Cost-effectiveness of the screen-and-treat strategies using HPV test linked to thermal ablation for cervical cancer prevention in China: a modeling study

Abstract

Background: Self-sampling HPV test and thermal ablation are effective tools to increase screening coverage and treatment compliance for accelerating cervical cancer elimination. We assessed the cost-effectiveness of their combined strategies to inform accessible, affordable, and acceptable cervical cancer prevention strategies.

Methods: We developed a hybrid model to evaluate costs, health outcomes, and incremental cost-effectiveness ratios (ICER) of six screen-and-treat strategies combining HPV testing (self-sampling or physician-sampling), triage modalities (HPV genotyping, colposcopy or none) and thermal ablation, from a societal perspective. A designated initial cohort of 100,000 females born in 2015 was considered. Strategies with an ICER less than the Chinese gross domestic product (GDP) per capita ($10,350) were considered highly cost-effective.

Results: Compared with current strategies in China (physician-HPV with genotype or cytology triage), all screen-and-treat strategies are cost-effective and self-HPV without triage is optimal with the most incremental quality-adjusted life-years (QALYs) gained (220 to 440) in rural and urban China. Each screen-and-treat strategy based on self-collected samples is cost-saving compared with current strategies (-$818,430 to -$3540) whereas more costs are incurred using physician-collected samples compared with current physician-HPV with genotype triage (+$20,840 to +$182,840). For screen-and-treat strategies without triage, more costs (+$9404 to +$380,217) would be invested in the screening and treatment of precancerous lesions rather than the cancer treatment compared with the current screening strategies. Notably, however, more than 81.6% of HPV-positive women would be overtreated. If triaged with HPV 7 types or HPV16/18 genotypes, 79.1% or 67.2% (respectively) of HPV-positive women would be overtreated with fewer cancer cases avoided (19 cases or 69 cases).

Conclusions: Screen-and-treat strategy using self-sampling HPV test linked to thermal ablation could be the most cost-effective for cervical cancer prevention in China. Additional triage with quality-assured performance could reduce overtreatment and remains highly cost-effective compared with current strategies.

Keywords: Cervical cancer; Cost-effectiveness; HPV test; Screen and treat; Thermal ablation.

Fig. 1

Cost-effectiveness analysis for all screen-and-treat strategies versus the currently used strategies. HPV, human papillomavirus; QALY, quality-adjusted life-years; phy, physician; ICER, incremental cost-effectiveness ratio

Fig. 2

Discounted costs of each cervical screening strategy over the lifetime, broken down by component. Note: Solid bars represent rural areas, and shaded bars represent urban areas. HPV, human papillomavirus; CIN, cervical intraepithelial neoplasia; phy, physician

Fig. 3

Overtreatment rates and harm-and-benefit tradeoff for each screen-and-treat strategy. HPV, human papillomavirus; CIN, cervical intraepithelial neoplasia; phy, physician

Fig. 4

Cost-effectiveness acceptability curves for all screen-and-treat strategies. HPV, human papillomavirus; GDP, gross domestic product; phy, physician

Fig. 5

Tornado diagram analysis for optimal strategy (self-HPV without triage) versus traditional strategy (physician-HPV with cytology) in China. QALY, quality-adjusted life-years; TA, thermal ablation; CIN, cervical intraepithelial neoplasia; LEEP, loop electrosurgical excision procedure; phy, physician