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1.
Lancet ; 395(10224): 575-590, 2020 02 22.
Artigo em Inglês | MEDLINE | ID: mdl-32007141

RESUMO

BACKGROUND: The WHO Director-General has issued a call for action to eliminate cervical cancer as a public health problem. To help inform global efforts, we modelled potential human papillomavirus (HPV) vaccination and cervical screening scenarios in low-income and lower-middle-income countries (LMICs) to examine the feasibility and timing of elimination at different thresholds, and to estimate the number of cervical cancer cases averted on the path to elimination. METHODS: The WHO Cervical Cancer Elimination Modelling Consortium (CCEMC), which consists of three independent transmission-dynamic models identified by WHO according to predefined criteria, projected reductions in cervical cancer incidence over time in 78 LMICs for three standardised base-case scenarios: girls-only vaccination; girls-only vaccination and once-lifetime screening; and girls-only vaccination and twice-lifetime screening. Girls were vaccinated at age 9 years (with a catch-up to age 14 years), assuming 90% coverage and 100% lifetime protection against HPV types 16, 18, 31, 33, 45, 52, and 58. Cervical screening involved HPV testing once or twice per lifetime at ages 35 years and 45 years, with uptake increasing from 45% (2023) to 90% (2045 onwards). The elimination thresholds examined were an average age-standardised cervical cancer incidence of four or fewer cases per 100 000 women-years and ten or fewer cases per 100 000 women-years, and an 85% or greater reduction in incidence. Sensitivity analyses were done, varying vaccination and screening strategies and assumptions. We summarised results using the median (range) of model predictions. FINDINGS: Girls-only HPV vaccination was predicted to reduce the median age-standardised cervical cancer incidence in LMICs from 19·8 (range 19·4-19·8) to 2·1 (2·0-2·6) cases per 100 000 women-years over the next century (89·4% [86·2-90·1] reduction), and to avert 61·0 million (60·5-63·0) cases during this period. Adding twice-lifetime screening reduced the incidence to 0·7 (0·6-1·6) cases per 100 000 women-years (96·7% [91·3-96·7] reduction) and averted an extra 12·1 million (9·5-13·7) cases. Girls-only vaccination was predicted to result in elimination in 60% (58-65) of LMICs based on the threshold of four or fewer cases per 100 000 women-years, in 99% (89-100) of LMICs based on the threshold of ten or fewer cases per 100 000 women-years, and in 87% (37-99) of LMICs based on the 85% or greater reduction threshold. When adding twice-lifetime screening, 100% (71-100) of LMICs reached elimination for all three thresholds. In regions in which all countries can achieve cervical cancer elimination with girls-only vaccination, elimination could occur between 2059 and 2102, depending on the threshold and region. Introducing twice-lifetime screening accelerated elimination by 11-31 years. Long-term vaccine protection was required for elimination. INTERPRETATION: Predictions were consistent across our three models and suggest that high HPV vaccination coverage of girls can lead to cervical cancer elimination in most LMICs by the end of the century. Screening with high uptake will expedite reductions and will be necessary to eliminate cervical cancer in countries with the highest burden. FUNDING: WHO, UNDP, UN Population Fund, UNICEF-WHO-World Bank Special Program of Research, Development and Research Training in Human Reproduction, Canadian Institute of Health Research, Fonds de recherche du Québec-Santé, Compute Canada, National Health and Medical Research Council Australia Centre for Research Excellence in Cervical Cancer Control.


Assuntos
Infecções por Papillomavirus/prevenção & controle , Vacinas contra Papillomavirus , Neoplasias do Colo do Útero/prevenção & controle , Adulto , Países em Desenvolvimento , Detecção Precoce de Câncer/métodos , Estudos de Viabilidade , Feminino , Humanos , Incidência , Renda , Programas de Rastreamento/métodos , Modelos Biológicos , Infecções por Papillomavirus/complicações , Neoplasias do Colo do Útero/diagnóstico , Neoplasias do Colo do Útero/epidemiologia , Neoplasias do Colo do Útero/virologia , Vacinação
2.
Lancet ; 395(10224): 591-603, 2020 02 22.
Artigo em Inglês | MEDLINE | ID: mdl-32007142

RESUMO

BACKGROUND: WHO is developing a global strategy towards eliminating cervical cancer as a public health problem, which proposes an elimination threshold of four cases per 100 000 women and includes 2030 triple-intervention coverage targets for scale-up of human papillomavirus (HPV) vaccination to 90%, twice-lifetime cervical screening to 70%, and treatment of pre-invasive lesions and invasive cancer to 90%. We assessed the impact of achieving the 90-70-90 triple-intervention targets on cervical cancer mortality and deaths averted over the next century. We also assessed the potential for the elimination initiative to support target 3.4 of the UN Sustainable Development Goals (SDGs)-a one-third reduction in premature mortality from non-communicable diseases by 2030. METHODS: The WHO Cervical Cancer Elimination Modelling Consortium (CCEMC) involves three independent, dynamic models of HPV infection, cervical carcinogenesis, screening, and precancer and invasive cancer treatment. Reductions in age-standardised rates of cervical cancer mortality in 78 low-income and lower-middle-income countries (LMICs) were estimated for three core scenarios: girls-only vaccination at age 9 years with catch-up for girls aged 10-14 years; girls-only vaccination plus once-lifetime screening and cancer treatment scale-up; and girls-only vaccination plus twice-lifetime screening and cancer treatment scale-up. Vaccination was assumed to provide 100% lifetime protection against infections with HPV types 16, 18, 31, 33, 45, 52, and 58, and to scale up to 90% coverage in 2020. Cervical screening involved HPV testing at age 35 years, or at ages 35 years and 45 years, with scale-up to 45% coverage by 2023, 70% by 2030, and 90% by 2045, and we assumed that 50% of women with invasive cervical cancer would receive appropriate surgery, radiotherapy, and chemotherapy by 2023, which would increase to 90% by 2030. We summarised results using the median (range) of model predictions. FINDINGS: In 2020, the estimated cervical cancer mortality rate across all 78 LMICs was 13·2 (range 12·9-14·1) per 100 000 women. Compared to the status quo, by 2030, vaccination alone would have minimal impact on cervical cancer mortality, leading to a 0·1% (0·1-0·5) reduction, but additionally scaling up twice-lifetime screening and cancer treatment would reduce mortality by 34·2% (23·3-37·8), averting 300 000 (300 000-400 000) deaths by 2030 (with similar results for once-lifetime screening). By 2070, scaling up vaccination alone would reduce mortality by 61·7% (61·4-66·1), averting 4·8 million (4·1-4·8) deaths. By 2070, additionally scaling up screening and cancer treatment would reduce mortality by 88·9% (84·0-89·3), averting 13·3 million (13·1-13·6) deaths (with once-lifetime screening), or by 92·3% (88·4-93·0), averting 14·6 million (14·1-14·6) deaths (with twice-lifetime screening). By 2120, vaccination alone would reduce mortality by 89·5% (86·6-89·9), averting 45·8 million (44·7-46·4) deaths. By 2120, additionally scaling up screening and cancer treatment would reduce mortality by 97·9% (95·0-98·0), averting 60·8 million (60·2-61·2) deaths (with once-lifetime screening), or by 98·6% (96·5-98·6), averting 62·6 million (62·1-62·8) deaths (with twice-lifetime screening). With the WHO triple-intervention strategy, over the next 10 years, about half (48% [45-55]) of deaths averted would be in sub-Saharan Africa and almost a third (32% [29-34]) would be in South Asia; over the next 100 years, almost 90% of deaths averted would be in these regions. For premature deaths (age 30-69 years), the WHO triple-intervention strategy would result in rate reductions of 33·9% (24·4-37·9) by 2030, 96·2% (94·3-96·8) by 2070, and 98·6% (96·9-98·8) by 2120. INTERPRETATION: These findings emphasise the importance of acting immediately on three fronts to scale up vaccination, screening, and treatment for pre-invasive and invasive cervical cancer. In the next 10 years, a one-third reduction in the rate of premature mortality from cervical cancer in LMICs is possible, contributing to the realisation of the 2030 UN SDGs. Over the next century, successful implementation of the WHO elimination strategy would reduce cervical cancer mortality by almost 99% and save more than 62 million women's lives. FUNDING: WHO, UNDP, UN Population Fund, UNICEF-WHO-World Bank Special Program of Research, Development and Research Training in Human Reproduction, Germany Federal Ministry of Health, National Health and Medical Research Council Australia, Centre for Research Excellence in Cervical Cancer Control, Canadian Institute of Health Research, Compute Canada, and Fonds de recherche du Québec-Santé.


Assuntos
Neoplasias do Colo do Útero/mortalidade , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Criança , Pré-Escolar , Países em Desenvolvimento , Detecção Precoce de Câncer/métodos , Feminino , Humanos , Renda , Lactente , Recém-Nascido , Programas de Rastreamento/métodos , Pessoa de Meia-Idade , Modelos Biológicos , Mortalidade/tendências , Infecções por Papillomavirus/complicações , Infecções por Papillomavirus/prevenção & controle , Vacinas contra Papillomavirus , Neoplasias do Colo do Útero/diagnóstico , Neoplasias do Colo do Útero/prevenção & controle , Neoplasias do Colo do Útero/virologia , Vacinação/métodos , Organização Mundial da Saúde , Adulto Jovem
3.
Lancet Public Health ; 2020 Feb 10.
Artigo em Inglês | MEDLINE | ID: mdl-32057315

RESUMO

BACKGROUND: In May, 2018, the Director-General of WHO issued a global call to eliminate cervical cancer as a public health problem, which will involve ambitious screening and vaccination coverage targets. We aimed to assess the potential for, and timing of, cervical cancer elimination in the USA and whether this could be expedited by adopting ambitious coverage targets, using two cervical cancer simulation models. METHODS: In this modelling study, we used two independently-developed cervical cancer microsimulation models-Harvard and Policy1-Cervix-to estimate changes in the incidence of human papillomavirus (HPV)-induced cervical cancer over time in the USA, including herd effects from vaccination. We compared nine alternative scenarios for prophylactic HPV vaccination and cervical screening scale-up with a status quo scenario that involved no additional interventions in the context of a threshold for cervical cancer elimination of four or fewer cases per 100 000 women-years. We also estimated the number of cervical cancer cases that could be averted between 2019 and 2100 associated with the adoption of ambitious goals for cervical cancer screening and vaccination coverage, and other potential strategies. FINDINGS: Under status quo assumptions, the Havard and Policy1-Cervix models projected that cervical cancer incidence would decrease to less than four or fewer new cases per 100 000 women-years by the 2038 and 2046, respectively. Scaling up screening coverage to 90% in 2020, was the most effective intervention to expedite time to elimination (10-13-year reduction), averting a mean of 1400-2088 additional cases annually between 2019 and 2100. Increasing HPV vaccination coverage to 90% or vaccinating adults aged 26-45 years had relatively little effect on cervical cancer incidence. Sensitivity analysis using different population structures resulted in differences in time to elimination (range -10 years to +27 years) compared with status quo predictions. INTERPRETATION: The USA is on track to eliminate cervical cancer as a public health problem in the next two to three decades. Time to elimination could be expedited by 10-13 years by achieving higher screening coverage. Targeting of underscreened and under-vaccinated women remains key to achieving cervical cancer elimination for all women. FUNDING: US National Cancer Institute.

4.
Cancer Epidemiol Biomarkers Prev ; 29(1): 22-30, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31666282

RESUMO

BACKGROUND: Data to inform evidence-based policy of human papillomavirus (HPV) vaccine delivery strategies in low- and middle-income countries are limited. We examined the cost-effectiveness of campaign compared with routine delivery strategies of adolescent female HPV vaccination in Uganda. METHODS: We used a multiple modeling approach that captured HPV transmission, cervical carcinogenesis, and population demographics to project health and economic outcomes associated with HPV vaccination. Costs included vaccination and operational costs and cervical cancer costs over the lifetimes of the current female population in Uganda. Health outcomes included number of cervical cancer cases and disability-adjusted life years (DALY). Incremental cost-effectiveness ratios (i.e., cost per DALY averted) were calculated and compared against gross domestic product (GDP) per capita. RESULTS: Compared with routine HPV vaccination of 9-year-old girls at 70% coverage, campaign vaccination yielded greater health benefits if campaigns occurred frequently and targeted a wide age range. Campaign delivery strategies were both less costly and more effective than routine HPV vaccination. Campaign vaccination of 9- to 30-year-old girls/women at a 3-year frequency (40% coverage) was considered cost-effective compared with the GDP per capita threshold for Uganda ($674 in U.S. 2015 dollars). CONCLUSIONS: We projected that campaign HPV vaccination would provide substantial population health benefits compared with routine vaccination. Expanding the target age range of campaign vaccination up to age 30 years may be an efficient strategy, depending on the achievable coverage level and campaign frequency. IMPACT: In settings where routine health systems infrastructure may be limited, reaching adolescent populations with a campaign delivery strategy may be an efficient use of resources.

5.
J Natl Cancer Inst ; 2019 Dec 10.
Artigo em Inglês | MEDLINE | ID: mdl-31821501

RESUMO

BACKGROUND: The natural history of human papillomavirus (HPV)-induced cervical cancer (CC) is not directly observable, yet the age of HPV acquisition and duration of preclinical disease (dwell time) impacts the effectiveness of alternative preventive policies. We performed a Cancer Intervention and Surveillance Modeling Network (CISNET) comparative modeling analysis to characterize the age of acquisition of cancer-causing HPV infections and implied dwell times for distinct phases of cervical carcinogenesis. METHODS: Using four CISNET-cervical models with varying underlying structures but fit to common U.S. epidemiological data, we estimated the age of acquisition of causal HPV infections and dwell times associated with three phases of cancer development: HPV, high-grade precancer, and cancer sojourn time. We stratified these estimates by HPV genotype under both natural history and CC screening scenarios, as screening prevents cancer development that impacts the mix of detected cancers. RESULTS: Median time from HPV acquisition to cancer detection ranged from 17.5-26.0 years across the four models. Three models projected that 50% of unscreened women acquired their causal HPV infection between ages 19-23 years, while one model projected these infections occurred later (age 34 years). In the context of imperfect compliance with U.S. screening guidelines, the median age of causal infection was 4.4-15.9 years later compared with model projections in the absence of screening. CONCLUSIONS: These validated CISNET-cervical cancer models, which reflect some uncertainty in the development of CC, elucidate important drivers of HPV vaccination and CC screening policies and emphasize the value of comparative modeling when evaluating public health policies.

6.
Lancet Oncol ; 20(7): 915-923, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31151906

RESUMO

BACKGROUND: Radiotherapy is standard of care for cervical cancer, but major global gaps in access exist, particularly in low-income and middle-income countries. We modelled the health and economic benefits of a 20-year radiotherapy scale-up to estimate the long-term demand for treatment in the context of human papillomavirus (HPV) vaccination. METHODS: We applied the Global Task Force on Radiotherapy for Cancer Control investment framework to model the health and economic benefits of scaling up external-beam radiotherapy and brachytherapy for cervical cancer in upper-middle-income, lower-middle-income, and low-income countries between 2015 and 2035. We estimated the unique costs of external-beam radiotherapy and brachytherapy and included a specific valuation of women's caregiving contributions. Model outcomes life-years gained and the human capital and full income net present value of investment. We estimated the effects of stage at diagnosis, radiotherapy delivery system, and simultaneous HPV vaccination (75% coverage) up to a time horizon set at 2072. FINDINGS: For the period from 2015 to 2035, we estimated that 9·4 million women in low-income and middle-income countries required treatment with external-beam radiotherapy, of which 7·0 million also required treatment with brachytherapy. Incremental scale-up of radiotherapy in these countries from 2015 to meet optimal radiotherapy demand by 2035 yielded 11·4 million life-years gained, $59·3 billion in human capital net present value (-$1·5 billion in low-income, $19·9 billion in lower-middle-income, and $40·9 billion in upper-middle-income countries), and $151·5 billion in full income net present value ($1·5 billion in low-income countries, $53·6 billion in lower-middle-income countries, and $96·4 billion in upper-middle-income countries). Benefits increased with advanced stage of cervical cancer and more efficient scale up of radiotherapy. Bivalent HPV vaccination of 12-year-old girls resulted in a 3·9% reduction in incident cases from 2015-2035. By 2072, when the first vaccinated cohort of girls reaches 70 years of age, vaccination yielded a 22·9% reduction in cervical cancer incidence, with 38·4 million requiring external-beam radiotherapy and 28·8 million requiring brachytherapy. INTERPRETATION: Effective cervical cancer control requires a comprehensive strategy. Even with HPV vaccination, radiotherapy treatment scale-up remains essential and produces large health benefits and a strong return on investment to countries at different levels of development. FUNDING: None.

7.
BMC Cancer ; 19(1): 426, 2019 May 07.
Artigo em Inglês | MEDLINE | ID: mdl-31064346

RESUMO

BACKGROUND: Public health efforts to prevent human papillomavirus (HPV)-related cancers include HPV vaccination and cervical cancer screening. We quantified the annual healthcare cost of six HPV-related cancers in order to provide inputs in cost-effectiveness analyses and quantify the potential economic savings from prevention of HPV-related cancers in Norway. METHODS: Using individual patient-level data from three unlinked population-based registries, we estimated the mean healthcare costs 1) annually across all phases of disease, 2) during the first 3 years of care following diagnosis, and 3) for the last 12 months of life for patients diagnosed with an HPV-related cancer. We included episodes of care related to primary care physicians, specialist care (private specialists and hospital-based care and prescriptions), and prescription drugs redeemed at pharmacies outside hospitals between 2012 and 2014. We valued costs (2014 €1.00 = NOK 8.357) based on diagnosis-related groups (DRG), patient copayments, reimbursement fees and pharmacy retail prices. RESULTS: In 2014, the total healthcare cost of HPV-related cancers amounted to €39.8 million, of which specialist care accounted for more than 99% of the total cost. The annual maximum economic burden potentially averted due to HPV vaccination will be lower for vulvar, penile and vaginal cancer (i.e., €984,620, €762,964 and €374,857, respectively) than for cervical, anal and oropharyngeal cancers (i.e., €17.2 million, €6.7 million and €4.6 million, respectively). Over the first three years of treatment following cancer diagnosis, patients diagnosed with oropharyngeal cancer incurred the highest total cost per patient (i.e. €49,774), while penile cancer had the lowest total cost per patient (i.e. €18,350). In general, costs were highest the first year following diagnosis and then declined; however, costs increased rapidly again towards end of life for patients who did not survive. CONCLUSION: HPV-related cancers constitute a considerable economic burden to the Norwegian healthcare system. As the proportion of HPV-vaccinated individuals increase and secondary prevention approaches advance, this study highlights the potential economic burden avoided by preventing these cancers.


Assuntos
Efeitos Psicossociais da Doença , Custos de Cuidados de Saúde/estatística & dados numéricos , Neoplasias/economia , Infecções por Papillomavirus/economia , Vacinas contra Papillomavirus/economia , Adolescente , Adulto , Criança , Análise Custo-Benefício/estatística & dados numéricos , Detecção Precoce de Câncer/economia , Detecção Precoce de Câncer/métodos , Feminino , Humanos , Masculino , Neoplasias/diagnóstico , Neoplasias/terapia , Neoplasias/virologia , Noruega , Papillomaviridae/imunologia , Infecções por Papillomavirus/diagnóstico , Infecções por Papillomavirus/terapia , Infecções por Papillomavirus/virologia , Vacinas contra Papillomavirus/administração & dosagem , Vacinação/economia , Adulto Jovem
8.
Prev Med ; 118: 44-50, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30316878

RESUMO

Women previously vaccinated against human papillomavirus (HPV) type 16 and 18 are now reaching the age (21 years) at which cervical-cancer screening is recommended in the U.S. The impact of HPV vaccination on risks of cervical precancer following a positive and negative screen among women aged 21-24 years who just started routine cervical screening are not well described. Therefore, three-year absolute and relative (RR) cumulative risks of cervical intraepithelial neoplasia grade 2 or more severe diagnoses (≥CIN2) and grade 3 or more severe diagnoses (≥CIN3) were estimated for women undergoing cervical screening at Kaiser Permanente Northern California. Risks were estimated in women aged 21-24 years (n = 75,008) undergoing cervical screening since late 2006, 6 months after HPV vaccination became available; women were categorized vaccinated at ages <18, 18-20, and 21-24 years and compared to those who were unvaccinated. Three-year risks were estimated for normal, low-grade, and high-grade cytology results. Three-year risks of ≥CIN2 and ≥CIN3 for unvaccinated women following low-grade cytology were 10.89% for and 3.70%, respectively. By comparison, Three-year risks of ≥CIN2 and ≥CIN3 were 5.26% (RR = 0.48, 95%CI = 0.24-0.99) and 0.99% (RR = 0.27, 95%CI = 0.06-1.13), respectively, for women vaccinated under the age of 18 years. Three-year ≥CIN2 and ≥CIN3 risks were lower for those HPV vaccinated at younger age for any screening result (ptrend ≤ 0.01 for all comparisons). These data support initiating cervical screening at an older age or changing the management of a low-grade cytology result in women aged 21-24 years who were vaccinated against HPV younger than age of 18 years.


Assuntos
Neoplasia Intraepitelial Cervical/diagnóstico , Detecção Precoce de Câncer/estatística & dados numéricos , Infecções por Papillomavirus/prevenção & controle , Vacinas contra Papillomavirus/administração & dosagem , Neoplasias do Colo do Útero/prevenção & controle , Adulto , California/epidemiologia , Neoplasia Intraepitelial Cervical/epidemiologia , Neoplasia Intraepitelial Cervical/prevenção & controle , Feminino , Humanos , Infecções por Papillomavirus/epidemiologia , Neoplasias do Colo do Útero/epidemiologia , Vacinação , Adulto Jovem
9.
JAMA ; 320(7): 706-714, 2018 08 21.
Artigo em Inglês | MEDLINE | ID: mdl-30140882

RESUMO

Importance: Evidence on the relative benefits and harms of primary high-risk human papillomavirus (hrHPV) testing is needed to inform guidelines. Objective: To inform the US Preventive Services Task Force by modeling the benefits and harms of various cervical cancer screening strategies. Design, Setting, and Participants: Microsimulation model of a hypothetical cohort of women initiating screening at age 21 years. Exposures: Screening with cytology, hrHPV testing, and cytology and hrHPV cotesting, varying age to switch from cytology to hrHPV testing or cotesting (25, 27, 30 years), rescreening interval (3, 5 years), and triage options for hrHPV-positive results (16/18 genotype, cytology testing). Current guidelines-based screening strategies comprised cytology alone every 3 years starting at age 21 years, with or without a switch to cytology and hrHPV cotesting every 5 years from ages 30 to 65 years. Complete adherence for all 19 strategies was assumed. Main Outcomes and Measures: Lifetime number of tests, colposcopies, disease detection, false-positive results, cancer cases and deaths, life-years, and efficiency ratios expressing the trade-off of harms (ie, colposcopies, tests) vs benefits (life-years gained, cancer cases averted). Efficient strategies were those that yielded more benefit and less harm than another strategy or a lower harm to benefit ratio than a strategy with less harms. Results: Compared with no screening, all modeled cervical cancer screening strategies were estimated to result in substantial reductions in cancer cases and deaths and gains in life-years. The effectiveness of screening across the different strategies was estimated to be similar, with primary hrHPV-based and alternative cotesting strategies having slightly higher effectiveness and greater harms than current guidelines-based cytology testing. For example, cervical cancer deaths associated with the guidelines-based strategies ranged from 0.30 to 0.76 deaths per 1000 women, whereas new strategies involving primary hrHPV testing or cotesting were associated with fewer cervical cancer deaths, ranging from 0.23 to 0.29 deaths per 1000 women. In all analyses, primary hrHPV testing strategies occurring at 5-year intervals were efficient. For example, 5-year primary hrHPV testing (cytology triage) based on switching from cytology to hrHPV screening at ages 30 years, 27 years, and 25 years had ratios per life-year gained of 73, 143, and 195 colposcopies, respectively. In contrast, strategies involving 3-year hrHPV testing had much higher ratios, ranging from 2188 to 3822 colposcopies per life-year gained. In most analyses, strategies involving cotesting were not efficient. Conclusions and Relevance: In this microsimulation modeling study, it was estimated that primary hrHPV screening may represent a reasonable balance of harms and benefits when performed every 5 years. Switching from cytology to hrHPV testing at age 30 years yielded the most efficient harm to benefit ratio when using colposcopy as a proxy for harms.


Assuntos
Técnicas de Apoio para a Decisão , Detecção Precoce de Câncer , Papillomaviridae/isolamento & purificação , Guias de Prática Clínica como Assunto , Neoplasias do Colo do Útero/diagnóstico , Esfregaço Vaginal , Adulto , Comitês Consultivos , Idoso , Colo do Útero/patologia , Colo do Útero/virologia , Colposcopia/estatística & dados numéricos , Detecção Precoce de Câncer/métodos , Feminino , Humanos , Incidência , Expectativa de Vida , Programas de Rastreamento , Pessoa de Meia-Idade , Estados Unidos , Neoplasias do Colo do Útero/epidemiologia , Neoplasias do Colo do Útero/mortalidade , Adulto Jovem
10.
Vaccine ; 36(32 Pt A): 4823-4829, 2018 08 06.
Artigo em Inglês | MEDLINE | ID: mdl-29807710

RESUMO

BACKGROUND: Although guidelines for prophylactic human papillomavirus (HPV) vaccination recommend two doses for girls ages 9-14 years, several studies have demonstrated similar protection with one dose. Our objective was to evaluate the long-term health and economic impacts of routine one-dose HPV vaccination compared to (1) no vaccination and (2) two-dose HPV vaccination in a low-income country. METHODS: We used a three-tiered hybrid modeling approach that captured HPV transmission, cervical carcinogenesis, and population demographics to project long-term health and economic outcomes associated with one-dose HPV vaccination (assuming 80% efficacy against HPV-16/18 infections under three waning scenarios) and two-dose HPV vaccination (assuming 100% efficacy over the lifetime) in Uganda. Costs included the vaccine program (dosage and delivery) costs over a 10-year period and cervical cancer costs over the lifetimes of the current population of Ugandan women. Health outcomes included number of cervical cancer cases and disability-adjusted life years (DALYs). Incremental cost-effectiveness ratios (i.e., cost per DALY averted) were calculated and compared against the Ugandan per-capita gross domestic product. RESULTS: Routine one-dose HPV vaccination of 9-year-old girls required substantial upfront investment but was cost-saving compared to no vaccination when accounting for the cost-offsets from future cancers averted. Forty years after initiating routine vaccination and depending on assumptions of vaccine waning, one-dose HPV vaccination with equivalent coverage (70%) averted 15-16% of cervical cancer cases versus 21% with two-dose vaccination but required only half the upfront economic investment. Vaccination with two doses had an attractive cost-effectiveness profile except if one-dose vaccination enabled higher coverage (90% vs. 70%) and did not wane. CONCLUSIONS: One-dose HPV vaccination resulted in cost-savings compared to no vaccination and could be cost-effective compared to two-dose vaccination if protection is longstanding and higher coverage can be achieved.


Assuntos
Assistência à Saúde/economia , Esquemas de Imunização , Vacinação em Massa/economia , Infecções por Papillomavirus/prevenção & controle , Vacinas contra Papillomavirus/administração & dosagem , Neoplasias do Colo do Útero/prevenção & controle , Adolescente , Criança , Análise Custo-Benefício , Feminino , Papillomavirus Humano 16/imunologia , Papillomavirus Humano 18/imunologia , Humanos , Infecções por Papillomavirus/epidemiologia , Vacinas contra Papillomavirus/uso terapêutico , Anos de Vida Ajustados por Qualidade de Vida , Uganda/epidemiologia , Neoplasias do Colo do Útero/epidemiologia
11.
J Acquir Immune Defic Syndr ; 79(1): 10-19, 2018 09 01.
Artigo em Inglês | MEDLINE | ID: mdl-29757775

RESUMO

OBJECTIVES: Men who have sex with men who are living with HIV are at highest risk for anal cancer. Our objective was to use empirical data to develop a comprehensive disease simulation model that reflects the most current understanding of anal carcinogenesis, which is uniquely positioned to evaluate future anal cancer screening strategies and provide insight on the unobservable course of the disease. SETTING: North America. METHODS: The individual-based simulation model was calibrated leveraging primary data from empirical studies, such as a longitudinal HIV-positive men who have sex with men cohort study [Human Immunodeficiency and Papilloma Virus Research Group (HIPVIRG); n = 247] and the North American AIDS Cohort Collaboration on Research and Design [(NA-ACCORD); n = 13,146]. We used the model to infer unobservable progression probabilities from high-grade precancer to invasive anal cancer by CD4 nadir and human papillomavirus (HPV) genotype. RESULTS: The calibrated model had good correspondence to data on genotype- and age-specific HPV prevalence; genotype frequency in precancer and cancer; and age- and nadir CD4-specific cancer incidence. The model-projected progression probabilities differed substantially by HPV genotype and nadir CD4 status. For example, among individuals with CD4 nadir <200, the median monthly progression probability from a high-grade lesion to invasive cancer was 0.054% (ie, 6.28% 10-year probability) and 0.004% (ie, 0.48% 10-year probability) for men with an HPV-16 infection versus without a detectable HPV infection, respectively. CONCLUSIONS: We synthesized existing evidence into a state-of-the-art anal cancer disease simulation model that will be used to quantify the tradeoffs of harms and benefits of alternative strategies, understand critical uncertainties, and inform national anal cancer prevention policy.


Assuntos
Neoplasias do Ânus/complicações , Infecções por HIV/complicações , Modelos Estatísticos , Infecções Tumorais por Vírus/complicações , Adulto , Alphapapillomavirus/isolamento & purificação , Fármacos Anti-HIV/uso terapêutico , Neoplasias do Ânus/virologia , Contagem de Linfócito CD4 , Calibragem , Infecções por HIV/tratamento farmacológico , Humanos , Masculino , Pessoa de Meia-Idade , Fatores de Risco , Infecções Tumorais por Vírus/virologia
12.
Prev Med ; 111: 177-179, 2018 06.
Artigo em Inglês | MEDLINE | ID: mdl-29548787

RESUMO

There is limited information on the cost-inefficiencies of non-adherence to recommended cervical cancer screening or the potential value for improving non-adherence. We estimated the incremental value of adhering to recommended screening every three years with cytology, using a disease simulation model that integrated real-world screening practice data from New Mexico. The amount that can be spent to improve adherence was estimated by calculating the incremental net monetary benefit (INMB) under scenarios of Current Practice (assuming a population of mixed adherence) and Uniformly Non-Adherent populations with imperfect or perfect adherence to follow-up of screen-positive women. Getting unscreened women screened every three years by cytology was a better value than increasing screening in the under-screened or reducing screening in the over-screened. For example, INMBs were $3998 for screening previously unscreened women versus $136 for eliminating annual screening at a willingness-to-pay threshold of $100,000 per quality-adjusted life-year gained. Strategies to reach unscreened women are potentially high-value investments.


Assuntos
Análise Custo-Benefício , Detecção Precoce de Câncer/economia , Guias como Assunto , Programas de Rastreamento/economia , Infecções por Papillomavirus/diagnóstico , Neoplasias do Colo do Útero/diagnóstico , Adulto , Feminino , Humanos , New Mexico , Infecções por Papillomavirus/economia , Anos de Vida Ajustados por Qualidade de Vida , Estados Unidos , Neoplasias do Colo do Útero/economia
13.
Acta Obstet Gynecol Scand ; 97(7): 795-807, 2018 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-29388202

RESUMO

New technologies such as human papillomavirus (HPV) testing and vaccination necessitate comprehensive policy analyses to optimize cervical cancer prevention. To inform future Scandinavian-specific policy analyses, we aimed to provide an overview of cervical cancer epidemiology and existing prevention efforts in Denmark, Norway and Sweden. We compiled and summarized data on current prevention strategies, population demography and epidemiology (for example, age-specific HPV prevalence and cervical cancer incidence over time) for each Scandinavian country by reviewing published literature and official guidelines, performing registry-based analyses using primary data and having discussions with experts in each country. In Scandinavia, opportunistic screening occurred as early as the 1950s and by 1996, all countries had implemented nationwide organized cytology-based screening. Prior to implementation of widespread screening and during 1960-66, cervical cancer incidence was considerably higher in Denmark than in Norway and Sweden. Decades of cytology-based screening later (i.e. 2010-2014), cervical cancer incidence has been considerably reduced and has converged across the countries since the 1960s, although it still remains lowest in Sweden. Generally, Scandinavian countries face similar cervical cancer burdens and utilize similar prevention approaches; however, important differences remain. Future policy analyses will need to evaluate whether these differences warrant differential prevention policies or whether efforts can be streamlined across Scandinavia.


Assuntos
Infecções por Papillomavirus/epidemiologia , Infecções por Papillomavirus/prevenção & controle , Neoplasias do Colo do Útero/epidemiologia , Neoplasias do Colo do Útero/prevenção & controle , Adolescente , Adulto , Feminino , Política de Saúde , Humanos , Incidência , Programas de Rastreamento , Pessoa de Meia-Idade , Prevalência , Países Escandinavos e Nórdicos/epidemiologia
14.
Eur J Cancer ; 91: 68-75, 2018 03.
Artigo em Inglês | MEDLINE | ID: mdl-29335156

RESUMO

BACKGROUND: Several countries have implemented vaccination against human papillomavirus (HPV) for adolescent girls and must decide whether and how to adapt cervical cancer (CC) screening for these low-risk women. We aimed to identify the optimal screening strategies for women vaccinated against HPV infections and quantify the amount that could be spent to identify vaccination status among women and stratify CC screening guidelines accordingly. METHODS: We used a mathematical model reflecting HPV-induced CC in Norway to project the long-term health benefits, resources and costs associated with 74 candidate-screening strategies that varied by screening test, start age and frequency. Strategies were considered separately for women vaccinated with the bivalent/quadrivalent (2/4vHPV) and nonavalent (9vHPV) vaccines. We used a cost-effectiveness framework (i.e. incremental cost-effectiveness ratios and net monetary benefit) and a commonly-cited Norwegian willingness-to-pay threshold of €75,000 per quality-adjusted life-year gained. RESULTS: The most cost-effective screening strategy for 9vHPV- and 2/4vHPV-vaccinated women involved HPV testing once and twice per lifetime, respectively. The value of stratifying guidelines by vaccination status was €599 (2/4vHPV) and €725 (9vHPV) per vaccinated woman. Consequently, for the first birth cohort of ∼22,000 women who were vaccinated in adolescence in Norway, between €10.5-13.2 million over their lifetime could be spent on identifying individual vaccination status and stratify screening while remaining cost-effective. CONCLUSION: Less intensive strategies are required for CC screening to remain cost-effective in HPV-vaccinated women. Moreover, screening can remain cost-effective even if large investments are made to identify individual vaccination status and stratify screening guidelines accordingly.


Assuntos
Detecção Precoce de Câncer/normas , Infecções por Papillomavirus/prevenção & controle , Vacinas contra Papillomavirus/administração & dosagem , Guias de Prática Clínica como Assunto/normas , Neoplasias do Colo do Útero/diagnóstico , Vacinação , Adulto , Fatores Etários , Simulação por Computador , Análise Custo-Benefício , Detecção Precoce de Câncer/economia , Feminino , Custos de Cuidados de Saúde , Humanos , Modelos Econômicos , Noruega/epidemiologia , Infecções por Papillomavirus/diagnóstico , Infecções por Papillomavirus/epidemiologia , Infecções por Papillomavirus/virologia , Vacinas contra Papillomavirus/efeitos adversos , Vacinas contra Papillomavirus/economia , Valor Preditivo dos Testes , Fatores de Proteção , Qualidade de Vida , Anos de Vida Ajustados por Qualidade de Vida , Fatores de Risco , Fatores de Tempo , Neoplasias do Colo do Útero/epidemiologia , Neoplasias do Colo do Útero/prevenção & controle , Neoplasias do Colo do Útero/virologia , Vacinação/efeitos adversos , Vacinação/economia
15.
Cancer Epidemiol Biomarkers Prev ; 27(2): 158-164, 2018 02.
Artigo em Inglês | MEDLINE | ID: mdl-29150480

RESUMO

Background: Patients who receive an abnormal cancer screening result require follow-up for diagnostic testing, but the time to follow-up varies across patients and practices.Methods: We used a simulation study to estimate the change in lifetime screening benefits when time to follow-up for breast, cervical, and colorectal cancers was increased. Estimates were based on four independently developed microsimulation models that each simulated the life course of adults eligible for breast (women ages 50-74 years), cervical (women ages 21-65 years), or colorectal (adults ages 50-75 years) cancer screening. We assumed screening based on biennial mammography for breast cancer, triennial Papanicolaou testing for cervical cancer, and annual fecal immunochemical testing for colorectal cancer. For each cancer type, we simulated diagnostic testing immediately and at 3, 6, and 12 months after an abnormal screening exam.Results: We found declines in screening benefit with longer times to diagnostic testing, particularly for breast cancer screening. Compared to immediate diagnostic testing, testing at 3 months resulted in reduced screening benefit, with fewer undiscounted life years gained per 1,000 screened (breast: 17.3%, cervical: 0.8%, colorectal: 2.0% and 2.7%, from two colorectal cancer models), fewer cancers prevented (cervical: 1.4% fewer, colorectal: 0.5% and 1.7% fewer, respectively), and, for breast and colorectal cancer, a less favorable stage distribution.Conclusions: Longer times to diagnostic testing after an abnormal screening test can decrease screening effectiveness, but the impact varies substantially by cancer type.Impact: Understanding the impact of time to diagnostic testing on screening effectiveness can help inform quality improvement efforts. Cancer Epidemiol Biomarkers Prev; 27(2); 158-64. ©2017 AACR.


Assuntos
Neoplasias da Mama/diagnóstico por imagem , Neoplasias Colorretais/diagnóstico , Detecção Precoce de Câncer/métodos , Neoplasias do Colo do Útero/diagnóstico , Idoso , Neoplasias da Mama/mortalidade , Neoplasias da Mama/prevenção & controle , Neoplasias Colorretais/mortalidade , Neoplasias Colorretais/prevenção & controle , Fezes , Feminino , Humanos , Incidência , Masculino , Mamografia/estatística & dados numéricos , Programas de Rastreamento , Pessoa de Meia-Idade , Modelos Estatísticos , Sangue Oculto , Teste de Papanicolaou/estatística & dados numéricos , Fatores de Tempo , Neoplasias do Colo do Útero/mortalidade , Neoplasias do Colo do Útero/prevenção & controle
16.
Eur J Public Health ; 27(6): 1089-1094, 2017 12 01.
Artigo em Inglês | MEDLINE | ID: mdl-29186461

RESUMO

Background: Attendance to routine cancer screening at repeated intervals is essential for reducing morbidity and mortality of targeted cancers, yet currently defined quality-assurance metrics evaluate coverage within a defined period of time (e.g. 3.5 years). Methods: We developed a longitudinal adherence metric that captures attendance to cancer screening at repeated intervals, and applied the metric to population-based data from the Cancer Registry of Norway that captures two decades of organised cervical cancer screening, including all screening tests and cervical cancer diagnoses for women living in Norway at any time during years 1992-2013 and eligible for at least two screening rounds (1 round = 3.5 years, N = 1 391 812). For each woman, we calculated the proportion of eligible screening rounds with at least one registered cytology test, and categorised women into one of five longitudinal adherence categories: never-screeners, severe under-screeners, moderate under-screeners, guidelines-based screeners and over-screeners. For each category, we evaluated cancer outcomes such as cancer stage at diagnosis. Results: Only 46% of screen-eligible women were consistently screened at least once every 3.5 years, and the majority of these were over-screened. In contrast, 29% were moderately under-screened, 17% were severely under-screened and 8% had never attended screening. Screening behaviour was associated with cancer outcomes; e.g., the proportion of cancers diagnosed at Stage I increased from 21% among never-screeners to 70% among over-screeners. Conclusion: The longitudinal adherence metric evaluates screening performance as a succession of screening episodes, reflecting both guidelines and the fundamental principles of screening, and may be a valuable addition to existing performance indicators.


Assuntos
Detecção Precoce de Câncer , Cooperação do Paciente/estatística & dados numéricos , Neoplasias do Colo do Útero/diagnóstico , Adulto , Idoso , Estudos de Avaliação como Assunto , Feminino , Humanos , Estudos Longitudinais , Pessoa de Meia-Idade , Noruega , Sistema de Registros , Fatores de Tempo
17.
Br J Cancer ; 117(6): 783-790, 2017 Sep 05.
Artigo em Inglês | MEDLINE | ID: mdl-28772279

RESUMO

BACKGROUND: Forthcoming cervical cancer screening strategies involving human papillomavirus (HPV) testing for women not vaccinated against HPV infections may increase colposcopy referral rates. We quantified health and resource trade-offs associated with alternative HPV-based algorithms to inform decision-makers when choosing between candidate algorithms. METHODS: We used a mathematical simulation model of HPV-induced cervical carcinogenesis in Norway. We compared the current cytology-based strategy to alternative strategies that varied by the switching age to primary HPV testing (ages 25-34 years), the routine screening frequency (every 3-10 years), and management of HPV-positive, cytology-negative women. Model outcomes included reductions in lifetime cervical cancer risk, relative colposcopy rates, and colposcopy rates per cervical cancer prevented. RESULTS: The age of switching to primary HPV testing and the screening frequency had the largest impacts on cancer risk reductions, which ranged from 90.9% to 96.3% compared to no screening. In contrast, increasing the follow-up intensity of HPV-positive, cytology-negative women provided only minor improvements in cancer benefits, but generally required considerably higher rates of colposcopy referrals compared to current levels, resulting in less efficient cervical cancer prevention. CONCLUSIONS: We found that in order to maximise cancer benefits HPV-based screening among unvaccinated women should not be delayed: rather, policy makers should utilise the triage mechanism to control colposcopy referrals.


Assuntos
Fatores Etários , Algoritmos , Colposcopia/estatística & dados numéricos , Programas de Rastreamento/estatística & dados numéricos , Papillomaviridae , Infecções por Papillomavirus/diagnóstico , Neoplasias do Colo do Útero/prevenção & controle , Adulto , Biópsia/métodos , Neoplasia Intraepitelial Cervical/patologia , Neoplasia Intraepitelial Cervical/virologia , Análise Custo-Benefício , DNA Viral/análise , Detecção Precoce de Câncer , Feminino , Humanos , Incidência , Modelos Teóricos , Noruega/epidemiologia , Papillomaviridae/genética , Papillomaviridae/isolamento & purificação , Infecções por Papillomavirus/prevenção & controle , Lesões Pré-Cancerosas/diagnóstico , Lesões Pré-Cancerosas/virologia , Encaminhamento e Consulta/estatística & dados numéricos , Risco , Sensibilidade e Especificidade , Fatores de Tempo , Incerteza , Neoplasias do Colo do Útero/epidemiologia , Neoplasias do Colo do Útero/patologia , Neoplasias do Colo do Útero/virologia
18.
Clin Infect Dis ; 65(6): 893-899, 2017 Sep 15.
Artigo em Inglês | MEDLINE | ID: mdl-28531261

RESUMO

Background: Although new human papillomavirus (HPV) infections can occur at all ages, the age at which women acquire their "causal" HPV infection that develops into cervical cancer is poorly understood and practically unobservable. We aimed to estimate the age distribution at which individuals acquired their causal HPV infection in the absence of HPV vaccination or screening to help guide the optimal use of both. Methods: Using an empirically calibrated mathematical model that simulates the natural history of cervical cancer, we estimated the cumulative number of causal HPV infections by age, stratified by HPV genotype (HPV16 vs. other HPV genotypes), and the direct age-specific reduction in cancer incidence for alternative vaccination initiation scenarios (i.e., age 9-45 years). Results: Our model projected that among all cervical cancers, 50% and 75% of women acquired their causal HPV infection by ages 20.6 (range: 20.1-21.1) and 30.6 (range: 29.6-31.6) years, respectively. HPV16 infections were acquired at an earlier age. Assuming 95% efficacy against HPV16 and HPV18 infections, the direct reduction in lifetime risk of cervical cancer varied from 55% (53-56%) among women vaccinated at age 9 years to 6% (range: 6-7%) among women vaccinated at age 45 years. Similar patterns were observed for the second-generation vaccine. Conclusions: Although new HPV infections and precancers can occur throughout a woman's lifetime, only a small proportion are acquired in mid-adult women and are vaccine-preventable. Our simulations highlight the potential limitations of using surrogate endpoints for vaccine efficacy studies of mid-adult women to guide policy decisions for implementation.


Assuntos
Papillomaviridae/genética , Infecções por Papillomavirus/epidemiologia , Infecções por Papillomavirus/prevenção & controle , Neoplasias do Colo do Útero/epidemiologia , Vacinação , Adolescente , Adulto , Distribuição por Idade , Idade de Início , Idoso , Criança , Simulação por Computador , Feminino , Genótipo , Papillomavirus Humano 16 , Papillomavirus Humano 18 , Humanos , Incidência , Pessoa de Meia-Idade , Modelos Biológicos , Infecções por Papillomavirus/complicações , Infecções por Papillomavirus/virologia , Neoplasias do Colo do Útero/virologia , Adulto Jovem
19.
J Natl Cancer Inst ; 109(2)2017 02.
Artigo em Inglês | MEDLINE | ID: mdl-27754955

RESUMO

Background: Current US cervical cancer screening guidelines do not differentiate recommendations based on a woman's human papillomavirus (HPV) vaccination status. Changes to cervical cancer screening policies in HPV-vaccinated women should be evaluated. Methods: We utilized an individual-based mathematical model of HPV and cervical cancer in US women to project the health benefits, costs, and harms associated with screening strategies in women vaccinated with the bivalent, quadrivalent, or nonavalent vaccine. Strategies varied by the primary screening test, including cytology, HPV, and combined cytology and HPV "cotesting"; age of screening initiation and/or switching to a new test; and interval between routine screens. Cost-effectiveness analysis was conducted from the societal perspective to identify screening strategies that would be considered good value for money according to thresholds of $50 000 to $200 000 per quality-adjusted life-year (QALY) gained. Results: Among women fully vaccinated with the bivalent or quadrivalent vaccine, optimal screening strategies involved either cytology or HPV testing alone every five years starting at age 25 or 30 years, with cost-effectiveness ratios ranging from $34 680 to $138 560 per QALY gained. Screening earlier or more frequently was either not cost-effective or associated with exceedingly high cost-effectiveness ratios. In women vaccinated with the nonavalent vaccine, only primary HPV testing was efficient, involving decreased frequency (ie, every 10 years) starting at either age 35 years ($40 210 per QALY) or age 30 years ($127 010 per QALY); with lower nonavalent vaccine efficacy, 10-year HPV testing starting at earlier ages of 25 or 30 years was optimal. Importantly, current US guidelines for screening were inefficient in HPV-vaccinated women. Conclusions: This model-based analysis suggests screening can be modified to start at later ages, occur at decreased frequency, and involve primary HPV testing in HPV-vaccinated women, providing more health benefit at lower harms and costs than current screening guidelines.


Assuntos
Detecção Precoce de Câncer/economia , Detecção Precoce de Câncer/métodos , Teste de Papanicolaou , Papillomaviridae/isolamento & purificação , Infecções por Papillomavirus/prevenção & controle , Neoplasias do Colo do Útero/diagnóstico , Adulto , Colposcopia/economia , Colposcopia/estatística & dados numéricos , Análise Custo-Benefício , Detecção Precoce de Câncer/efeitos adversos , Feminino , Vacina Quadrivalente Recombinante contra HPV tipos 6, 11, 16, 18 , Humanos , Modelos Teóricos , Teste de Papanicolaou/economia , Infecções por Papillomavirus/diagnóstico , Guias de Prática Clínica como Assunto , Anos de Vida Ajustados por Qualidade de Vida , Fatores de Tempo , Neoplasias do Colo do Útero/economia , Vacinação/estatística & dados numéricos , Esfregaço Vaginal/economia , Adulto Jovem
20.
Cancer Epidemiol Biomarkers Prev ; 26(1): 95-103, 2017 01.
Artigo em Inglês | MEDLINE | ID: mdl-27624639

RESUMO

BACKGROUND: Human papillomavirus (HPV) testing allows women to self-collect cervico-vaginal cells at home (i.e., self-sampling). Using primary data from a randomized pilot study, we evaluated the long-term consequences and cost-effectiveness of using self-sampling to improve participation to routine cervical cancer screening in Norway. METHODS: We compared a strategy reflecting screening participation (using reminder letters) to strategies that involved mailing self-sampling device kits to women noncompliant to screening within a 5- or 10-year period under two scenarios: (A) self-sampling respondents had moderate under-screening histories, or (B) respondents to self-sampling had moderate and severe under-screening histories. Model outcomes included quality-adjusted life-years (QALY) and lifetime costs. The "most cost-effective" strategy was identified as the strategy just below $100,000 per QALY gained. RESULTS: Mailing self-sampling device kits to all women noncompliant to screening within a 5- or 10-year period can be more effective and less costly than the current reminder letter policy; however, the optimal self-sampling strategy was dependent on the profile of self-sampling respondents. For example, "10-yearly self-sampling" is preferred ($95,500 per QALY gained) if "5-yearly self-sampling" could only attract moderate under-screeners; however, "5-yearly self-sampling" is preferred if this strategy could additionally attract severe under-screeners. CONCLUSIONS: Targeted self-sampling of noncompliers likely represents good value-for-money; however, the preferred strategy is contingent on the screening histories and compliance of respondents. IMPACT: The magnitude of the health benefit and optimal self-sampling strategy is dependent on the profile and behavior of respondents. Health authorities should understand these factors prior to selecting and implementing a self-sampling policy. Cancer Epidemiol Biomarkers Prev; 26(1); 95-103. ©2016 AACR.


Assuntos
Análise Custo-Benefício , Detecção Precoce de Câncer/economia , Infecções por Papillomavirus/diagnóstico , Cooperação do Paciente/estatística & dados numéricos , Autoexame/métodos , Neoplasias do Colo do Útero/prevenção & controle , Adulto , Detecção Precoce de Câncer/métodos , Feminino , Humanos , Programas de Rastreamento/economia , Programas de Rastreamento/métodos , Pessoa de Meia-Idade , Noruega , Infecções por Papillomavirus/epidemiologia , Projetos Piloto , Avaliação de Programas e Projetos de Saúde , Melhoria de Qualidade , Anos de Vida Ajustados por Qualidade de Vida , Autoexame/economia , Neoplasias do Colo do Útero/virologia , Esfregaço Vaginal/métodos
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