Inefficiencies and High-Value Improvements in U.S. Cervical Cancer Screening Practice: A Cost-Effectiveness Analysis

Abstract

Background: Studies suggest that cervical cancer screening practice in the United States is inefficient. The cost and health implications of nonadherence in the screening process compared with recommended guidelines are uncertain.

Objective: To estimate the benefits, costs, and cost-effectiveness of current cervical cancer screening practice and assess the value of screening improvements.

Design: Model-based cost-effectiveness analysis.

Data sources: New Mexico HPV Pap Registry; medical literature.

Target population: Cohort of women eligible for routine screening.

Time horizon: Lifetime.

Perspective: Societal.

Intervention: Current cervical cancer screening practice; improved adherence to guidelines-based screening interval, triage testing, diagnostic referrals, and precancer treatment referrals.

Outcome measures: Reductions in lifetime cervical cancer risk, quality-adjusted life-years (QALYs), lifetime costs, incremental cost-effectiveness ratios, and incremental net monetary benefits (INMBs).

Results of base-case analysis: Current screening practice was associated with lower health benefit and was not cost-effective relative to guidelines-based strategies. Improvements in the screening process were associated with higher QALYs and small changes in costs. Perfect adherence to screening every 3 years with cytologic testing and adherence to colposcopy/biopsy referrals were associated with the highest INMBs ($759 and $741, respectively, at a willingness-to-pay threshold of $100,000 per QALY gained); together, the INMB increased to $1645.

Results of sensitivity analysis: Current screening practice was inefficient in 100% of simulations. The rank ordering of screening improvements according to INMBs was stable over a range of screening inputs and willingness-to-pay thresholds.

Limitation: The effect of human papillomavirus vaccination was not considered.

Conclusions: The added health benefit of improving adherence to guidelines, especially the 3-year interval for cytologic screening and diagnostic follow-up, may justify additional investments in interventions to improve U.S. cervical cancer screening practice.

Primary funding source: U.S. National Cancer Institute.

Figure 1. Health benefits and costs of current and improved cervical cancer screening

The figure displays the tradeoff of quality-adjusted life years (QALYs, left y-axis) and reductions in lifetime cervical cancer incidence (right y-axis) against lifetime costs (x-axis) for each of the screening scenarios. Circle represents no screening; diamonds represent cytology (cyto) only; triangle represents 3-year cytology-only from ages 21–29, switching to 5-year co-testing from age 30 (cotest); green symbols indicate current U.S. guidelines-based strategies; blue square represents current screening practice; red squares represent scenarios in which screening improvements are assumed (i.e., full adherence to the indicated screening parameter(s)); for example, the red square labeled “HPV triage” represents the scenario in which inappropriate human papillomavirus (HPV) triage testing is eliminated from current screening practice. For all scenarios, screening begins at age 21 and ends at age 65. The curve indicates the strategies that are efficient; the incremental cost-effectiveness ratios of strategies on the curve represent the increase in lifetime cost divided by the increase in QALYs compared to the next less-costly strategy. Both QALYs and lifetime costs are discounted at 3% per year.