Overtreatment and Cost-Effectiveness of the See-and-Treat Strategy for Managing Cervical Precancer

Abstract

Background: See-and-treat using loop electrosurgical excision procedure (LEEP) has been recommended as an alternative in managing high-grade cervical squamous intraepithelial lesions, but existing literature lacks evidence of the strategy's cost-effectiveness. We evaluated the overtreatment and cost-effectiveness of the see-and-treat strategy compared with usual care.

Methods: We modeled a hypothetical cohort of 40-year-old females who had not been screened for cervical cancer and followed them through their lifetimes using a Markov model. From a U.S. health-system perspective, the analysis was conducted in 2012 dollars and measured effectiveness in quality-adjusted life-years (QALY). We estimated incremental cost-effectiveness ratios (ICER) using a willingness-to-pay threshold of $50,000/QALY. The robustness of the see-and-treat strategy's cost-effectiveness and its overtreatment rates were further examined in various sensitivity analyses.

Results: In the base-case, the see-and-treat strategy yielded an ICER of $70,774/QALY compared with usual care. For most scenarios in the deterministic sensitivity analysis, this strategy had ICERs larger than $50,000/QALY, and its cost-effectiveness was sensitive to the disutility of LEEP treatment and biopsy-directed treatment adherence under usual care. Probabilistic sensitivity analysis showed that the see-and-treat strategy had a 50.1% chance to be cost-effective. It had an average overtreatment rate of 7.1% and a 78.8% chance to have its overtreatment rate lower than the 10% threshold.

Conclusion: The see-and-treat strategy induced an acceptable overtreatment rate. Its cost-effectiveness, compared with usual care, was indiscriminating at the chosen willingness-to-pay threshold but much improved when the threshold increased.

Impact: The see-and-treat strategy was reasonable for particular settings, that is, those with low treatment adherence. Cancer Epidemiol Biomarkers Prev; 25(5); 807-14. ©2016 AACR.

Figure 1

Cost-effectiveness acceptability curves compared the see-and-treat strategy with usual care. At the given willingness-to-pay threshold of $50,000/QALY, the see-and-treat strategy had 50.1% chance of being cost-effective.

Figure 2

Overtreament acceptablity curve demonstrated the proportion of simulations when the see-and-treat strategy yielded a number of overtreatments below the given threshold. The x-axis showed potential thresholds for overtreatment. The rate of 10% is the standard threshold recommended by the Cochrane Colposcopy and Cervical Cytopathology Collaborative and the U.S. Standards and Quality in Colposcopy (5, 22). The see-and-treat strategy obtained a 78.8% chance to have an overtreatment rate lower than 10%.

Figure 3

Harm-and-benefit tradeoff curve compared the see-and-treat strategy with various proportions of females following the see-and-treat protocol (in parentheses) with usual care. There was a positive relationship between the number of quality-adjusted life years (QALYs) gained and the number of overtreatments in the see-and-treat strategy compared to usual care in a cohort of 10,000 forty-year-old females. Note: 0% represents usual care, and 100% represents the see-and-treat strategy.