Primary screening for human papillomavirus compared with cytology screening for cervical cancer in European settings: cost effectiveness analysis based on a Dutch microsimulation modelBMJ 2012; 344 doi: https://doi.org/10.1136/bmj.e670 (Published 05 March 2012) Cite this as: BMJ 2012;344:e670
- Inge M C M de Kok, postdoctoral researcher1,
- Joost van Rosmalen, postdoctoral researcher1,
- Joakim Dillner, professor of infectious disease epidemiology2,
- Marc Arbyn, head of unit3,
- Peter Sasieni, professor of biostatistics and cancer epidemiology4,
- Thomas Iftner, professor of biostatistics and cancer epidemiology5,
- Marjolein van Ballegooijen, associate professor of epidemiology1
- 1Erasmus MC, University Medical Center, Department of Public Health, PO Box 2040, 3000 CA Rotterdam, Netherlands
- 2Department of Laboratory Medicine, Lund University, Malmö University Hospital, Malmö, Sweden
- 3Unit of Cancer Epidemiology, Scientific Institute of Public Health, Brussels, Belgium
- 4Cancer Research UK Centre for Epidemiology, Mathematics and Statistics, Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, UK
- 5Institute for Medical Virology, University Hospital Tuebingen, Tuebingen, Germany
- Correspondence to: I M C M de Kok
- Accepted 14 November 2011
Objectives To investigate, using a Dutch model, whether and under what variables framed for other European countries screening for human papillomavirus (HPV) is preferred over cytology screening for cervical cancer, and to calculate the preferred number of examinations over a woman’s lifetime.
Design Cost effectiveness analysis based on a Dutch simulation model. Base case analyses investigated the cost effectiveness of more than 1500 different screening policies using the microsimulation model. Subsequently, the policies were compared for five different scenarios that represent different possible scenarios (risk of cervical cancer, previous screening, quality associated test characteristics, costs of testing, and prevalence of HPV).
Setting Various European countries.
Population Unvaccinated women born between 1939 and 1992.
Main outcome measures Optimal screening strategy in terms of incremental cost effectiveness ratios (costs per quality adjusted life years gained) compared with different cost effectiveness thresholds, for two levels of sensitivity and costs of the HPV test.
Results Primary HPV screening was the preferred primary test over the age of 30 in many considered scenarios. Primary cytology screening was preferred only in scenarios with low costs of cytology and in scenarios with a high prevalence of HPV in combination with high costs of HPV testing.
Conclusions Most European countries should consider switching from primary cytology to HPV screening for cervical cancer. HPV screening must, however, only be implemented in situations where screening is well controlled.
Contributors: IMCMdK and JvR did the analyses. TI is the principal investigator of the total EU project. MvB is the principal investigator of this specific research project. All authors contributed to writing the manuscript. IMCMdK and MvB are the guarantors.
Funding: This study was supported by a grant from the European Union, European Union Biomed 5 contract HPV-based cervical cancer screening (QLG4-CT2000-01238). It was partly supported by a grant from the Dutch National Institute for Public Health and the Environment (RIVM, grant No 019/09 pDG/NvdV/EMG). PS was supported by a Cancer Research UK programme grant (C8162/A10406). The study sponsor had no role in the design of the study; the collection, analysis, or interpretation of the data; the writing of the manuscript; or the decision to submit the manuscript for publication.
Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf and declare: IMCMdK, MvB, and JvR were supported by the European Union and the Dutch National Institute for Public Health and the Environment, MA was supported by the European Union and the Belgian Foundation against Cancer, and JD was supported by the European Union; IMCMdK and MvB have received a grant from GlaxoSmithKline that might have an interest in the submitted work in the previous three years; MA has received a grant from the University of Gent that might have an interest in the submitted work in the previous three years; TI has received money for consultancy from Siemens Healthcare, grants from Roche, Hologic, and Gen-Probe, payment for lectures including service on speakers bureaus from with Hologic, Gen-Probe, Roche Diagnostics, Sanofi Pasteur MSD, Siemens Healthcare Diagnostics, GlaxoSmithKline, Qiagen, and Greiner BioOne, and patents from Greiner BioOne, that might have an interest in the submitted work in the previous three years; PS has received a grant from the Cancer Research UK programme, money for consultancy from Gen-Probe, and travel/accommodations/meeting expenses from GlaxoSmithKline that might have an interest in the submitted work in the previous three years; JD has received a grant from Merck/Sanofi Pasteur MSD that might have an interest in the submitted work in the previous three years; and no other relationships or activities that could appear to have influenced the submitted work.
Ethical approval: Not required.
Data sharing: Model inputs, technical details, and more extensive or intermediate results are available from the corresponding author at email@example.com. Extra material supplied by the author is also available at http://hdl.handle.net/1765/31582: graphic representation of screening strategies; efficient frontier of scenario of high risk with no past screening and low sensitivity, specificity, and cost of cytology for primary cytology and primary HPV screening; description of MISCAN-cervix model; and calculation tool.
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