Abstract
BackgroundPrecursors to anal squamous cell carcinoma may be detectable through screening; however, the literature suggests that population-level testing is not cost-effective. Given that high-grade cervical neoplasia (CIN) is associated with an increased risk of developing anal cancer, and in light of changing guidelines for the follow-up and management of cervical neoplasia, it is worthwhile to examine the costs and effectiveness of an anal cancer screening program delivered to women with previously-detected CIN.MethodsA model of anal cancer screening and treatment was constructed, to estimate the cost-effectiveness of a population of CIN II/III+ women who were screened using anal cytology vs. one that received no anal cancer screening. Costs were based on Canadian estimates, and survival was based on estimates taken from the scientific literature. Effectiveness was measured in terms of life years gained (LYG) and quality-adjusted life years (QALYs). The model was run for 50 cycles, with each cycle representing one year.ResultsIncremental cost (screened vs. unscreened) was $82.17 per woman in the model. Incremental effectiveness was 0.004 LYG, and was equivalent to zero in terms of QALY. An ICER of $20,561/LYG was calculated, while no meaningful incremental cost-effectiveness ratio (ICER) could be calculated for quality-adjusted survival.ConclusionOur analysis suggests that anal cancer screening is cost-effective in terms of overall survival in women with a previous diagnosis of CIN II or CIN III as part of regular follow-up, but may not contribute meaningfully-different quality-adjusted survival due to the adverse effects of screening-related interventions.Electronic supplementary materialThe online version of this article (doi:10.1186/s12913-016-1442-2) contains supplementary material, which is available to authorized users.
Highlights
Precursors to anal squamous cell carcinoma may be detectable through screening; the literature suggests that population-level testing is not cost-effective
Probabilistic Sensitivity Analysis (PSA) strongly suggests a great deal of uncertainty around quality-adjusted outcomes – incremental quality-adjusted life year (QALY) estimates were greater than zero nearly as often as they were smaller than zero
The reduction in Quality of life (QoL) associated with screening, primarily resection of low- and highgrade dysplasia, is greater than the avoided QoL loss that accompanies the reduction in cancer frequency
Summary
Precursors to anal squamous cell carcinoma may be detectable through screening; the literature suggests that population-level testing is not cost-effective. Given that high-grade cervical neoplasia (CIN) is associated with an increased risk of developing anal cancer, and in light of changing guidelines for the follow-up and management of cervical neoplasia, it is worthwhile to examine the costs and effectiveness of an anal cancer screening program delivered to women with previously-detected CIN. Neoplasia (CIN), often detected through cervical cancer screening, is linked to high-risk HPV subtypes and progression to invasive cervical cancer if left untreated [2,3,4] and multiple studies have shown that women with a past diagnosis of CIN or cervical cancer are at increased risk of developing anal cancer [5,6,7,8,9]. Anal cancer screening strategies have predominantly been applied to high-risk populations, mainly HIV
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