Impact of patient adherence and test performance on the cost-effectiveness of cervical cancer screening in developing countries: the case of Honduras.
OBJECTIVE
We examined the impact of patient adherence and screening test performance on the cost-effectiveness of visual inspection with acetic acid (VIA) and Pap smears when used with colposcopy for diagnosis.


METHODS
Cost-effectiveness analysis was performed using computer modeling. The primary outcome was cancer prevalence in the 10 years after screening. Three hypothetical populations of 35-year-old women were compared: never-screened women, women screened with VIA, and women screened with Pap smears. We used community-based data from our screening program in Honduras to estimate screening test sensitivity and specificity, adherence to follow-up, and costs of screening and colposcopy services. Published data were used to model disease outcomes.


RESULTS
VIA was more sensitive than Pap smears (70% vs. 4%), less expensive (U.S. 0.23 dollars vs. 3.17 dollars), and the 2-vist VIA system had a higher rate of adherence to follow-up than the 3-visit Pap smear system (84% vs. 38%). VIA had a higher false-positive rate than Pap smears resulting in higher colposcopy referral rates, but more dysplasia was detected and treated. Cost-effectiveness analysis revealed that screening with VIA would cost U.S. 3,198 dollars per cancer case avoided and reduce cancer cases by 42%, versus U.S. 36,802 dollars and 2% for Pap screening. Although Pap smear quality was low in Honduras, sensitivity analysis showed that VIA was more cost-effective than Pap smears, even when test accuracy was equivalent.


CONCLUSIONS
In developing countries, systems barriers can limit the cost-effectiveness of Pap smears. VIA may be a cost-effective alternative for some resource-poor settings, although systems barriers, quality control, and feasibility issues must be considered.
Perkins
Rebecca B
RB
Department of Obstetrics and Gynecology, Boston University Medical Center, 85 E. Concord St. 6th Floor, Boston, MA 02118, USA. rebecca.perkins@bmc.org
Langrish
Sarah M
SM
Stern
Linda J
LJ
Burgess
James F
JF
Simon
Carol J
CJ
D019342:Acetic Acid; D000328:Adult; D003362:Cost-Benefit Analysis; D003906:Developing Countries; D055088:Early Detection of Cancer / Q000191:economics*; D005260:Female; D019983:Guideline Adherence / Q000191:economics; D006721:Honduras; D006801:Humans; D008403:Mass Screening / Q000191:economics*; D065006:Papanicolaou Test; D010349:Patient Compliance / Q000706:statistics & numerical data*; D011795:Surveys and Questionnaires; D002583:Uterine Cervical Neoplasms / Q000191:economics / Q000517:prevention & control*; D014626:Vaginal Smears / Q000191:economics*; D002578:Uterine Cervical Dysplasia / Q000191:economics / Q000517:prevention & control*
D019342:Acetic Acid