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Noncompliance has lessened efficacy of cervical cancer screening
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The current U.S. cervical cancer screening practice appeared associated with a lower health benefit and greater costs than guideline-based strategies, according to results of a model-based cost-effective analysis.
Researchers deemed noncompliance with recommended screening guidelines as the primary reason for the inefficiencies of the current screening practice.
Although cytology-based screening has led to substantial declines in cervical cancer incidence and mortality, previous research has suggested screening rates are variable and management of women with abnormal results is suboptimal.
Jane J. Kim, PhD, associate professor of health decision science in the department of health policy and management at Harvard School of Public Health in Boston, and colleagues sought to estimate benefits, cost and cost-effectiveness of current cervical cancer screening practices, as well as to assess the value of screening improvements.
Researchers evaluated data from the New Mexico HPV Pap Registry and medical literature to calculate reduction in lifetime cervical cancer risk, quality-adjusted life-years (QALYs), lifetime costs, incremental cost-effectiveness ratios and incremental net monetary benefits (INMBs).
Overall, results showed current U.S. screening practices appeared associated with a lower health benefit and cost-effectiveness than guideline-based strategies. Improvements in these screening processes yielded more QALYs and small changes in cost.
Current screening practices conferred a 48.5% reduction in lifetime cervical cancer incidence and a 58.4% reduction in cervical cancer mortality with an ICER of $19,350 per QALY gained. However, guideline-based cytologic screening every 3 years yielded an 80.9% reduction in cervical cancer incidence and an 86.7% reduction in mortality with an ICER of $15,260 per QALY gained. Cotesting every 5 years at age 30 years appeared associated with a greater cancer benefit (incidence reduction, 91.9%; mortality reduction, 93.5%) but greater costs (ICER, $59,440 per QALY gained).
“Our analysis indicates that improvements in current screening practice can generate greater health gains with nominal changes in costs,” Kim and colleagues wrote. “Even without considering any implementation costs of improving adherence, scenarios with higher screening adherence were generally more costly than current screening; however, the added costs were low.”
Results of a sensitivity analysis of 50 calibrated natural history parameter sets showed the scenario of current screening practices remained inefficient in all 50 analyses. However, guideline-based screening appeared efficient at less than $100,000 per QALY gained in all 50 simulations.
Researchers then considered how different improvements would change the efficiency of current screening practice. They observed the highest INMBs with perfect adherence to screening every 3 years with cytologic testing (INMB, $759) and additional adherence to referrals for biopsies or colposcopies (INMB, $741) at a willingness-to-pay threshold of $100,000 per QALY gained. Together, the incremental net monetary benefit increased to $1,645.
Researchers acknowledge that the analysis has several limitations. Data culled from the New Mexico HPV Pap Registry is reliant on the ability of the researchers to be able to perform linkages between cervical cancer screening, diagnosis and treatment reports. Further, these data represent a limited time (2007-2012), causing the researchers to make simplified assumptions regarding screening over a lengthier period.
Also, screening practice in New Mexico may not be generalizable to the rest of the country, even though cancer incidence and mortality in New Mexico mirrors the rest of the United States.
Finally, INMB estimates were generated based on perfect adherence, which may not be realistic.
“Despite these limitations our findings robustly support the notion that there is room for improvement in the current practice of cervical cancer screening,” the researchers wrote. “Multiple breakdowns along the screening pathway contribute to the relatively low health benefit and inefficiency compared with currently recommended strategies.
“Our analysis indicates that we stand to gain the most health benefit by equalizing the screening rate for all eligible women and ensuring complete diagnostic follow-up and that we can make sizeable investments toward these improvements.” – by Anthony SanFilippo
Disclosure: Kim reports grants from the NCI during the study. Please see the full study for a list of all other researchers’ relevant financial disclosures.
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