Abstract
BackgroundWith human papillomavirus (HPV) vaccination introduced in a number of countries, there is considerable interest in evaluating the cost-effectiveness of HPV testing as the primary cervical screening test in these settings. However, the availability of utility scores for these newer interventions is limited. Our aim in this paper is to present utility scores for HPV vaccination, HPV testing and cytology based screening states among women targeted for cervical screening.MethodsWe invited a random sample of women targeted for cervical screening (aged 20-69 years) living in Sydney, Australia, to participate in a face-to-face interview. Participants were asked to indicate preferences (rank and utility scores) for 10 hypothetical health states relating to HPV vaccination, cytology and primary HPV screening, cervical precursor disease and early stage cervical cancer. Preferences for hypothetical health states were measured through ranking then a two-stage standard gamble. Each participant’s own health state was measured as a utility score using the EQ5D. Potential differences by age were assessed using the Wilcox Rank Sum test.ResultsA maximum of 276 women were contacted, of which 43 (mean age 49 years) agreed to be interviewed (15.6%). The overall health state of women as measured by the EQ5D was 0.86 (95% CI: 0.83-0.89). Of the 10 health states, the highest ranked were ‘normal cytology’ and ‘HPV vaccination’ (equal 1st). States involving an HPV positive result with a subsequent normal cytology or colposcopy were ranked below those for low grade cytological abnormalities with or without a subsequent colposcopic normal result (ranks 3-4 vs. 4-5). However, mean utility scores were broadly similar for all health states, except cervical cancer. No significant differences in scores were identified between age groups.ConclusionOur survey suggests health states relating to HPV testing are ranked below ‘low grade cytology’ disease abnormalities. However, this difference was minimal on the utility scale, as most values for health states were largely clustered. These results provide a preliminary set of non-clinic population-based utilities that may be used with other values to explore the economic implications of introducing HPV testing as a primary screening tool in the context of HPV vaccination.Electronic supplementary materialThe online version of this article (doi:10.1186/1756-0500-7-899) contains supplementary material, which is available to authorized users.
Highlights
With human papillomavirus (HPV) vaccination introduced in a number of countries, there is considerable interest in evaluating the cost-effectiveness of HPV testing as the primary cervical screening test in these settings
Primary HPV DNA testing has emerged as an alternative screening technology to cervical cytology (‘Pap smears’), such that several randomised controlled trials in Europe and North America highlight higher sensitivity of primary HPV testing for detecting high grade precursor lesions (Cervical Intraepithelial Neoplasia grades 2 and 3 and above; CIN2+ and CIN3+) relative to cytology in baseline rounds of screening, with lower rates of these high grade precursor cervical lesions detected in subsequent screening rounds [2,3,4,5,6], as well as lower rates of invasive cervical cancer in HPV-screened women compared to cytology-screened women [5]
Decision analytic models used to evaluate the incremental cost-effectiveness of HPV vaccination in the context of existing cervical cytology screening programs have adopted a specific set of health state preference scores to quantify the quality of life effects associated with cervical screening and any detected disease [7,8]
Summary
With human papillomavirus (HPV) vaccination introduced in a number of countries, there is considerable interest in evaluating the cost-effectiveness of HPV testing as the primary cervical screening test in these settings. Primary HPV DNA testing has emerged as an alternative screening technology to cervical cytology (‘Pap smears’), such that several randomised controlled trials in Europe and North America highlight higher sensitivity of primary HPV testing (i.e. testing for a bank of oncogenic HPV types) for detecting high grade precursor lesions (Cervical Intraepithelial Neoplasia grades 2 and 3 and above; CIN2+ and CIN3+) relative to cytology in baseline rounds of screening, with lower rates of these high grade precursor cervical lesions detected in subsequent screening rounds [2,3,4,5,6], as well as lower rates of invasive cervical cancer in HPV-screened women compared to cytology-screened women [5] Due both to the emergence of these data on primary HPV testing and to the implementation of HPV vaccination, a number of countries are formally evaluating a transition to primary HPV screening. This is important because the trade-off between benefits and harms of cervical screening potentially differs substantially between younger and older (>45-50 years) women, since there are some data to indicate that treatment for cervical precancerous abnormalities increases the risk of subsequent adverse obstetric outcomes in fertile women [9]
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