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Adalsteinn D. Brown; Alan M. Garber, MD, PhD

JAMA. 1999;281:347-353.

Context  ThinPrep, AutoPap, and Papnet are 3 new technologies that increase the sensitivity and cost of cervical cancer screening.

Objective  To estimate the cost-effectiveness of these technological enhancements to Papanicolaou (Pap) tests.

Design  We estimated the increase in sensitivity from using these technologies by combining results of 8 studies meeting defined criteria. We used published literature and additional sources for cost estimates. To estimate overall cost-effectiveness, we applied a 9-state time-varying transition state model to these data and information about specific populations.

Setting  A hypothetical program serving a cohort of 20- to 65-year-old women who begin screening at the same age and are representative of the US population.

Results  The new technologies increased life expectancy by 5 hours to 1.6 days, varying with the technology and the frequency of screening. All 3 technologies also increased the cost per woman screened by $30 to $257 (1996 US dollars). AutoPap dominated ThinPrep in the base case. At each screening interval, AutoPap increased survival at the lowest cost. The cost per year of life saved rose from $7777 with quadrennial screening to $166,000 with annual screening. Papnet produced more life-years at a higher cost per year of life saved. However, when used with triennial screening, each of them produced more life-years at lower cost than conventional Pap testing every 2 years. The cost-effectiveness ratio of each technology improved with increases in the prevalence of disease, decreases in the sensitivity of conventional Pap testing, and increases in the improvement in sensitivity produced by the technology.

Conclusions  Technologies to increase the sensitivity of Pap testing are more cost-effective when incorporated into infrequent screening. Increases in sensitivity and decreases in cost may eventually make each technology more cost-effective.

Author Affiliations: Department of Public Health and Primary Care, University of Oxford, Oxford, England (Mr Brown), and Veterans Affairs Palo Alto Health Care System and Center for Primary Care and Outcomes Research, Stanford University School of Medicine, Stanford, Calif (Dr Garber). Mr Brown is now with the Department of Epidemiology and Biostatistics and Department of Family Medicine, University of Western Ontario, London.

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