Economic evaluation of HPV DNA test as primary screening method for cervical cancer: A health policy discussion in Greece

Background
HPV test appears to be more effective in cervical cancer (CC) screening. However, the decision of its adoption as a primary screening method by substituting the established cytology lies in the evaluation of multiple criteria. Aim of this study is to evaluate the economic and clinical impact of HPV test as primary screening method for CC.
Methods
A decision tree and a Markov model were developed to simulate the screening algorithm and the natural history of CC. Fourteen different screening strategies were evaluated, for women 25–65 years old. Clinical inputs were drawn from the HERMES study and cost inputs from the official price lists. In the absence of CC treatment cost data, the respective Spanish costs were used after being converted to 2017 Greek values. One-way and probabilistic sensitivity analyses were conducted.
Results
All screening strategies, that offer as primary screening method triennial HPV genotyping (simultaneous or reflex) alone or as co-testing with cytology appear to be more effective than all other strategies, with regards to both annual CC mortality, due to missed disease (-10.1), and CC incidence(-7.5) versus annual cytology (current practice). Of those, the strategy with HPV test with simultaneous 16/18 genotyping is the strategy that provides savings of 1.050 million euros annually. However, when the above strategy is offered quinquennially despite the fact that outcomes are decreased it remains more effective than current practice (-7.7 deaths and -1.3 incidence) and more savings per death averted (1.323 million) or incidence reduced (7.837 million) are realized.
Conclusions
HPV 16/18 genotyping as a primary screening method for CC appears to be one of the most effective strategies and dominates current practice in respect to both cost and outcomes. Even when compared with all other strategies, the outcomes that it generates justify the cost that it requires, representing a good value for money alternative.

研究背景：人乳头瘤病毒（Human Papillomavirus, HPV）检测在宫颈癌（Cervical Cancer, CC）筛查中展现出更优的应用效果。然而，将其替代现行细胞学检查作为一线筛查手段的决策，需基于多项标准开展综合评估。本研究旨在评估HPV检测作为宫颈癌一线筛查手段的经济学与临床影响。
研究方法：本研究构建了决策树与马尔可夫（Markov）模型，以模拟宫颈癌筛查流程与疾病自然史。针对25~65岁女性群体，共评估了14种不同的筛查策略。临床参数源自HERMES研究，成本参数则取自官方定价清单。由于缺乏宫颈癌治疗成本的直接数据，本研究采用西班牙地区的相关成本数据，并转换为2017年希腊货币价值。此外，本研究开展了单因素敏感性分析与概率敏感性分析。
研究结果：相较于现行的年度细胞学检查策略，所有以每三年一次HPV分型检测（单独开展或同步/溯源分型）作为一线筛查手段，或联合细胞学检查实施该检测的策略，在宫颈癌年死亡率（因漏诊导致）与发病率方面均表现更优，分别可降低死亡率10.1、发病率7.5。其中，同步开展16/18型HPV分型检测的策略，每年可节省105万欧元。但若将该策略调整为每五年一次实施，尽管筛查结局有所下降，仍优于现行筛查方案（可降低死亡率7.7、发病率1.3），且每挽救一例生命所需节省的成本达132.3万欧元，每减少一例发病所需节省的成本达783.7万欧元。
研究结论：将16/18型HPV分型检测作为宫颈癌一线筛查手段，是目前最为有效的筛查策略之一，在成本与筛查结局两方面均优于现行临床实践。即便与其他所有筛查策略相比，该策略所达成的筛查结局也足以覆盖其投入成本，是一种具备高性价比的替代方案。