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Benefits and Costs of Using HPV Testing to Screen for Cervical Cancer
Jeanne S. Mandelblatt, MD,MPH;
William F. Lawrence, MD,MSc;
Sharita Mizell Womack, PhD;
Denise Jacobson, PhD;
Bin Yi, MS;
Yi-ting Hwang, PhD;
Karen Gold, PhD;
James Barter, MD;
Keerti Shah, MD,PhD
JAMA. 2002;287:2372-2381.
Context Despite quality assurance standards, Papanicolaou (Pap) test characteristics remain less than optimal.
Objective To compare the societal costs and benefits of human papillomavirus (HPV) testing, Pap testing, and their combination to screen for cervical cancer.
Design, Setting, and Population A simulation model of neoplasia natural history was used to estimate the societal costs and quality-adjusted life expectancy associated with 18 different general population screening strategies: Pap plus HPV testing, Pap testing alone, and HPV testing alone every 2 or 3 years among hypothetical longitudinal cohorts of US women beginning at age 20 years and continuing to 65 years, 75 years, or death.
Main Outcome Measure Discounted costs per quality-adjusted life-year (QALY) saved of each screening strategy.
Results Maximal savings in lives were achieved by screening every 2 years until death with combined HPV and Pap testing at an incremental cost of $76 183 per QALY compared with Pap testing alone every 2 years. Stopping biennial screening with HPV and Pap testing at age 75 years captures 97.8% of the benefits of lifetime screening at a cost of $70 347 per QALY. Combined biennial HPV and Pap testing to age 65 years captures 86.6% of the benefits achievable by continuing to screen until age 75 years. Human papillomavirus screening alone was equally effective as Pap testing alone at any given screening interval or age of screening cessation but was more costly and therefore was dominated. In sensitivity analyses, HPV testing would be more effective and less costly than Pap testing at a cost threshold of $5 for an HPV test.
Conclusions Screening with HPV plus Pap tests every 2 years appears to save additional years of life at reasonable costs compared with Pap testing alone. Applying age limits to screening is a viable option to maintain benefits while reducing costs.
Author Affiliations: Departments of Oncology (Drs Mandelblatt, Lawrence, and Hwang and Mr Yi), Medicine (Drs Mandelblatt and Lawrence), and Obstetrics & Gynecology (Dr Barter), Georgetown University Medical Center and Clinical and Economic Outcomes Core, Lombardi Cancer Center, Washington, DC; Department of Social and Preventive Medicine, State University of New York at Buffalo and Department of Cancer Prevention, Epidemiology and Biostatistics, Roswell Park Cancer Institute, Buffalo, NY (Dr Womack); Department of Community Health/Family Medicine, Tufts University School of Medicine, Boston, Mass (Dr Jacobson); Department of Biomathematics and Biostatistics, Georgetown University School of Medicine, Washington, DC (Dr Gold); and Department of Microbiology, Johns Hopkins School of Medicine and School of Public Health, Baltimore, Md (Dr Shah). Dr Gold is now with Abt Associates, Bethesda, Md.
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