Shen Mingwang, Zou Zhuoru, Bao Heling, Fairley Christopher K, Canfell Karen, Ong Jason J, Hocking Jane, Chow Eric P F, Zhuang Guihua, Wang Linhong, Zhang Lei
China-Australia Joint Research Center for Infectious Diseases, School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, Shaanxi 710061, China.
Key Laboratory for Disease Prevention and Control and Health Promotion of Shaanxi Province, Xi'an, Shaanxi 710061, China.
Lancet Reg Health West Pac. 2023 Mar 3;34:100726. doi: 10.1016/j.lanwpc.2023.100726. eCollection 2023 May.
The 2021 World Health Organization (WHO) guidelines for cervical cancer screening recommend human papillomavirus (HPV) DNA or mRNA testing. Artificial intelligence (AI)-assisted liquid-based cytology (LBC) systems also have the potential to facilitate rapid scale-up of cervical cancer screening. We aimed to evaluate the cost-effectiveness of AI-assisted LBC testing, compared with the manual LBC and HPV-DNA testing, for primary cervical cancer screening in China.
We developed a Markov model for a cohort of 100,000 women aged 30 years over a lifetime to simulate the natural history of cervical cancer progression. We evaluated the incremental cost-effectiveness ratios (ICER) of 18 screening strategies (a combination of the three screening methods with six screening frequencies) from a healthcare provider's perspective. The willingness-to-pay threshold (US$30,828) was chosen as three times the Chinese per-capita gross domestic product in 2019. Univariate and probabilistic sensitivity analyses were performed to examine the robustness of the results.
Compared with no screening, all 18 screening strategies were cost-effective, with an ICER of $622-24,482 per quality-adjusted life-year (QALY) gained. If HPV testing after scaling up to population level screening costs $10.80 or more, screening once every 5 years using AI-assisted LBC would be the most cost-effective strategy with an ICER of $8790/QALY gained compared with the lower-cost non-dominated strategy on the cost-effectiveness frontier. Its probability of being cost-effective was higher (55.4%) than other strategies. Sensitivity analyses showed that the most cost-effective strategy would become AI-assisted LBC testing once every 3 years if the sensitivity (74.1%) and specificity (95.6%) of this method were both reduced by ≥10%. The most cost-effective strategy would become HPV-DNA testing once every 5 years if the cost of AI-assisted LBC was more expensive than manual LBC or if the HPV-DNA test cost is slightly reduced (from $10.8 to <$9.4).
AI-assisted LBC screening once every 5 years could be more cost-effective than manually-read LBC. Using AI-assisted LBC could have comparable cost-effectiveness to HPV DNA screening, but the relative pricing of HPV DNA testing is critical in this result.
National Natural Science Foundation of China, National Key R&D Program of China.
世界卫生组织（WHO）2021年宫颈癌筛查指南推荐进行人乳头瘤病毒（HPV）DNA或mRNA检测。人工智能（AI）辅助的液基细胞学（LBC）系统也有潜力促进宫颈癌筛查的快速推广。我们旨在评估在中国进行原发性宫颈癌筛查时，与手动LBC和HPV-DNA检测相比，AI辅助LBC检测的成本效益。
我们建立了一个马尔可夫模型，用于模拟100,000名30岁女性一生中宫颈癌进展的自然史。我们从医疗服务提供者的角度评估了18种筛查策略（三种筛查方法与六种筛查频率的组合）的增量成本效益比（ICER）。支付意愿阈值（30,828美元）被设定为2019年中国人均国内生产总值的三倍。进行单因素和概率敏感性分析以检验结果的稳健性。
与不进行筛查相比，所有18种筛查策略都具有成本效益，每获得一个质量调整生命年（QALY）的ICER为622美元至24,482美元。如果扩大到人群水平筛查后的HPV检测成本为10.80美元或更高，那么每5年使用AI辅助LBC进行一次筛查将是最具成本效益的策略，与成本效益前沿上成本较低的非劣势策略相比，每获得一个QALY的ICER为8790美元。其具有成本效益的概率（55.4%）高于其他策略。敏感性分析表明，如果该方法的敏感性（74.1%）和特异性（95.6%）均降低≥10%，则最具成本效益的策略将变为每3年进行一次AI辅助LBC检测。如果AI辅助LBC的成本高于手动LBC，或者HPV-DNA检测成本略有降低（从10.8美元降至<9.4美元），则最具成本效益的策略将变为每5年进行一次HPV-DNA检测。
每5年进行一次AI辅助LBC筛查可能比手动读取的LBC更具成本效益。使用AI辅助LBC可能与HPV DNA筛查具有相当的成本效益，但HPV DNA检测的相对定价对这一结果至关重要。
中国国家自然科学基金、中国国家重点研发计划。
