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After incorporating women’s preferences into a cost-effectiveness analysis, what are the estimated quality of life and economic outcomes associated with cervical cancer screening strategies currently recommended in the United States?
Of 12 strategies evaluated in a cost-effectiveness model, cytologic testing every 3 years for women aged 21 to 29 years with either continued triennial cytologic testing or switching to a low-cost high-risk human papillomavirus test every 5 years from age 30 to 65 years conferred a reasonable balance of benefits, harms, and costs from both a societal and health care sector perspective.
Cytologic testing every 3 years and low-cost high-risk human papillomavirus testing every 5 years both may be considered reasonable cervical cancer screening options for women aged 30 to 65 years.
Many cervical cancer screening strategies are now recommended in the United States, but the benefits, harms, and costs of each option are unclear.
To estimate the cost-effectiveness of 12 cervical cancer screening strategies.
Design, Setting, and Participants
The cross-sectional portion of this study enrolled a convenience sample of 451 English-speaking or Spanish-speaking women aged 21 to 65 years from September 22, 2014, to June 16, 2016, identified at women's health clinics in San Francisco. In this group, utilities (preferences) were measured for 23 cervical cancer screening–associated health states and were applied to a decision model of type-specific high-risk human papillomavirus (hrHPV)–induced cervical carcinogenesis. Test accuracy estimates were abstracted from systematic reviews. The evaluated strategies were cytologic testing every 3 years for women aged 21 to 65 years with either repeat cytologic testing in 1 year or immediate hrHPV triage for atypical squamous cells of undetermined significance (ASC-US), cytologic testing every 3 years for women age 21 to 29 years followed by cytologic testing plus hrHPV testing (cotesting), or primary hrHPV testing alone for women aged 30 to 65 years. Screening frequency, abnormal test result management, and the age to switch from cytologic testing to hrHPV testing (25 or 30 years) were varied. Analyses were conducted from both the societal and health care sector perspectives.
Main Outcomes and Measures
Utilities for 23 cervical cancer screening–associated health states (cross-sectional study) and quality-adjusted life-years (QALYs) and total costs for each strategy.
Utilities were measured in a sociodemographically diverse group of 451 women (mean [SD] age, 38.2 [10.7] years; 258 nonwhite [57.2%]). Cytologic testing every 3 years with repeat cytologic testing for ASC-US yielded the most lifetime QALYs and conferred more QALYs at higher costs ($2166 per QALY) than the lowest-cost strategy (cytologic testing every 3 years with hrHPV triage of ASC-US). All cytologic testing plus hrHPV testing (cotesting) and primary hrHPV testing strategies provided fewer QALYs at higher costs. Adding indirect costs did not change the conclusions. In sensitivity analyses, hrHPV testing every 5 years with genotyping triage beginning at age 30 years was the lowest-cost strategy when hrHPV test sensitivity was markedly higher than cytologic test sensitivity or when hrHPV test cost was equated to the lowest reported cytologic test cost ($14).
Conclusions and Relevance
Cytologic testing every 3 years for women aged 21 to 29 years with either continued cytologic testing every 3 years or switching to a low-cost hrHPV test every 5 years confers a reasonable balance of benefits, harms, and costs. Comparative modeling is needed to confirm the association of these novel utilities with cost-effectiveness.
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Accepted for Publication: March 11, 2019.
Published Online: May 13, 2019. doi:10.1001/jamainternmed.2019.0299
Correction: This article was corrected on June 17, 2019, to fix an error in Table 2.
Corresponding Author: George F. Sawaya, MD, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, 550 16th St, Floor 7, San Francisco, CA 94143 (email@example.com).
Author Contributions: Drs Sawaya and Kulasingam had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Sawaya, Smith-McCune, Gregorich, Silverberg, Kuppermann, Kulasingam.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: Sawaya, Alarid-Escudero, Kuppermann, Kulasingam.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Alarid-Escudero, Leyden.
Obtained funding: Sawaya, Smith-McCune, Gregorich, Kuppermann.
Administrative, technical, or material support: Sawaya, Smith-McCune, Leyden, Kulasingam.
Supervision: Sawaya, Kuppermann.
Conflict of Interest Disclosures: Dr Sawaya reported receiving grants from the National Cancer Institute during the conduct of the study. Dr Smith-McCune reported receiving grants from the National Institutes of Health during the conduct of the study. Dr Gregorich reported receiving grants from the National Institutes of Health/National Cancer Institute during the conduct of the study. Dr Leyden reported receiving grants from the National Cancer Institute during the conduct of the study. Dr. Huchko reported receiving grants from the University of California, San Francisco, Department of Obstetrics/Gynecology during the conduct of the study. Dr Kulasingam reported receiving grants from the National Cancer Institute during the conduct of the study. No other disclosures were reported.
Funding/Support: This work was funded by grant 1R01CA169093 from the US National Cancer Institute.
Role of the Funder/Sponsor: The funding source had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Additional Contributions: Allison O’Leary, MPH, and Melissa Duncanson, BA, University of California, San Francisco, provided research administration assistance. Allison O’Leary, MPH, Mayra Carrillo, BS, Xochilt Borja, BS, and Rachel Freyre, BS, University of California, San Francisco, conducted participant interviews. Michelle Moghadassi, MPH, and Cinthia Blat, PhD, University of California, San Francisco, provided statistical support. Hilary Whitham, PhD, and Ran Zhao, MPH, University of Minnesota, provided modeling assistance. All individuals except Ms Duncanson were compensated for their contributions.
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