Revisiting the Cost-Effectiveness of HPV Co-Testing Versus Primary HPV Testing for Cervical Cancer Screening

Abstract

Objectives: Consensus U.S. cervical cancer screening guidelines recommend women aged 30–65 years should be screened: (1) every 5 years with high-risk HPV testing alone; or (2) every 5 years with Pap and high-risk HPV co-testing; or (3) every 3 years with Pap alone. However, nearly 1-in-5 cancers (18.6%) are missed by HPV testing alone and 12.2% of cancers are missed by Pap testing alone. Hence, co-testing is the preferred screening method, but the cost implications are not fully known. For deeper understanding, we performed updated clinical-economic comparisons of cervical cancer screening with co-testing versus primary HPV from a U.S. perspective. Methods: A health state transition (Markov) model with one-year cycling was previously developed using epidemiologic, clinical, and economic data from healthcare databases and published literature. After updating the model, it was used to perform simulations of women receiving either 3-year or 5-year interval cervical cancer screening with either co-testing or HPV primary, starting from age 30 years and running up through age 64 years. Outcomes included total and incremental differences in costs, number of referral colposcopies (true and false positive), invasive cervical cancer (ICC) cases, ICC deaths, and quality-adjusted life years (QALYs) for cost-effectiveness calculations. Results: In the 3-year and 5-year screening interval scenarios, per-patient cumulative costs of screening and management over 35 years with co-testing versus HPV primary led to cost savings of $15 and $217, respectively. These cost saving resulted from fewer referral colposcopies, fewer ICC cases, and fewer ICC deaths. Co-testing also conferred more QALYs. Cost-effectiveness calculations showed co-testing as the economically dominant screening strategy by simultan-eously confers greater effectiveness (i.e., more QALYs) at lower cost compared with HPV primary. National average annual cost savings of $154 to $655 million could be realized if every woman in the U.S. was routinely screened with co-testing instead of HPV primary. Conclusions: Model results demonstrate that cervical cancer screening with co-testing provides valuable clinical and economic outcomes when compared to primary HPV testing alone. These findings are relevant to healthcare payers and women’s health policy advocates seeking cost-effective cervical cancer screening options.