Vaccinating women previously treated for human papillomavirus-related cervical precancerous lesions is highly cost-effective in China

Abstract

Background: The 2021 Chinese Expert Consensus on the Clinical Application of the Human Papillomavirus (HPV) Vaccine recommended vaccination for women who previously received ablative or excisional treatment for high-grade squamous intraepithelial lesion (HSIL). This study evaluates the cost-effectiveness of HPV vaccination in women previously treated for cervical precancerous lesions.

Methods: We used a Markov model to simulate the disease progression of both low- and high-risk HPV subtypes. We followed a cohort of 100,000 women aged 18-45 years who received treatment for cervical precancerous lesions for a lifetime (80 years). We used the Incremental Cost-Effectiveness Ratios (ICER) with a 5% discount rate to measure the cost-effectiveness of nine vaccination strategies, including a combination of HPV bivalent (HPV-2), quadrivalent (HPV-4) and nonavalent vaccine (HPV-9), each with three vaccination doses (one-, two- and three-dose). We conducted one-way sensitivity analysis and probabilistic sensitivity analysis. We followed the CHEERS 2022 guidelines.

Results: Compared to the status quo, the nine vaccination strategies would result in $3.057-33.124 million incremental cost and 94-1,211 incremental quality-adjusted life-years (QALYs) in 100,000 women previously treated for cervical precancerous lesions. Three vaccination strategies were identified on the cost-effectiveness frontier. In particular, ICER for one-dose HPV-4 vaccination was US$10,025/QALY compared to the status quo (no vaccination); ICER for two-dose HPV-4 vaccination was US$17,641//QALY gained compared to one-dose HPV-4 vaccination; ICER for three-dose HPV-4 vaccination was US$27,785/QALY gained compared with two-dose HPV-4 vaccination. With a willingness-to-pay of three times gross domestic product per capita (US$37655), three-dose HPV-4 vaccination was the most cost-effective vaccination strategy compared with the lower-cost non-dominated strategy on the cost-effectiveness frontier. A probabilistic sensitivity analysis confirmed a 99.1% probability of being cost-effective. If the cost of the HPV-9 is reduced to 50% of the current price, three-dose HPV-9 vaccination would become the most cost-effective strategy.

Discussion: Three-dose HPV-4 vaccination is the most cost-effective vaccination strategy for women treated for precancerous cervical lesions in the Chinese setting.

Keywords: HPV vaccination; cervical precancerous lesions; health economics (cost-effectiveness analysis); healthcare provider; women.

Figure 1

Markov model of the natural history of low and high risk type of HPV. HPV, human papillomavirus; CIN, cervical intraepithelial neoplasia; LR-HPV(+): HPV6/11 only, no other low-risk HPV infections considered; HPV-16/18(+): infected with HPV-16 alone, with HPV-18 alone or with both HPV-16 and 18; HPV-31/33/45/52/58(+): HPV-31, HPV33, HPV45, HPV52 or HPV58 alone, or co-infection with two or more of these five types of HPV; Other HR-HPV(+): Infection with high-risk HPV types other than HPV16, HPV18, HPV-31, HPV33, HPV45, HPV52 or HPV58.

Figure 2

Cost-effectiveness frontier for nine vaccination strategies (100000 cohort members). QALYs, quality-adjusted life years, GDP, gross domestic product, HPV-2: HPV bivalent vaccine, HPV-4, HPV quadrivalent vaccine, HPV-9, HPV nonavalent vaccine.

Figure 3

Cost-effectiveness acceptability curves for all strategies. QALYs, quality-adjusted life years, GDP, gross domestic product, HPV-2: HPV bivalent vaccine, HPV-4, HPV quadrivalent vaccine, HPV-9, HPV nonavalent vaccine.