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Shalini L. Kulasingam, PhD; Evan R. Myers, MD, MPH

JAMA. 2003;290:781-789.

Context  Recently published results suggest that effective vaccines against cervical cancer—associated human papillomavirus (HPV) may become available within the next decade.

Objective  To examine the potential health and economic effects of an HPV vaccine in a setting of existing screening.

Design, Setting, and Population  A Markov model was used to estimate the lifetime (age 12-85 years) costs and life expectancy of a hypothetical cohort of women screened for cervical cancer in the United States. Three strategies were compared: (1) vaccination only; (2) conventional cytological screening only; and (3) vaccination followed by screening. Two of the strategies incorporated a vaccine targeted against a defined proportion of high-risk (oncogenic) HPV types. Screening intervals of 1, 2, 3, and 5 years and starting ages for screening of 18, 22, 24, 26, and 30 years were chosen for 2 of the strategies (conventional cytological screening only and vaccination followed by screening).

Main Outcome Measures  Incremental cost per life-year gained.

Results  Vaccination only or adding vaccination to screening conducted every 3 and 5 years was not cost-effective. However, at more frequent screening intervals, strategies combining vaccination and screening were preferred. Vaccination plus biennial screening delayed until age 24 years had the most attractive cost-effectiveness ratio ($44 889) compared with screening only beginning at age 18 years and conducted every 3 years. However, the strategy of vaccination with annual screening beginning at age 18 years had the largest overall reduction in cancer incidence and mortality at a cost of $236 250 per life-year gained compared with vaccination and annual screening beginning at age 22 years. The cost-effectiveness of vaccination plus delayed screening was highly sensitive to age of vaccination, duration of vaccine efficacy, and cost of vaccination.

Conclusions  Vaccination for HPV in combination with screening can be a cost-effective health intervention, but it depends on maintaining effectiveness during the ages of peak oncogenic HPV incidence. Identifying the optimal age for vaccination should be a top research priority.

Author Affiliation: Department of Obstetrics and Gynecology and Center for Clinical Health Policy Research, Duke University, Durham, NC.

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