Candidate for the Lee B. Lusted Student Prize Competition
Purpose: While the estimated age-standardized cervical cancer (CC) rate in Lebanon is relatively low (3.8 per 100,000 women years), most cases are detected at later stages. There is no national organized CC screening program in Lebanon. Rather, screening is opportunistic and limited to women who can afford to pay out-of-pocket for exams. As a result, a small percentage of women receive frequent screening with annual cytology while the majority are never screened. We evaluated the health and economic effects of expanding screening coverage and extending screening intervals in Lebanon.
Method: We used an individual-based Monte Carlo simulation model that simulates the natural history of HPV and cervical disease, as well preventive interventions. Using a likelihood-based approach, we calibrated the model to primary epidemiological data from Lebanon, including CC incidence and HPV type distribution among women with lesions and cancer. Analyses were conducted using the 50 best-fitting parameter sets. We evaluated cytology screening strategies for women aged 25 to 60 years, varying coverage from 20-80% and frequency from annual to every five years. Lifetime costs included direct medical costs associated with screening, diagnosis, and treatment, as well as patient time and transportation. Sensitivity analyses were conducted to explore the effects of screening performance, screening modality, and cost.
Result: Repeated annual cytologic screening among 20% of screen-eligible women reduced CC incidence by only 14% and cost I$52,740 per quality-adjusted life year (QALY) gained, compared to triennial screening of the same population; this far exceeded Lebanon’s gross domestic product (GDP) per capita (I$12,610), a common threshold for identifying strategies that are good value for money. Increasing screening coverage to 50% at triennial intervals resulted in a greater CC reduction (26%) and was cost-effective at I$8,040 per QALY. Further raising coverage levels to 70% with triennial screening yielded the highest CC reductions (43%) and was associated with a cost per QALY that fell just below Lebanon’s GDP per capita. Increasing coverage of annual cytology was not found to be cost-effective under plausible scenarios.
Conclusion: Current screening practice in Lebanon of repeated cytology in a small percentage of women is very inefficient. Increasing screening coverage to 70% with extended screening intervals provides greater health benefits at a reasonable cost and will likely lead to more equitable distribution of health gains.