Cost-effectiveness analysis of human papillomavirus DNA testing and Pap smear for cervical cancer screening in a publicly financed health-care system

Abstract

Objective: to evaluate the long-term cost-effectiveness of different strategies for human papillomavirus (HPV) DNA testing combined with Pap smear for cervical cancer screening in Taiwan.

Methods: this study adopts a perspective of Department of Health in cost-effectiveness analysis to compare a no-screening strategy with nine different screening strategies. These strategies comprise three screening tools (Pap smear alone, HPV DNA testing followed by Pap smear triage, and HPV DNA testing combined with Pap smear), and three screening intervals (annually, every 3 years, and every 5 years). Outcomes are life expectancy, quality-adjusted life years (QALYs), lifetime costs, and incremental cost-effectiveness ratios (ICERs). Probabilistic sensitivity analyses (PSAs) were conducted to assess parameter uncertainty.

Results: when three times gross domestic product per capita is used as the decision threshold, all nine screening strategies were cost-effective compared with the no-screening strategy. Compared with the current screening strategy (an annual Pap smear), HPV DNA testing followed by Pap smear triage every 5 years and every 3 years were cost-effective. Results of PSA also indicated that a HPV DNA testing followed by Pap smear triage every 5 or every 3 years achieved the highest expected net benefits.

Conclusions: possible economic advantages are associated with extending the cervical cancer screening interval from one Pap smear annually to HPV DNA testing followed by Pap smear triage every 5 years with an ICER $1 247 000 per QALY gained, especially in a country with a publicly financed health-care system.

Figure 1

Screening decision tree showing different screening tests at three screening intervals and follow-up management.

Figure 2

Base-case efficiency frontier depicting costs and QALYs for cervical cancer screening strategies. The 1-year (30%), 3-year (60%), and 5-year coverage rates (75%) were assumed those who underwent at least one Pap smear during a 1-, 3-, or 5-year period.

Figure 3

Sensitivity analysis efficiency frontier depicting costs and QALYs for cervical cancer screening strategy. Screening coverage rate was assumed 100% for all screening intervals.

Figure 4

Cost-effectiveness acceptability frontier curves.