Abstract
Objectives
Human papillomavirus (HPV) testing can be incorporated into the post-treatment pathway
of cervical intraepithelial neoplasia (CIN) to confirm disease-free status. To inform
a post-treatment strategy based on risk of recurrence, we modelled disease and economic
outcomes.
Methods
The current Alberta, Canada, post-treatment care pathway—cytology testing with colposcopy
assessment—was compared with 6 other scenarios incorporating cytology, HPV testing,
or both tests at different time points in a modelling study based on a microsimulation
program. Input parameter values for the screening participation, screening age groups,
and follow-up options and test compliance for HPV, cytology, and colposcopy were varied,
based on Alberta cervical cancer screening program data. Health outcomes over the
short- and long-term were projected, which incorporated the increasing population-level
coverage of HPV vaccination. Lifetime incremental cost-effectiveness ratios (ICERs)
were used to evaluate economic outcomes and descriptive statistics compared with numbers
of tests, visits, and procedures as well as changes in incidence and mortality rates
between the scenarios.
Results
At 5 years after implementation of the “HPV testing alone at 6 and 18 months” post-treatment
pathway, the number of colposcopies dropped by 36% and the number of pre-cancer treatments,
by 6%. Lifetime ICERs were CAD $6170 versus $248,495 per quality-adjusted life-year
compared with the status quo pathway. Cervical cancer incidence and mortality rates
decreased significantly and similarly in all scenarios.
Conclusion
Strategies that involve HPV testing in CIN post-treatment follow-up care are expected
to be more cost effective with improved clinical outcomes than traditional cytology
and colposcopy-based follow-up.
Résumé
Objectifs
Le dépistage du virus du papillome humain (VPH) peut être intégré dans le parcours
de soins post-traitement de la néoplasie intraépithéliale cervicale (CIN) pour confirmer
l’absence de maladie. Pour guider la stratégie post-traitement d’après le risque de
récidive, nous avons modélisé la maladie et les répercussions économiques.
Méthodologie
Le parcours de soins post-traitement de l’Alberta (Canada), qui consiste en un dépistage
cytologique avec une évaluation colposcopique, a été comparé avec 6 autres scénarios
intégrant la cytologie, le dépistage du VPH, ou les deux tests, à différents moments
dans une étude de modélisation réalisée à l’aide d’un programme de microsimulation.
Les valeurs des paramètres d’entrée pour la participation au dépistage, les tranches
d’âges soumises au dépistage, les options de suivi et l’adhésion au dépistage du VPH,
à la cytologie et à la colposcopie sont variées, d’après les données du programme
albertain de dépistage du cancer du col de l’utérus. Les résultats cliniques à court
et à long terme ont été projetés en tenant compte de la couverture vaccinale croissante
contre le VPH dans la population. Les rapports coût-efficacité différentiels (RCED)
à vie ont été utilisés pour évaluer les répercussions économiques et les statistiques
descriptives par rapport au nombre de dépistages, de consultations et d’interventions
ainsi qu’aux différences de l’incidence et du taux de mortalité entre les scénarios.
Résultats
À 5 ans après la mise en œuvre du parcours post-traitement « dépistage du VPH seul
à 6 et 18 mois », le nombre de colposcopies a diminué de 36 % et le nombre de traitements
pour des lésions précancéreuses a quant à lui diminué de 6 %. Les RCED à vie étaient
de 6 170 $ CA par rapport à 248 495 $ par année de vie pondérée par la qualité comparativement
au parcours post-traitement selon un statu quo. L’incidence du cancer du col de l’utérus
et le taux de mortalité associé ont diminué de façon significative et similaire dans
tous les scénarios.
Conclusion
Les stratégies qui intègrent le dépistage du VPH dans le suivi post-traitement des
CIN devraient s’avérer plus économiques et améliorer les résultats cliniques comparativement
au suivi classique par cytologie et colposcopie.
Keywords
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References
- Risk of recurrent high-grade cervical intraepithelial neoplasia after successful treatment: a long-term multi-cohort study.Lancet Oncol. 2011; 12: 441-450
- Cervical intraepithelial neoplasia outcomes after treatment: long-term follow-up from the British Columbia cohort study.J Natl Cancer Inst. 2009; 101: 721-728
- Long term risk of invasive cancer after treatment for cervical intraepithelial neoplasia grade 3: population based cohort study.BMJ. 2007; 335: 1077
- Long-term risk of invasive cervical cancer after treatment of squamous cervical intraepithelial neoplasia.Int J Cancer. 2006; 118: 2048-2055
- Incomplete excision of cervical intraepithelial neoplasia and risk of treatment failure: a meta-analysis.Lancet Oncol. 2007; 8: 985-993
- Colposcopic management of abnormal cervical cytology and histology.J Obstet Gynaecol Can. 2012; 34: 1188-1202
- HPV testing in the context of post-treatment follow up (test of cure).J Clin Virol. 2016; 76: S56-S61
- Post–loop electrosurgical excision procedure high-risk human papillomavirus testing as a test of cure: the British Columbia experience.J Low Genit Tract Dis. 2017; 21: 284-288
- Evaluation of commercial HPV assays in the context of post-treatment follow-up: Scottish test of cure study (STOCS-H).J Clin Pathol. 2014; 67: 458-463
- High-risk HPV platforms and test of cure: should specific HPV platforms more suited to screening in a ‘test of cure’ scenario be recommended?.Cytopathology. 2015; 26: 381-387
- Cost-effectiveness of human papillomavirus testing after treatment for cervical intraepithelial neoplasia.BJOG. 2007; 114: 416-424
- Cost effectiveness of human papillomavirus test of cure after treatment for cervical intraepithelial neoplasia in England: economic analysis from NHS sentinel sites study.BMJ. 2012; 345e7086
- Long-term costs of introducing HPV-DNA post-treatment surveillance to national cervical cancer screening in Ireland.Expert Rev Pharmacoecon Outcomes Res. 2015; 15: 999-1005
- Surveillance after treatment for cervical intraepithelial neoplasia: outcomes, costs, and cost-effectiveness.Obstet Gynecol. 2010; 116: 1158-1170
- OncoSim program. Canadian partnership against cancer.(Available at:) (Accessed Janaury 27, 2022)
- Cervical cancer screening.(Available at:) (Accessed January 5, 2021)
- Projected time to elimination of cervical cancer in the USA: a comparative modelling study.Lancet Public Health. 2020; 5: e213-e222
- Follow-up after loop electrosurgical excision of cervical intraepithelial neoplasia: the use of combined cytology and human papillomavirus testing.J Low Genit Tract Dis. 2021; 25: 126-129
- Prediction of recurrence after treatment for high-grade cervical intraepithelial neoplasia: the role of human papillomavirus testing and age at conisation.BJOG. 2006; 113: 1303-1307
- High-risk human papillomavirus testing versus cytology in predicting post-treatment disease in women treated for high-grade cervical disease: a systematic review and meta-analysis.Gynecol Oncol. 2012; 125: 500-507
- Patterns of persistent HPV infection after treatment for cervical intraepithelial neoplasia (CIN): a systematic review.Int J Cancer. 2017; 141: 8-23
- Guidelines for the economic evaluation of health technologies: Canada, 4th edition.CADTH, Ottawa2017
References
- The Oncosim model: development and use for better decision-making in Canadian cancer control.Curr Oncol. 2017; 24: 401
- Evaluation of the natural history of cancer of the cervix, implications for prevention. The cancer risk management model (CRMM)–human papillomavirus and cervical components.J Can Pol. 2015; 4: 1-6
- Guidelines for the economic evaluation of health technologies: Canada, 4th edition.CADTH, Ottawa2017
Article info
Publication history
Published online: February 23, 2022
Accepted:
January 28,
2022
Received:
November 3,
2021
Footnotes
Disclosures: The authors received a Seed Grant Award from the Cancer Strategic Clinical Network, Alberta Health Services, which funded this research.
All authors have indicated they meet the journal’s requirements for authorship.
Identification
Copyright
© 2022 The Society of Obstetricians and Gynaecologists of Canada/La Société des obstétriciens et gynécologues du Canada. Published by Elsevier Inc. All rights reserved.
