Sunday, October 18, 2009
Grand Ballroom, Salons 1 & 2 (Renaissance Hollywood Hotel)
Jane J. Kim, PhD, Jesse D. Ortendahl, BS and Sue J. Goldie, MD, MPH, Harvard School of Public Health, Boston, MA
Purpose: Women over the age of 30 are the main beneficiaries of improved cervical cancer screening with human papillomavirus (HPV) DNA testing. The role of vaccination against HPV types 16 and 18, recommended routinely in pre-adolescent girls, is unclear. We assessed the health and economic outcomes of HPV vaccination in older women participating in the U.S. screening program. Method: We used a previously-developed individual-based Monte Carlo simulation model that simulates the natural history of HPV and cervical disease, as well as primary and secondary preventive interventions. Using a likelihood-based approach, the model was calibrated to fit to epidemiological data, including HPV prevalence, cervical cancer incidence, and HPV type distribution among women with lesions and cancer from the U.S. We conducted analyses of HPV vaccination added to screening strategies that differed by test (cytology, HPV DNA testing, combined) and frequency (1- to 5-year) among women ages 35 to 45 years, compared to screening alone. Lifetime costs included direct medical costs associated with vaccination, screening, diagnosis, and treatment, as well as patient time and transportation. Sensitivity analyses were conducted to explore how results were influenced by uncertainties, such as screening performance, vaccine efficacy, and vaccine cost. A probabilistic sensitivity analysis was conducted using 50 good-fitting parameter sets. Result: Among women undergoing annual or biennial screening using cytology with HPV DNA testing as triage, adding vaccination ranged from $116,950 to $272,350 per quality-adjusted life year (QALY) gained compared to screening alone, depending on age and screening frequency. In the context of current U.S. screening patterns, in which women are screened with variable frequency, adding HPV vaccination ranged from $127,030 to $178,850 per QALY using cytology testing with HPV triage for screening, and from $187,380 to $263,860 per QALY using combination cytology and HPV DNA testing for screening after age 30. The incremental cost-effectiveness of adding vaccination to screening was less attractive at older ages. Probabilistic sensitivity analysis revealed that the probability of HPV vaccination being cost-effective for screened women ages 35-45 was <10% at thresholds considered good value for money. Conclusion: Given currently available information, the incremental effectiveness of HPV vaccination of screened women over age 30 appears to be small. Compared with current screening that uses sensitive HPV DNA testing, vaccination is not cost-effective in this population.
Candidate for the Lee B. Lusted Student Prize Competition
