Jane J. Kim, MS1, Shalini Kulasingam, PhD
2, William F. Lawrence, MD, MSc
3, Jeanne Mandelblatt, MD, MPH
4, Evan Myers, MD, MPH
2, Mark Schiffman, MD, MPH
5, Diane Solomon, MD
5, and Sue J. Goldie, MD, MPH
1. (1) Harvard School of Public Health, Cambridge, MA, (2) Duke University, Durham, NC, (3) Agency for Healthcare Research and Quality, Rockville, MD, (4) Georgetown University Medical Center and Cancer Clinical and Economic Outcomes Core, Washington, DC, (5) National Cancer Institute, NIH DHHS, Rockville, MD
Purpose: Findings from the ASCUS and LSIL Triage Study (ALTS) suggest that for women with ASCUS Pap test results, human papillomavirus (HPV) DNA testing is effective at detecting underlying high-grade precancerous lesions or cancer (CIN3+). While policy analyses have been conducted to explore the long-term cost-effectiveness of such a recommendation, a cost-effectiveness analysis of the trial based on the primary data has not yet been performed. In this study, we used the ALTS trial data to determine the short-term cost-effectiveness of alternative strategies for the management of ASCUS. Methods: Data from the ALTS trial were used in conjunction with medical care costs in a short-term decision model. The model compared the incremental costs per case of detected CIN 3+ for five ASCUS triage strategies employed in the three arms of the trial: (1) immediate colposcopy (IC); (2) HPV DNA testing; and (3) conservative management (CM), involving a program of up to 1, 2, or 3 repeat cytology visits. Results: The observed sensitivity of colposcopy and biopsy for detecting CIN 3+ ranged from 46% to 91% in the trial. Using these data in the base case model, the least costly strategy was CM with 1 repeat cytology for referral to colposcopy. Triage to colposcopy based on a positive HPV DNA test result had an incremental cost-effectiveness ratio of $3,514 per CIN 3+ detected compared to CM with 1 repeat cytology visit. Strategies of IC and CM with (up to) 3 repeat cytology visits were dominated by HPV DNA testing. HPV DNA triage had a lower cost-effectiveness ratio in women 30 years and older than in younger women ($2,917 vs. $3,806 per CIN 3+ detected, compared to CM). Immediate colposcopy only became non-dominated when colposcopy and biopsy were assumed to be perfectly sensitive and specific, and cost $20,370 per CIN 3+ detected, compared to HPV DNA triage. Conclusions: These results support that HPV DNA testing is an economically viable strategy for triage of ASCUS cytology, consistent with findings from other policy analyses. The analysis also underscores the need to account for the sub-optimal performance of colposcopy and biopsy in future clinical practice guidelines and policy analyses.
See more of Poster Session II
See more of The 27th Annual Meeting of the Society for Medical Decision Making (October 21-24, 2005)
