Policy analysis of cervical cancer screening strategies in low-resource settings - Clinical benefits and cost-effectiveness
Policy analysis of cervical cancer screening strategies in low-resource settings - Clinical benefits and cost-effectiveness
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DOI：
10.1001/jama.285.24.3107
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发表时间：
2001-06-27
影响因子：
120.7
通讯作者：
Wright, TC
中科院分区：
文献类型：
--
作者：
Goldie, SJ;Kuhn, L;Wright, TC
宫颈癌是发展中国家妇女癌症相关死亡的主要原因。在这种资源匮乏的环境中，基于细胞学的筛查很难实施，而不太复杂的策略可能提供额外的选择。目的利用人群特异性数据评估几种宫颈癌筛查策略的成本-效果。设计和设置使用数学模型和假设的30岁南非黑人妇女未接受筛查的队列进行成本效益分析。筛查试验包括宫颈直接目视检查（DVI）、细胞学方法和高危型人乳头瘤病毒（HPV） DNA检测，策略因临床就诊次数、筛查频率和对阳性检测结果的反应而异。数据来源包括南非筛查研究、国家调查和费用表以及已发表的文献。主要观察指标挽救生命年数（YLS）、以美元计算的生命周期成本和增量成本-效果比（每YLS成本）。结果：当分析35岁时进行单一终身筛查的所有策略时，与不进行筛查相比，HPV检测后在第二次就诊时对筛查阳性妇女进行治疗，成本为39美元/YLS（癌症发病率降低27%）；DVI加上筛查阳性妇女在第一次就诊时立即治疗是第二有效的（减少26%的癌症发病率），并节省了费用；对于任何给定的筛查频率，当策略进行增量比较时，HPV DNA检测通常比DVI更有效，但也更昂贵，并且总是比细胞学更有效，成本更低。当同时比较所有筛查频率的策略时，DVI是非主导策略，直到每3年的频率（增量成本-效果比，460美元/YLS）， HPV检测每3年（增量成本-效果比，11500美元/YLS）是最有效的策略。结论：在低资源环境下，结合DVI或HPV DNA检测和消除阴道镜检查的宫颈癌筛查策略可能是基于细胞学的筛查方案的有吸引力的替代方案。
Context Cervical cancer is a leading cause of cancer-related death among women in developing countries. In such low-resource settings, cytology-based screening is difficult to implement, and less complex strategies may offer additional options.Objective To assess the cost-effectiveness of several cervical cancer screening strategies using population-specific data.Design and Setting Cost-effectiveness analysis using a mathematical model and a hypothetical cohort of previously unscreened 30-year-old black South African women. Screening tests included direct visual inspection (DVI) of the cervix, cytologic methods, and testing for high-risk types of human papillomavirus (HPV) DNA, Strategies differed by number of clinical visits, screening frequency, and response to a positive test result. Data sources included a South African screening study, national surveys and fee schedules, and published literature.Main Outcome Measures Years of life saved (YLS), lifetime costs in US dollars, and incremental cost-effectiveness ratios (cost per YLS).Results When analyzing all strategies performed as a single lifetime screen at age 35 years compared with no screening, HPV testing followed by treatment of screen-positive women at a second visit, cost $39/YLS (27% cancer incidence reduction); DVI, coupled with immediate treatment of screen-positive women at the first visit was next most effective (26% cancer incidence reduction) and was cost saving; cytology, followed by treatment of screen-positive women at a second visit was least effective (19% cancer incidence reduction) at a cost of $81/YLS, For any given screening frequency, when strategies were compared incrementally, HPV DNA testing generally was more effective but also more costly than DVI, and always was more effective and less costly than cytology. When comparing all strategies simultaneously across screening frequencies, DVI was the nondominated strategy up to a frequency of every 3 years (incremental cost-effectiveness ratio, $460/YLS), and HPV testing every 3 years (incremental cost-effectiveness ratio, $11 500/YLS) was the most effective strategy.Conclusion Cervical cancer screening strategies that incorporate DVI or HPV DNA testing and eliminate colposcopy may offer attractive alternatives to cytology-based screening programs in low-resource settings.