Should the age range of the Dutch hrHPV-based cervical cancer screening program be broadened? A modelling study using cohort effects

Abstract

In the Netherlands, women are invited for human papillomavirus (HPV) screening between the ages of 30 and 60 (with conditional screening at age 65). However, an increase in cervical cancer (CC) incidence has been observed in younger women recently. Meanwhile, HPV-vaccinated cohorts reached the screening age of 30 in 2023. Moreover, increasing healthy life expectancy is a consideration for screening in older age groups. Due to these developments, the starting and ending ages of the HPV screening programs should be reconsidered. Microsimulation model MISCAN-Cervix was recalibrated for cohort effects using updated CC incidence data. We used this model to calculate the cost-effectiveness of screening unvaccinated women in birth cohorts 1962-1992 until 65 years old. Additionally, we considered starting screening at 25 for partly vaccinated cohorts (born in 2002-2006). Vaccination effects were calculated using microsimulation model STDSIM. Main outcome measures included cancers prevented, life years gained (LYG), costs, and referrals compared to the current strategy (2027 onwards). Adding screening at age 65 to the current strategy leads to +3.5% cancers prevented, +10.3% referrals, +2.4% LYG and +57.0% costs (cost-effectiveness ratio: €275,096/LYG). Adding screening at age 25 results in extra cases prevented (+1.3%-5.7%, depending on the target group's vaccination status) and LYG (+0.8%-3.7%), but increases referrals (12.9%-37.1%) and costs (+14.0%-33.1%) (cost-effectiveness ratio: €120,017-€323,813/LYG). So, screening unvaccinated women at 65 years old and screening women in (partly-)vaccinated cohorts at age 25 might not represent good value for money.

Keywords: HPV vaccination; age range; cohort effects; hrHPV‐based screening; simulation model.

FIGURE 1

Cancer incidence as an average over 5 years for birth cohorts 1978–1982, 1983–1987, 1988–1992, and 1993+. The black data points are national cancer registry data with corresponding 95% confidence intervals. Blue and red lines are model outcomes before and after recalibration, respectively. CC, cervical cancer.

FIGURE 2

(Undiscounted) harms and benefits for unvaccinated cohorts (A) and partly vaccinated cohorts (B) compared to a situation without screening. *Women are additionally screened at age 65 if they tested HPV‐positive at age 60 and were not referred to a gynecologist.