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Background Cervical-cancer screening strategies that involve the use of conventional cytology and require multiple visits have been impractical in developing countries.
Methods We used computer-based models to assess the cost-effectiveness of a variety of cervical-cancer screening strategies in India, Kenya, Peru, South Africa, and Thailand. Primary data were combined with data from the literature to estimate age-specific incidence and mortality rates for cancer and the effectiveness of screening for and treatment of precancerous lesions. We assessed the direct medical, time, and program-related costs of strategies that differed according to screening test, targeted age and frequency, and number of clinic visits required. Single-visit strategies involved the assumption that screening and treatment could be provided in the same day. Outcomes included the lifetime risk of cancer, years of life saved, lifetime costs, and cost-effectiveness ratios (cost per year of life saved).
Results The most cost-effective strategies were those that required the fewest visits, resulting in improved follow-up testing and treatment. Screening women once in their lifetime, at the age of 35 years, with a one-visit or two-visit screening strategy involving visual inspection of the cervix with acetic acid or DNA testing for human papillomavirus (HPV) in cervical cell samples, reduced the lifetime risk of cancer by approximately 25 to 36 percent, and cost less than $500 per year of life saved. Relative cancer risk declined by an additional 40 percent with two screenings (at 35 and 40 years of age), resulting in a cost per year of life saved that was less than each country's per capita gross domestic product — a very cost-effective result, according to the Commission on Macroeconomics and Health.
Conclusions Cervical-cancer screening strategies incorporating visual inspection of the cervix with acetic acid or DNA testing for HPV in one or two clinical visits are cost-effective alternatives to conventional three-visit cytology-based screening programs in resource-poor settings.
Source Information
From the Department of Health Policy and Management, Harvard School of Public Health, Boston (S.J.G.); JHPIEGO, Baltimore (L.G.); the Ph.D. Program in Health Policy, Harvard University, Cambridge, Mass. (J.D.G.-F.); the Pan American Health Organization–World Health Organization, Washington, D.C. (A.G.-T.); the Program for Appropriate Technology in Health, Seattle (C.L.); the International Agency for Research on Cancer–World Health Organization, Lyon, France (C.M.); and the College of Physicians and Surgeons, Columbia University, New York (T.C.W.).
Address reprint requests to Dr. Goldie at the Department of Health Policy and Management, Harvard School of Public Health, Harvard University Initiative for Global Health, 104 Mt. Auburn St., 3rd Fl., Cambridge, MA 02138, or at sue_goldie{at}harvard.edu.
Related Letters:
Cost-Effectiveness of Cervical-Cancer Screening in Developing Countries
Suba E. J., Frable W. J., Raab S. S., Goldie S. J.
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N Engl J Med 2006;
354:1535-1536, Apr 6, 2006.
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