Sharma Monisha, Seoud Muhieddine, Kim Jane J
University of Washington, Department of Epidemiology, 1959 NE Pacific Street, Seattle, WA 98195, USA.
Department of Obstetrics and Gynecology, Gynecologic Oncology, American University of Beirut, Beirut, Lebanon.
Vaccine. 2017 Jan 23;35(4):564-569. doi: 10.1016/j.vaccine.2016.12.015. Epub 2016 Dec 22.
Most cervical cancer (CC) cases in Lebanon are detected at later stages and associated with high mortality. There is no national organized CC screening program so screening is opportunistic and limited to women who can pay out-of-pocket. Therefore, a small percentage of women receive repeated screenings while most are under-or never screened. We evaluated the cost-effectiveness of increasing screening coverage and extending intervals.
We used an individual-based Monte Carlo model simulating HPV and CC natural history and screening. We calibrated the model to epidemiological data from Lebanon, including CC incidence and HPV type distribution. We evaluated cytology and HPV DNA screening for women aged 25-65years, varying coverage from 20 to 70% and frequency from 1 to 5years.
At 20% coverage, annual cytologic screening reduced lifetime CC risk by 14% and had an incremental cost-effectiveness ratio of I$80,670/year of life saved (YLS), far exceeding Lebanon's gross domestic product (GDP) per capita (I$17,460), a commonly cited cost-effectiveness threshold. By comparison, increasing cytologic screening coverage to 50% and extending screening intervals to 3 and 5years provided greater CC reduction (26.1% and 21.4, respectively) at lower costs compared to 20% coverage with annual screening. Screening every 5years with HPV DNA testing at 50% coverage provided greater CC reductions than cytology at the same frequency (23.4%) and was cost-effective assuming a cost of I$18 per HPV test administered (I$12,210/YLS); HPV DNA testing every 4years at 50% coverage was also cost-effective at the same cost per test (I$16,340). Increasing coverage of annual cytology was not found to be cost-effective.
Current practice of repeated cytology in a small percentage of women is inefficient. Increasing coverage to 50% with extended screening intervals provides greater health benefits at a reasonable cost and can more equitably distribute health gains. Novel HPV DNA strategies offer greater CC reductions and may be more cost-effective than cytology.
黎巴嫩的大多数宫颈癌（CC）病例在晚期才被发现，且死亡率很高。该国没有全国性的有组织的CC筛查项目，因此筛查是机会性的，仅限于能够自掏腰包的女性。所以，只有一小部分女性接受重复筛查，而大多数女性筛查不足或从未接受过筛查。我们评估了提高筛查覆盖率和延长筛查间隔的成本效益。
我们使用了一个基于个体的蒙特卡洛模型来模拟HPV和CC的自然史及筛查情况。我们根据黎巴嫩的流行病学数据对模型进行校准，包括CC发病率和HPV类型分布。我们评估了25至65岁女性的细胞学和HPV DNA筛查，覆盖率从20%到70%不等，筛查频率从1年到5年不等。
在20%的覆盖率下，每年进行细胞学筛查可将终身CC风险降低14%，每挽救一年生命（YLS）的增量成本效益比为80,670美元，远远超过黎巴嫩的人均国内生产总值（17,460美元），这是一个常用的成本效益阈值。相比之下，将细胞学筛查覆盖率提高到50%，并将筛查间隔延长至3年和5年，与每年20%覆盖率的筛查相比，能以更低的成本更大程度地降低CC风险（分别为26.1%和21.4%）。在50%的覆盖率下每5年进行一次HPV DNA检测，与相同频率的细胞学筛查相比，能更大程度地降低CC风险（23.4%），并且在每次HPV检测成本为18美元的情况下具有成本效益（每YLS为12,210美元）；在50%的覆盖率下每4年进行一次HPV DNA检测，在相同的每次检测成本下也具有成本效益（每YLS为16,340美元）。增加每年细胞学筛查的覆盖率未发现具有成本效益。
目前一小部分女性重复进行细胞学检查的做法效率低下。将覆盖率提高到50%并延长筛查间隔能以合理成本带来更大的健康益处，并能更公平地分配健康收益。新型HPV DNA策略能更大程度地降低CC风险，可能比细胞学检查更具成本效益。
