title: Cost-effectiveness analysis based on the atypical squamous cells of undetermined significance/low-grade squamous intraepithelial lesion Triage Study (ALTS).
abstract: BACKGROUND
  The ALTS (atypical squamous cells of undetermined significance [ASCUS] and low-grade squamous intraepithelial lesion [LSIL] Triage Study) suggests that, for women diagnosed with ASCUS, human papillomavirus (HPV) DNA testing followed by referral to colposcopy of only those women with oncogenic HPV (i.e., HPV DNA testing) is as effective at detecting cervical intraepithelial neoplasia (CIN) 3 or cancer (CIN3+) as referring all women with ASCUS for immediate colposcopy. We conducted a cost-effectiveness analysis of the ALTS trial to determine whether HPV DNA testing is a cost-effective alternative to immediate colposcopy or conservative management with up to three cytology examinations.
  
  
  METHODS
  Data from the ALTS trial were used in conjunction with medical care costs in a short-term decision model. The model compared the incremental costs per case of CIN3+ detected as measured by the incremental cost-effectiveness ratio (ICER) for the following management strategies for women with ASCUS: immediate colposcopy, HPV DNA testing, and conservative management with up to three cytology examinations.
  
  
  RESULTS
  The least costly and least sensitive strategy was conservative management with one repeat cytology examination using a threshold of high-grade squamous intraepithelial lesion (HSIL) for referral to colposcopy. Compared with this strategy, triage to colposcopy based on a positive HPV DNA test result had an ICER of 3517 dollars per case of CIN3+ detected. Immediate colposcopy and conservative management with up to three repeat cytology visits detected fewer cases of CIN3+ and were more costly than HPV DNA testing. Immediate colposcopy became cost-effective at 20,370 dollars compared with HPV DNA testing only if colposcopy and biopsy were assumed to be 100% sensitive.
  
  
  CONCLUSIONS
  HPV DNA testing is an economically viable strategy for triage of ASCUS cytology. The less than perfect sensitivity of colposcopy and biopsy needs to be accounted for in future clinical guidelines and policy analyses.
authors.affiliation: Department of Obstetrics and Gynecology, Duke University, Durham, NC, USA. kulas002@mc.duke.edu
authors.forename: Shalini L
authors.initials: SL
authors.lastname: Kulasingam
authors.forename: Jane J
authors.initials: JJ
authors.lastname: Kim
authors.forename: William F
authors.initials: WF
authors.lastname: Lawrence
authors.forename: Jeanne S
authors.initials: JS
authors.lastname: Mandelblatt
authors.forename: Evan R
authors.initials: ER
authors.lastname: Myers
authors.forename: Mark
authors.initials: M
authors.lastname: Schiffman
authors.forename: Diane
authors.initials: D
authors.lastname: Solomon
authors.forename: Sue J
authors.initials: SJ
authors.lastname: Goldie
mesh_terms: D000328:Adult; D000368:Aged; D002294:Carcinoma, Squamous Cell / Q000175:diagnosis / Q000191:economics* / Q000821:virology; D003127:Colposcopy / Q000191:economics*; D003362:Cost-Benefit Analysis; D015344:DNA Probes, HPV / Q000191:economics*; D004279:DNA, Viral / Q000302:isolation & purification; D003663:Decision Trees; D004180:Direct Service Costs; D005260:Female; D006801:Humans; D008403:Mass Screening / Q000191:economics* / Q000379:methods; D008875:Middle Aged; D015337:Multicenter Studies as Topic; D027383:Papillomaviridae / Q000235:genetics / Q000302:isolation & purification*; D016032:Randomized Controlled Trials as Topic; D012680:Sensitivity and Specificity; D014218:Triage / Q000191:economics; D014481:United States; D002583:Uterine Cervical Neoplasms / Q000175:diagnosis / Q000191:economics* / Q000821:virology; D002578:Uterine Cervical Dysplasia / Q000175:diagnosis / Q000191:economics
chemical_list: D015344:DNA Probes, HPV; D004279:DNA, Viral