Health economic aspects of cervical cancer screening

Healthcare reform and rising costs are driving demand for resource efficiency to facilitate better-informed healthcare decisions. Health economics represent an interdisciplinary set of tools and concepts to assess the value of everyday decisions, taken in complex healthcare settings, to improve healthcare. Many alternative screening methods are currently available, but knowledge about costs and the value of potential health gains is inadequate. The aims of the thesis were to study the efficiency in the allocation of resources to cervical cancer screening of importance for setting priorities: the cost of the most prevalent Human Papillomavirus (HPV) related diseases namely cervical dysplasia, cervical cancer and genital warts, modeling the cost-effectiveness of cervical cancer screening and exploring knowledge of HPV, compliance with screening and its correlates.

In one study, we estimated the costs from a societal perspective, of the HPV-related diseases namely cervical dysplasia, cervical cancer and genital warts. Results provided an estimate of €108 million annually showing a significant economic burden on the Swedish welfare system appointed by the most prevalent HPV-related diseases attributable to HPV 6, 11, 16 and 18 infections. A Markov model was developed to simulate the natural history of HPV, cervical dysplasia and cervical cancer to project the cost-effectiveness of HPV self-sampling within the framework of the Swedish organized screening program. Projected results showed that screening with conventional cytology up to age 35 and thereafter screening with HPV self-sampling at home with five-year time intervals between screening opportunities is potentially cost-effective compared with either no screening or with current cytology based screening practice. A decision analytic model was developed to evaluate cost-effectiveness of follow-up with HPV triage compared with repeat cytology and immediate colposcopy with biopsy on women with index smear diagnosis of ASCUS and LSIL within the Swedish organized screening program. Model results showed that immediate colposcopy with biopsy was a cost effective follow-up strategy compared with the alternatives. Given the improvement in HPV testing techniques at lower costs, HPV triage can become a cost-effective alternative for follow-up of minor cytological abnormalities. A descriptive study approach was used to assess possible barriers to and facilitators of cervical cancer screening by estimating time and travel costs and other direct non-medical costs incurred in clinic-based screening, investigating compliance with screening and reasons for noncompliance, determining women’s knowledge of human papillomavirus (HPV), and investigating correlates of HPV knowledge and compliance with screening. Via self-administered questionnaires, data were obtained from 1 510 women attending the Swedish organized cervical cancer screening program. The study concluded that time and travel costs of clinic-based screening can be substantial, may influence overall cost effectiveness of screening programs and constitute barriers to screening. Women with knowledge of HPV and who did not take time off work to attend screening were more likely to comply with screening.

Altogether, this thesis has contributed new health economic data on the societal cost of HPV related diseases; cervical dysplasia, cervical cancer and genital warts on a national level, and patient-level data of indirect costs and other direct non-medical costs for women attending the Swedish organized screening program. This together with data on women's knowledge about HPV and their compliance with screening are valuable information for further policy decisions on revising the organized screening program. By assessing the impact of HPV-related diseases in terms of costs is one important step towards efficient allocation of resources to reduce the economic burden of these diseases. These data are also valuable contribution to economic evaluations, providing information for resource allocation when choosing among different screening methods to reduce disease burden, as well as contributing to knowledge of compliance with population-based preventive health programs.

List of scientific papers

I. Östensson E, Fröberg M, Hjerpe A, Zethraeus N, Andersson S. Economic analysis of human papillomavirus triage, repeat cytology, and immediate colposcopy in management of women with minor cytological abnormalities in Sweden. Acta Obstetricia et Gynecologica. 2010;89(10):1316-25.
https://doi.org/10.3109/00016349.2010.512066

II. Östensson E, Hellström A-C, Hellman K, Gustavsson I, Gyllensten U, Wilander E, Zethraeus N, Andersson S. Projected cost-effectiveness of repeat high-risk human papillomavirus testing using self-collected vaginal samples in the Swedish cervical cancer screening program. Acta Obstetricia et Gynecologica. 2013;92(7):830-40.
https://doi.org/10.1111/aogs.12143

III. Östensson E, Adler S, Elfström K.M, Sundström K, Zethraeus N, Andersson S. Barriers to and facilitators of compliance with clinic-based cervical cancer screening: population-based cohort study of women aged 23-60 years. [Manuscript]

IV. Östensson E, Fröberg E, Leval A, Hellström A-C, Bäcklund M, Zethraeus N, and Andersson S. Cost of preventing, managing and treating human papillomavirus (HPV)-related diseases before the introduction of quadrivalent HPV vaccination. [Manuscript]