Adapting cervical cancer screening for women vaccinated against human papillomavirus infections: The value of stratifying guidelines

Abstract

BackgroundSeveral 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. MethodsWe 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. ResultsThe 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. ConclusionLess 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.