Artikel
The Benefit-Harm Balance of Different Primary Cervical Cancer Screening Strategies including HPV, p16/Ki-67 and Cytology Testing – A Decision Analysis for the Austrian Health Care Context
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Autoren
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Gaby Sroczynski
- Dep. of Public Health, Health Services Research, and Health Technology Assessment, UMIT - University for Health Sciences, Medical Informatics and Technology; Division of Health Technology Assessment and Bioinformatics, ONCOTYROL Center for Personalized Cancer Medicine, Hall i.T. /Innsbruck, Österreich
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Eva Esteban
- Dep. of Public Health, Health Services Research, and Health Technology Assessment, UMIT - University for Health Sciences, Medical Informatics and Technology; Division of Health Technology Assessment and Bioinformatics, ONCOTYROL Center for Personalized Cancer Medicine, Hall i.T. / Innsbruck, Österreich
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Andreas Widschwendter
- Department of Obstetrics and Gynecology, Medical University Innsbruck, Innsbruck, Österreich
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Willi Oberaigner
- Institute for Clinical Epidemiology, Cancer Registry Tyrol, Tirol Kliniken, Innsbruck, Österreich
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Wegene Borena
- Division of Virology, Department of Hygiene, Microbiology, Social Medicine, Medical University of Innsbruck, Innsbruck, Österreich
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Dorothee von Laer
- Division of Virology, Department of Hygiene, Microbiology, Social Medicine, Medical University of Innsbruck, Innsbruck, Österreich
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Monika Hackl
- Statistics Austria, Austrian National Cancer Registry, Wien, Österreich
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Gottfried Endel
- Department for Evidence Based Economic Health Care, Main Association of Austrian Social Insurance Institutions, Wien, Österreich
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Uwe Siebert
- Dep. of Public Health, Health Services Research, and Health Technology Assessment, UMIT - University for Health Sciences, Medical Informatics and Technology; Division of Health Technology Assessment and Bioinformatics, ONCOTYROL Center for Personalized Cancer Medicine, Austria; Center for Health Decision Science, Dep. Health Policy and Management, Harvard T. H. Chan School of Public Health; Institute for Technology Assessment and Dep. Radiology, MGH, Harvard Medical School, USA, Hall i. T. / Innsbruck, Österreich
| Veröffentlicht: | 23. Februar 2016 |
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Gliederung
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Introduction/Objectives: Primary cervical cancer screening may be optimized using new screening and follow-up algorithms with improved benefit-harm trade-offs. Our aim was to systematically evaluate and compare the benefit-harm balance of different cervical cancer primary screening strategies for the Austrian context.
Methods: A Markov-state-transition model for the Austrian health care context simulating HPV-infection and cervical cancer development was applied to evaluate different screening strategies, that differ by screening test, interval, and follow-up algorithms, including cytology, p16/Ki-67, and HPV-testing alone or in combinations. We used Austrian clinical, epidemiological and economic data, and test accuracy data from international meta-analyses and trials. Predicted outcomes were reduction in cervical cancer cases and deaths, life expectancy, unnecessary treatment (defined as conization with histological diagnosis of no lesion or lesion below CIN3), and the incremental harm-benefit ratios (IHBR). Comprehensive sensitivity analyses were performed.
Results: Within the same screening interval, HPV-based primary screening strategies are more effective (relative cancer reduction: 42%-68% for 5-2 yearly screening intervals) compared with Pap with p16/Ki-67-triage (33%-57%) or with p16/Ki-67 testing alone (40%-66%). In the base-case analysis (33% average screening adherence in women age < 60 years), the IHBRs measured in numbers of unnecessary conizations per additional prevented cervical cancer death were 31 (5-yearly Pap+p16/Ki-67-triage), 49 (3-yearly Pap+p16/Ki-67-triage), 58 (3-yearly HPV+Pap cotesting), 66 (2-yearly HPV+Pap cotesting), 189 (annual Pap+p16/Ki-67-triage), and 401 (annual p16/Ki-67 testing alone). In populations with screening adherence below 40% HPV+Pap cotesting may be performed in 2-yearly intervals, and may be extended to 3 years with 40% - 60% adherence or to 5 years with adherence above 60%. The age for screening initiation could be extended to 24 years without significant loss in effectiveness, but with reduced harms.
Conclusions: Based on our benefit-harm analysis, bi- or triennial HPV-based screening in women age 30 years and older with biennial Pap with p16/Ki-67-triage in younger women could be recommended as optimal screening strategy for the setting in Austria. With high screening adherence, the screening interval may be extended to 5 years in low-risk women. Screening should be initiated in the age range of 20-24 years.
