OPTIMIZING CERVICAL CANCER SCREENING PARTICIPATION

Purpose: Participation and follow-up compliance in screening programs are typically well below 100 percent, resulting in forgone health benefits and excessive costs. In Norway, approximately 60% of eligible women attend cervical cancer screening according to recommendations (every 3 years), but the remaining never attend (10%), attend less frequently than recommended (20%), or attend more frequently than recommended (10%). In addition, approximately 25% of women who receive abnormal results fail to return for follow-up testing. We conducted a threshold analysis to estimate the maximum amount that could be spent to optimize participation and follow-up rates in order to improve cervical cancer prevention in Norway.

Method: We employed a first-order Monte Carlo simulation model that was empirically calibrated to reflect the natural history of cervical cancer in Norway and previously used to identify optimal screening approaches being actively considered by the Norwegian government. A scenario reflecting status quo screening participation was compared to three scenarios that target different subgroups of non-compliant screeners. Scenario 1 targets women who fail to follow-up abnormal results, scenario 2 targets women who either attend too frequently or too seldom in addition to those who fail to follow-up abnormal results, and scenario 3 assumes additionally targeting nonscreeners (i.e., perfect participation and follow-up). The analysis was conducted with a sample of good-fitting parameter sets to generate plausible ranges around the mean expected benefit and cost of the scenarios.

Result: All three scenarios resulted in increased lifetime costs per woman (i.e., no strategy was cost saving or cost neutral). However, all strategies produced positive net monetary benefits according to the current willingness-to-pay threshold of 500,000 Norwegian Kroner per year of life saved (≈$83,000). For example, we found that Norwegian authorities could spend an additional $256 on average (range: $145-$390) per woman on a program specifically targeted to improving the follow-up rate for women with abnormal results. Likewise, completely optimizing screening (i.e., scenario 3) was found to be yield positive net monetary benefits provided the cost of improving participation and follow-up was $368 (range: $165-$577) per woman or less.

Conclusion: This threshold analysis indicates that considerable funds could be allocated towards policies that improve compliance to screening recommendations among those who under- or over-screen and/or by improving follow-up among women with abnormal results.