivity for detecting cellular abnormality. Our objective was to determine if routine ECC was cost-effective compared with colposcopy alone in women with atypical squamous cells of undetermined significance or low-grade squamous intraepithelial lesion cervical cytology, who are older and younger than 50 years.
We generated a cost-effectiveness model using outcomes from cervical screening including repeat Pap smears, colposcopy, and loop electrosurgical excision procedure. Cervical cancer costs, survival, as well as incidence and complications after loop electrosurgical excision procedure (preterm birth, cervical stenosis, dysmenorrhea, amenorrhea, and infertility) were modeled. Cost and probability values were obtained from published literature and Medicare databases. Direct medical costs were analyzed in 2011 US dollars. Effectiveness outcomes were cervical cancer deaths and incident cases of cancer prevented. Model robustness was evaluated using probabilistic sensitivity analysis.
For women older than 50 years, routine ECC is the dominant strategy (less expensive and more effective at reducing cervical cancer deaths/incidence). For women younger than 50 years, routine ECC costs $96,737 more per cervical cancer death prevented. Cost per incident cancer case prevented ranged from $21,894 (local spread or greater) to $235,873 (distal spread). Sensitivity analysis confirmed these conclusions. In women older than 50 years, routine ECC was always the most likely cost-effective choice. In women younger than 50, routine ECC was most likely cost-effective for all willingness-to-pay thresholds greater than $80,000 to prevent 1 cancer death.
In women older than 50 years, routine ECC is favored over colposcopy alone because this strategy is cost saving and reduces the number of cancer deaths and incident cancer cases. For women younger than 50 years, cost-effectiveness is dependent on willingness to pay to prevent 1 cancer death but still seems to be cost-effective.
宫颈管搔刮术（ECC）一直与阴道镜引导下活检联合使用，以提高检测细胞异常的诊断敏感性。我们的目的是确定在宫颈细胞学检查显示意义不明确的非典型鳞状细胞或低级别鳞状上皮内病变、年龄大于和小于50岁的女性中，与单纯阴道镜检查相比，常规ECC是否具有成本效益。
我们使用宫颈筛查结果（包括重复巴氏涂片、阴道镜检查和环形电切术）建立了一个成本效益模型。对宫颈癌成本、生存率以及环形电切术后的发病率和并发症（早产、宫颈狭窄、痛经、闭经和不孕）进行了建模。成本和概率值来自已发表的文献和医疗保险数据库。直接医疗成本以2011年美元进行分析。有效性结果为宫颈癌死亡人数和预防的癌症病例数。使用概率敏感性分析评估模型的稳健性。
对于年龄大于50岁的女性，常规ECC是主要策略（成本更低且在降低宫颈癌死亡/发病率方面更有效）。对于年龄小于50岁的女性，每预防一例宫颈癌死亡，常规ECC的成本要高出96,737美元。每预防一例癌症病例的成本从21,894美元（局部扩散或更严重）到235,873美元（远处扩散）不等。敏感性分析证实了这些结论。在年龄大于50岁的女性中，常规ECC始终是最有可能具有成本效益的选择。在年龄小于50岁的女性中，对于所有支付意愿阈值大于80,000美元以预防1例癌症死亡的情况，常规ECC最有可能具有成本效益。
在年龄大于50岁的女性中，常规ECC优于单纯阴道镜检查，因为该策略节省成本并减少了癌症死亡人数和癌症病例数。对于年龄小于50岁的女性，成本效益取决于预防1例癌症死亡的支付意愿，但似乎仍然具有成本效益。
