Rapid elimination of cervical cancer while maintaining the harms and benefits ratio of cervical cancer screening: a modelling study.

BACKGROUND: Human papillomavirus (HPV) vaccination and intensifying screening expedite cervical cancer (CC) elimination, yet also deteriorate the balance between harms and benefits of screening. We aimed to find screening strategies that eliminate CC rapidly but maintain an acceptable harms-benefits ratio of screening. METHODS: Two microsimulation models (STDSIM and MISCAN) were applied to simulate HPV transmission and CC screening for the Dutch female population between 2022 and 2100. We estimated the CC elimination year and harms-benefits ratios of screening for 228 unique scenarios varying in vaccination (coverage and vaccine type) and screening (coverage and number of lifetime invitations in vaccinated cohorts). The acceptable harms-benefits ratio was defined as the number of women needed to refer (NNR) to prevent one CC death under the current programme for unvaccinated cohorts (82.17). RESULTS: Under current vaccination conditions (bivalent vaccine, 55% coverage in girls, 27.5% coverage in boys), maintaining current screening conditions is projected to eliminate CC by 2042, but increases the present NNR with 41%. Reducing the number of lifetime screens from presently five to three and increasing screening coverage (61% to 70%) would prevent an increase in harms and only delay elimination by 1 year. Scaling vaccination coverage to 90% in boys and girls with the nonavalent vaccine is estimated to eliminate CC by 2040 under current screening conditions, but exceeds the acceptable NNR with 23%. Here, changing from five to two lifetime screens would keep the NNR acceptable without delaying CC elimination. CONCLUSIONS: De-intensifying CC screening in vaccinated cohorts leads to little or no delay in CC elimination while it substantially reduces the harms of screening. Therefore, de-intensifying CC screening in vaccinated cohorts should be considered to ensure acceptable harms-benefits ratios on the road to CC elimination.

The potential of imaging techniques as a screening tool for colorectal cancer: a cost-effectiveness analysis.

OBJECTIVE: Imaging may be promising for colorectal cancer (CRC) screening, since it has test characteristics comparable with colonoscopy but is less invasive. We aimed to assess the potential of CT colonography (CTC) and MR colonography (MRC) in terms of (cost-effectiveness) using the Adenoma and Serrated pathway to Colorectal CAncer model. METHODS: We compared several CTC and MRC strategies with 5- or 10-yearly screening intervals with no screening, 10-yearly colonoscopy screening and biennial faecal immunochemical test (FIT) screening. We assumed trial-based participation rates in the base-case analyses and varied the rates in sensitivity analyses. Incremental lifetime costs and health effects were estimated from a healthcare perspective. RESULTS: The health gain of CTC and MRC was similar and ranged from 0.031 to 0.048 life-year gained compared with no screening, for 2-5 screening rounds. Lifetime costs per person for MRC strategies were €60-110 higher than those for CTC strategies with an equal number of screening rounds. All imaging-based strategies were cost-effective compared with no screening. FIT screening was the dominant screening strategy, leading to most LYG and highest cost-savings. Compared with three rounds of colonoscopy screening, CTC with five rounds was found to be cost-effective in an incremental analysis of imaging strategies. Assumptions on screening participation have a major influence on the ordering of strategies in terms of costs and effects. CONCLUSION: CTC and MRC have potential for CRC screening, compared with no screening and compared with three rounds of 10-yearly colonoscopy screening. When taking FIT screening as the reference, imaging is not cost-effective. Participation is an important driver of effectiveness and cost estimates. ADVANCES IN KNOWLEDGE: This is the first study to assess the cost-effectiveness of MRC screening for CRC.

Cost-effectiveness of cervical cancer prevention in Central and Eastern Europe and Central Asia.

We studied the cost-effectiveness of cervical cancer prevention strategies in the Central and Eastern Europe and Central Asia (CEECA) region. The cost-effectiveness of human papillomavirus (HPV)16/18 vaccination of 12 year-old girls was calculated for 28 countries, under the assumption that vaccination prevents 70% of all cervical cancer cases and that cervical cancer and all-cause mortality rates are stable without vaccination. At three-dose vaccination costs of I$ 100 per vaccinated girl (currency 2005 international dollars), HPV16/18 vaccination was very cost-effective in 25 out of 28 countries using the country's gross domestic product (GDP) per capita as cost-effectiveness threshold (criterion by World Health Organization). A three-dose vaccination cost of I$ 100 is within the current range of vaccine costs in European immunization programs, and therefore our results indicate that HPV vaccination may be good value for money. To evaluate the cost-effectiveness of cervical cancer screening combined with vaccination, we calibrated a published simulation model to HPV genotype data collected in Slovenia, Poland, and Georgia. The screening interval was varied at 3, 6, and 10 years starting at age 25 or 30 and ending at age 60. In Slovenia and Poland, combined vaccination and 10-yearly HPV (DNA) screening (vaccination coverage 70%, screening coverage per round 70%) was very cost-effective when the cost of three-dose vaccination was I$ 100 per vaccinated girl. More intensive screening was very cost-effective when the screening coverage per round was 30% or 50%. In Georgia, 10-yearly Pap screening was very cost-effective in unvaccinated women. Vaccination combined with 10-yearly HPV screening was likely to be cost-effective if the three-dose vaccination cost was I$ 50 per vaccinated girl. To conclude, cervical cancer prevention strategies utilizing both HPV16/18 vaccination and HPV screening are very cost-effective in countries with sufficient resources. In low-resource settings, low vaccine pricing is essential for strategies of combined vaccination and screening to be cost-effective. This article forms part of a regional report entitled "Comprehensive Control of HPV Infections and Related Diseases in the Central and Eastern Europe and Central Asia Region" Vaccine Volume 31, Supplement 7, 2013. Updates of the progress in the field are presented in a separate monograph entitled "Comprehensive Control of HPV Infections and Related Diseases" Vaccine Volume 30, Supplement 5, 2012.