Cost-effectiveness On Various Modalities Of Cervical Cancer Screening In Rural China

ObjectiveTo assess cost-effectiveness of various screening strategies to provide evidence for decision makers on cervical cancer control in China.Materials and MethodsWe constructed a series of models on natural history,screening,diagnosis and treatment of cervical cancer and input magnitude epidemic and cost data based on rural population.Cost-effectiveness of twenty screening strategies,in a combination of four screening methods(VIA,VIA/VILI,careHPV@1.0 and careHPV@0.5) and five screening intervals(once lifetime,twice lifetime,once every ten years,once every five years and 3-yealy in women aged 25-49 years and 5-yearly in women aged 50-64 years (recommended by IARC)),were assessed.Other factors such as screening age were also considered.Impacts on incidence,mortality and cumulative life risk of cervical cancer by different strategies were predicted in our model.Cost per life years saved(LYS) and cost per qualified adjusted life years(QALY) were used as index in the calculation of cost-effectiveness ratio(CER) compared with no screening and incremental cost-effectiveness ratio(ICER) compared with the next best strategy.The best age was determined if screened once lifetime and sensitivity analysis on several factors were also performed.ResultsOur model showed that screening method of VIA would decrease cancer incidence, mortality and cumulative life risk to the least extent,followed by VIA/VILI, careHPV@1.0 and careHPV@0.5 based on rural data.Decreased cervical cancer mortality was more significant with increased screening frequency as follows:once lifetime(7.7-12.0%),twice lifetime(15.0-23.1%),once every ten years(18.3-27.0%), once every five years(30.2-40.8%) and IARC recommended interval(40.9-51.8%).All CER values of twenty screening strategies were less than local gross domestic product (GDP) per capita,ranged from 2509.18 to 10588.84 yuan per YLS and from 2370.95 to 10082.02 yuan per QALY.ICER analysis revealed that most strategies on the "efficiency curve" involved visual inspection screening.The most effective age of once-lifetime screening was found between 35-50 years.Our sensitivity analysis detected that the model was very sensitive to the progression rate from CIN3 to cancer,discount rate, screening cost and sensitivity of screening methods etc.ConclusionsWhen using local per capita GDP as threshold,all strategies evaluated in our model are very cost-effective.At present,primary visual inspection could be effective and cost-effective in rural population.Primary screening would be an optimal ideal in future when it becomes available in rural area.The best once-lifetime screening age falls in the range of 35-50 years.Once-lifetime screening might have relatively limited long term effects on cancer incidence and mortality,thus more frequent screening strategies in lifetime are recommended.This study offered evidence for the feasibility of incorporating cervical screening into government-covered public health programs and for the decision makers to choose most effective and cost-effective cervical screening strategy in rural China.