Campos Nicole G, Mvundura Mercy, Jeronimo Jose, Holme Francesca, Vodicka Elisabeth, Kim Jane J
Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA.
PATH, Devices and Tools Program, Seattle, Washington, USA.
BMJ Open. 2017 Jun 15;7(6):e015048. doi: 10.1136/bmjopen-2016-015048.
To evaluate the cost-effectiveness of human papillomavirus (HPV) DNA testing (versus Papanicolaou (Pap)-based screening) for cervical cancer screening in Nicaragua.
A previously developed Monte Carlo simulation model of the natural history of HPV infection and cervical cancer was calibrated to epidemiological data from Nicaragua. Cost data inputs were derived using a micro-costing approach in Carazo, Chontales and Chinandega departments; test performance data were from a demonstration project in Masaya department.
Nicaragua's public health sector facilities.
Women aged 30-59 years.
Screening strategies included (1) Pap testing every 3 years, with referral to colposcopy for women with an atypical squamous cells of undetermined significance or worse result ('Pap'); (2) HPV testing every 5 years, with referral to cryotherapy for HPV-positive eligible women (HPV cryotherapy or 'HPV-Cryo'); (3) HPV testing every 5 years, with referral to triage with visual inspection with acetic acid (VIA) for HPV-positive women ('HPV-VIA'); and (4) HPV testing every 5 years, with referral to Pap testing for HPV-positive women ('HPV-Pap').
Reduction in lifetime risk of cancer and incremental cost-effectiveness ratios (ICER; 2015 US$ per year of life saved (YLS)).
HPV-based screening strategies were more effective than Pap testing. HPV-Cryo was the least costly and most effective strategy, reducing lifetime cancer risk by 29.5% and outperforming HPV-VIA, HPV-Pap and Pap only, which reduced cancer risk by 19.4%, 12.2% and 10.8%, respectively. With an ICER of US$320/YLS, HPV-Cryo every 5 years would be very cost-effective using a threshold based on Nicaragua's per capita gross domestic product of US$2090. Findings were robust across sensitivity analyses on test performance, coverage, compliance and cost parameters.
HPV testing is very cost-effective compared with Pap testing in Nicaragua, due to higher test sensitivity and the relatively lower number of visits required. Increasing compliance with recommended follow-up will further improve the health benefits and value for public health dollars.
评估人乳头瘤病毒（HPV）DNA检测（相对于基于巴氏涂片（Pap）的筛查）用于尼加拉瓜宫颈癌筛查的成本效益。
先前开发的HPV感染和宫颈癌自然史的蒙特卡洛模拟模型根据尼加拉瓜的流行病学数据进行了校准。成本数据输入采用微成本核算方法，来自卡拉佐、琼塔莱斯和奇南德加省；检测性能数据来自马萨亚省的一个示范项目。
尼加拉瓜的公共卫生部门设施。
30 - 59岁的女性。
筛查策略包括：（1）每3年进行一次巴氏检测，对意义不明确的非典型鳞状细胞或更差结果的女性转诊至阴道镜检查（“Pap”）；（2）每5年进行一次HPV检测，对HPV阳性的符合条件女性转诊至冷冻治疗（HPV冷冻治疗或“HPV - Cryo”）；（3）每5年进行一次HPV检测，对HPV阳性女性转诊至用醋酸肉眼检查（VIA）进行分流（“HPV - VIA”）；（4）每5年进行一次HPV检测，对HPV阳性女性转诊至巴氏检测（“HPV - Pap”）。
降低终生患癌风险和增量成本效益比（ICER；每挽救一年生命的2015年美元成本）。
基于HPV的筛查策略比巴氏检测更有效。HPV冷冻治疗是成本最低且最有效的策略，将终生患癌风险降低了29.5%，优于HPV - VIA、HPV - Pap和仅巴氏检测，后三者分别将患癌风险降低了19.4%、12.2%和10.8%。每5年进行一次HPV冷冻治疗的ICER为320美元/年生命挽救，按照基于尼加拉瓜人均国内生产总值2090美元的阈值来看，这将是非常具有成本效益的。在对检测性能、覆盖率、依从性和成本参数的敏感性分析中，研究结果都很稳健。
在尼加拉瓜，与巴氏检测相比，HPV检测具有很高的成本效益，这是由于检测灵敏度更高且所需就诊次数相对较少。提高对推荐随访的依从性将进一步改善健康效益和公共卫生资金的价值。
