Scale-up of radiotherapy for cervical cancer in the era of human papillomavirus vaccination in low-income and middle-income countries: a model-based analysis of need and economic impact

Abstract

Background: Radiotherapy is standard of care for cervical cancer, but major global gaps in access exist, particularly in low-income and middle-income countries. We modelled the health and economic benefits of a 20-year radiotherapy scale-up to estimate the long-term demand for treatment in the context of human papillomavirus (HPV) vaccination.

Methods: We applied the Global Task Force on Radiotherapy for Cancer Control investment framework to model the health and economic benefits of scaling up external-beam radiotherapy and brachytherapy for cervical cancer in upper-middle-income, lower-middle-income, and low-income countries between 2015 and 2035. We estimated the unique costs of external-beam radiotherapy and brachytherapy and included a specific valuation of women's caregiving contributions. Model outcomes life-years gained and the human capital and full income net present value of investment. We estimated the effects of stage at diagnosis, radiotherapy delivery system, and simultaneous HPV vaccination (75% coverage) up to a time horizon set at 2072.

Findings: For the period from 2015 to 2035, we estimated that 9·4 million women in low-income and middle-income countries required treatment with external-beam radiotherapy, of which 7·0 million also required treatment with brachytherapy. Incremental scale-up of radiotherapy in these countries from 2015 to meet optimal radiotherapy demand by 2035 yielded 11·4 million life-years gained, $59·3 billion in human capital net present value (-$1·5 billion in low-income, $19·9 billion in lower-middle-income, and $40·9 billion in upper-middle-income countries), and $151·5 billion in full income net present value ($1·5 billion in low-income countries, $53·6 billion in lower-middle-income countries, and $96·4 billion in upper-middle-income countries). Benefits increased with advanced stage of cervical cancer and more efficient scale up of radiotherapy. Bivalent HPV vaccination of 12-year-old girls resulted in a 3·9% reduction in incident cases from 2015-2035. By 2072, when the first vaccinated cohort of girls reaches 70 years of age, vaccination yielded a 22·9% reduction in cervical cancer incidence, with 38·4 million requiring external-beam radiotherapy and 28·8 million requiring brachytherapy.

Interpretation: Effective cervical cancer control requires a comprehensive strategy. Even with HPV vaccination, radiotherapy treatment scale-up remains essential and produces large health benefits and a strong return on investment to countries at different levels of development.

Funding: None.

Figure 1:. Analytical structure

The model inputs box displays the three models in dark blue that served as the core inputs for the GTFRCC radiotherapy investment framework: demand, costing, and survival. The demand and survival models were based on the work of the CCORE, and the costing model was developed in collaboration with the International Atomic Energy Agency. The light blue HPV vaccine scale-up model box identifies how the Papillomavirus Rapid Interface for Modelling and Economics model best case parameters were integrated into the GTFRCC model input structure by modulating the demand model. The dotted lines around the demand and survival boxes represent the model inputs that were varied in our sensitivity analysis on the population distribution of cervical cancer stage at diagnosis. The model outputs included the life years saved and return on investment (human capital and full income net present value). CCORE=Collaboration for Cancer Outcomes Research and Evaluation. GTFRCC=Global Task Force on Radiotherapy for Cancer Control. HPV=human papillomavirus.

Figure 2:. Net present value of radiotherapy scale-up (nominal and efficient scenarios) to universal access for patients with cervical cancer in low-income and middle-income countries, 2015–35

Axes reflect the individual data ranges of each graph and are not uniform. All costs are presented in 2015 US$.

Figure 3:. Effect of universal human papillomavirus vaccination strategy on cervical cancer incidence

Vaccination strategy reflects the implementation of bivalent vaccination of 12-year-old girls beginning in 2014 with 75% coverage. Full assumptions are detailed in the Methods section and in the appendix (pp 9–10). Axes reflect the individual data ranges of each graph and are not uniform.

Figure 4:. Effect of universal human papillomavirus vaccination strategy on demand for external-beam radiotherapy and brachytherapy in low-income and middle-income countries

The columns on each graph represent the total number of cervical cancer cases projected by GLOBOCAN for the periods indicated (2015–35 and 2015–72). The blue portion of each column represents the number of cases estimated to be prevented through implementation of a bivalent vaccination strategy with 75% coverage of 12-year-old girls, beginning in 2014.