OVERTREATMENT AND COST-EFFECTIVENESS OF SEE-AND-TREAT APPROACH IN MANAGING CERVICAL SQUAMOUS INTRAEPITHELIAL LESIONS IN THE US SETTING

Purpose:

   The see-and-treat approach for high-grade intraepithelial lesions involves loop electrosurgical excision procedure (LEEP) at time of colposcopy without histological confirmation (as is done in usual care). This see-and-treat strategy may especially be appropriate for populations with poor adherence rates – it may save costs, but may also lead to overtreatment. This study investigates the overtreatment and cost-effectiveness of the see-and-treat strategy compared with usual care.

Methods:

   We created a hypothetical cohort to simulate a group of women that would be seen at a colposcopy clinic: we modeled a cohort of 12-year-old females who have not been screened for cervical cancer through the age of 40. We followed this cohort through their lifetimes using a state-transition Markov model. From a U.S. health system perspective, the analysis was conducted in 2012 dollars and effectiveness was measured in quality-adjusted life-years (QALYs). We used incremental cost-effectiveness ratios (ICERs) using a willingness-to-pay threshold of $50,000/QALY to determine whether the see-and-treat strategy was favorable. The robustness of the see-and-treat strategy's cost-effectiveness was further examined in deterministic and probabilistic sensitivity analyses. Finally, we estimated the overtreatment rate of the see-and-treat strategy.

Results:

   In the base-case analysis, the see-and-treat strategy increased the quality-adjusted life expectancy by 0.006 QALY and yielded an ICER of $74,821/QALY compared with usual care. In deterministic sensitivity analysis, the cost-effectiveness of the see-and-treat strategy was sensitive to the disutility of LEEP treatment and to the lack of treatment adherence after the required biopsy in usual care. Other factors that influenced the cost-effectiveness included the specificity and the cost of the Papanicolaou smear, the cost of LEEP treatment, and the diagnostic ability of the colposcopic procedure. The cost-effectiveness acceptability curves showed that the see-and-treat strategy was less likely to be cost-effective compared with the usual care. Of note, the overtreatment rate in the see-and-treat was 7.3% (95%CI: 6.7%-7.9%).

Conclusion:

   The see-and-treat strategy yields an acceptably low overtreatment rate. However, it is not cost-effective compared with the usual care from a health system perspective. The cost-effectiveness of the see-and-treat strategy is most affected by treatment compliance in usual care and the disutility of LEEP treatment. The cost savings achieved by reduced utilization of biopsy in the see-and-treat strategy were outweighed by the cost of the additional LEEP treatments.