Cost effectiveness of human papillomavirus test of cure after treatment for cervical intraepithelial neoplasia in England: economic analysis from NHS Sentinel Sites Study

Abstract

Objectives: To evaluate the cost effectiveness of human papillomavirus testing after treatment for cervical intraepithelial neoplasia (CIN).

Design: Economic analysis using a Markov modelling approach to combine cost and epidemiological data from the NHS Sentinel Sites Study with data from previous studies of post-treatment recurrence rates.

Setting: English NHS Cervical Cancer Screening Programme.

Interventions: Management guidelines after treatment of CIN involving annual cytology follow-up for 10 years, compared with alternative protocols using the human papillomavirus test to reduce the amount of post-treatment surveillance.

Main outcome measures: Cases of underlying CIN3+ averted at 10 years and costs per 1000 women treated.

Results: Model predictions indicated that, at observed levels of compliance with post-treatment recommendations, management with only cytological follow-up would result in 29 residual cases of recurrent CIN3+ by 10 years and would cost £358,222 (€440,426; $574,910) (discounted) per 1000 women treated. Implementation of human papillomavirus test of cure in cytologically negative women according to the sentinel sites protocol would avert an additional 8.4 cases of CIN 3+ and reduce costs by £9388 per 1000 women treated.

Conclusions: Human papillomavirus test of cure would be more effective and would be cost saving compared with cytology only follow-up. The results of this evaluation support the full scale implementation of human papillomavirus test of cure after treatment of CIN within the NHS Cervical Screening Programme.

Fig 1 Model predicted prevalence of residual recurrent underlying cases of cervical intraepithelial neoplasia (CIN) 3+ over 10 years after initial treatment. HPV=human papillomavirus

Fig 2 Effect of various model assumptions on cost per additional residual recurrent cervical intraepithelial neoplasia (CIN) 3+ case averted, compared with cytology only follow-up. HPV=human papillomavirus; LBC=liquid based cytology. *Under perfect compliance assumptions, this strategy was predicted to result in more underlying CIN3+ at 10 years than cytology only follow-up, so cost per underlying case of CIN3+ averted should be interpreted as cost per underlying case of CIN3+ averted by cytology only follow-up compared with HPV testing strategy. †Population composition (age structure and proportion treated for CIN1 v CIN2+) was varied to reflect different post-treatment populations observed in HPV Sentinel Sites Study and in a recent study of post-treatment management.² Baseline analyses reflected HPV sentinel sites population, in which 63% of treated women were younger than 35 years and 10% of women were treated for CIN1 and the remainder for CIN2+. The “younger” population had a higher proportion of treated women aged <35 years (73%), consistent with that observed in a previous study; the “more CIN1” population had a higher proportion of women treated for CIN1 (23.6%), consistent with that observed in a previous study. ‡Sensitivity and specificity varied within feasible range. §Effect on outcomes was too small to show substantial variation in this depiction. ¶Negative values indicate that strategy prevents more cases and is cost saving compared with cytology only follow-up