| ObjectiveIn 2018,the World Health Organization(WHO)made a global call for action towards elimination of cervical cancer as a public health problem,and took responsibility for drafting a Global Strategy to Accelerate the Elimination of Cervical Cancer.Whether it is feasible to eliminate cervical cancer and how to achieve the goal of elimination while minimizing the cost through an optimal pathway are the issues of major concern to the WHO and countries all over the world.This thesis takes China as an example to assess the budget optimization strategy and the possibility of eliminating cervical cancer,and try to tailor an optimal pathway for eliminating cervical cancer and evaluate its significance for public health services and health economics.MethodsAs an epidemiologic modeling study,a hybrid model was developed to assess the effectiveness of measures for cervical cancer prevention and treatment.The hybrid model consists of a human papillomavirus(HPV)dynamic transmission model and a cervical cancer natural history model.The calibrated model was used to simulate all Chinese living or projected to be born during 2015 to 2100,under the projected trends in aging,urbanization,and sexual activity.Budget optimization was performed under the constraints of current budget and two times of the current budget.Trends of cervical cancer incidence in China were projected under the scenarios of no intervention,status quo,adopting of the budget optimization strategy and no budget constraints.An optimal pathway towards cervical cancer elimination was synthesized by comprehensive evaluating the strategies for routine and catch-up HPV vaccination,and cervical cancer screening for women with different immunization history(unvaccinated,bivalent vaccinated and 9-valent vaccinated).Its effectiveness and cost-effectiveness were then evaluated from the perspective of public health services and health economic evaluation.ResultsUnder the current strategy,by 2100,the age-standardized incidence of cervical cancer is projected to increase to three times the incidence in 2015.However,if China adopts a budget optimization strategy from 2020 onwards,cervical cancer elimination can be achieved by 2072 in urban China and 2074 in rural China,with no increase to the budget for cervical cancer prevention.If the current budget were doubled from 2020 onwards,elimination would be achieved by 2063 in urban China and 2069 in rural China.The year of cervical cancer elimination would be 2057 in urban China and 2060 in rural China with no budgetary restrictions.Compared with no intervention,urban and rural areas would avoid 11.02 million and 3.149 million new cervical cancer cases in 2020 to 2100,by adopting budget optimization strategy under current budget.The most cost-effective pathway to achieve the goal of cervical cancer elimination in China is to make full use of the best available resources,comprehensively integrate the optimal strategies of different birth cohort,and thus generate an optimal pathway characterized by specific period and phase during the elimination.The optimal pathway includes six components:routine HPV vaccination,catch-up vaccination,cervical cancer screening for women with different immunization history(unvaccinated,bivalent vaccinated and 9-valent vaccinated),management and treatment of cervical intraepithelial lesions.If China fully adopts the optimal pathway,the goal of cervical cancer elimination would be achieved by 2047(95%confidence interval,2043 to 2050).Compared to the status quo,China needs to increase investment for cervical cancer prevention during 2021 to 2035.In return,the optimal pathway would eventually save China $99.711(79.441 to 129.313)billion of costs and 116(98 to 138)million of quality adjusted life years(QALYs)among women living or born in 2021 to 2100,and further avert a total of 7,509,192(6,922,744 to 8,359,074)cervical cancer cases and 2,529,873(2,366,826 to 2,802,604)cervical cancer deaths in 2021 to 2100.The discounted incremental cost-effectiveness ratio of the optimal pathway versus status quo was $-339(-687 to-79)per QALY.ConclusionsCervical cancer incidence in China would continue to increase under current cervical cancer prevention strategies.As such,it is difficult for China to achieve the goal of cervical cancer elimination.However,under the budget optimization strategy from 2020 onwards,cervical cancer would be eliminated by the early 2070s,with no increase to the budget of cervical cancer prevention.A tailored optimal pathway is the best choice in China to achieve the goal of cervical cancer elimination.By adopting the optimal pathway from 2021(namely,the year of the first Chinese Centennial Goals)onwards,cervical cancer could be eliminated by 2047(namely,ahead of the second Chinese Centennial Goals)in China.To achieve the goal of elimination,China needs to increase investment for cervical cancer prevention during 2021 to 2035,because such investment is worthwhile both from the perspective of public health services and health economic evaluation. |
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