International Journal of Technology Assessment in Health Care

GENERAL ESSAYS

Cost-effectiveness of primarily human papillomavirus–based cervical cancer screening in settings with currently established Pap screening: A systematic review commissioned by the German Federal Ministry of Health

Nikolai Mühlbergera1, Gaby Sroczynskia1, Eva Estebana1, Thomas Mittendorfa2, Rebecca A. Miksada3 and Uwe Sieberta4

a1 UMIT—University for Health Sciences, Medical Informatics and Technology

a2 Leibniz University Hannover

a3 Beth Israel Deaconess Medical Center and Massachusetts General Hospital

a4 UMIT—University of Health, Sciences, Medical Informatics and Technology and Harvard Medical School

Abstract

Objectives: The aim of this study was to summarize the current evidence for the cost-effectiveness of primarily human papillomavirus (HPV) -based cervical cancer screening in settings with already established Papanicolaou test (Pap) programs. Emphasis was placed on the German situation with annual Pap screening.

Methods: Medical, economic, and health technology assessment (HTA) databases were systematically searched for cost-effectiveness studies comparing HPV to Pap screening. Study data were extracted, standardized, and summarized in cost-effectiveness plots contrasting HPV strategies to Pap screening with 1-, 2-, 3-, and 5-years interval. For each Pap setting, the likelihood of cost-effective HPV screening was assessed depending on willingness-to-pay.

Results: We reviewed twelve decision-analytic cost-effectiveness models. Study results showed wide variation due to methodical heterogeneity. Data synthesis revealed that the cost-effectiveness of HPV screening depends on the interval of the established Pap screening strategy. In comparison with Pap screening every 2 years, only 25 percent of the HPV-based screening strategies were cost-effective. However, in comparison with Pap screening every 1, 3, or 5 years, 83 percent, 55 percent, and 92 percent of HPV screening strategies were cost-effective, respectively. Results for settings with annual Pap screening are based on models assuming 100 percent screening coverage.

Conclusions: The introduction of HPV-based screening programs is cost-effective if the screening interval of the established Pap program exceeds 2 years. In settings with biennial Pap screening, introduction of HPV-based screening is unlikely to be cost-effective. Results also suggest cost-effectiveness of HPV-based screening in settings with annual Pap screening; however, this finding should be confirmed under realistic screening adherence assumptions.

Footnotes

This study was commissioned and in part funded by the German Agency for Health Technology Assessment at the German Institute of Medical Documentation and Information (DAHTA@DIMDI), a subsidiary of the German Federal Ministry of Health. U. Siebert, G. Sroczynski, and T. Mittendorf received funding for health technology assessments related to cervical cancer screening commissioned by the German Agency for Health Technology Assessment at the German Institute of Medical Documentation and Information (DAHTA@DIMDI), a subsidiary of the German Federal Ministry of Health [Grant nos. H 1044/3 and No. 08/05]. N. Mühlberger, U. Siebert, G. Sroczynski and E. Esteban received an independent educational research grant by Digene Corp (manufacturer of HPV test assays) to evaluate the cost-effectiveness of HPV screening. R. Miksad was supported in part by R25 CA92203 (Program in Cancer Outcomes Research Training) from the National Institutes of Health. Funding organizations or sponsors had no role in design and conduct of the study; collection, management, analysis, and interpretation of the data; or preparation, review, or approval of the manuscript. The underlying health technology assessment report was reviewed by the German Agency for Health Technology Assessment at the German Institute of Medical Documentation and Information (DAHTA@DIMDI).