Cost-effectiveness of human papillomavirus vaccination and screening in Spain.
BACKGROUND
In Spain, prophylactic vaccination against human papillomavirus (HPV) types 16 and 18 is being offered free-of-charge to one birth cohort of girls aged 11-14. Screening is opportunistic (annual/biannual) contributing to social and geographical disparities.


METHODS
A multi-HPV-type microsimulation model was calibrated to epidemiologic data from Spain utilising likelihood-based methods to assess the health and economic impact of adding HPV vaccination to cervical cancer screening. Strategies included (1) screening alone of women over age 25, varying frequency (every 1-5 years) and test (cytology, HPV DNA testing); (2) HPV vaccination of 11-year-old girls combined with screening. Outcomes included lifetime cancer risk, life expectancy, lifetime costs, number of clinical procedures and incremental cost-effectiveness ratios.


RESULTS
After the introduction of HPV vaccination, screening will need to continue, and strategies that incorporated HPV testing are more effective and cost-effective than those with cytology alone. For vaccinated girls, 5-year organised cytology with HPV testing as triage from ages 30 to 65 costs 24,350€ per year of life saved (YLS), assuming life-long vaccine immunity against HPV-16/18 by 3 doses with 90% coverage. Unvaccinated girls would benefit from organised cytology screening with HPV testing as triage; 5-year screening from ages 30 to 65 costs 16,060€/YLS and 4-year screening from ages 30 to 85 costs 38,250€/YLS. Interventions would be cost-effective depending on the cost-effectiveness threshold and the vaccine price.


CONCLUSIONS
In Spain, inequitable coverage and overuse of cytology make screening programmes inefficient. If high vaccination coverage among pre-adolescent girls is achieved, organised cytology screening with HPV triage starting at ages 30 to at least 65 every 4-5 years represents the best balance between costs and benefits.
Diaz
Mireia
M
Unit of Infections and Cancer, Cancer Epidemiology Research Program, Catalan Institute of Oncology, IDIBELL, Av. Gran Via 199-203, 08907 L'Hospitalet de Llobregat, Barcelona, Spain. mireia@iconcologia.net
de Sanjose
Silvia
S
Ortendahl
Jesse
J
O'Shea
Meredith
M
Goldie
Sue J
SJ
Bosch
F Xavier
FX
Kim
Jane J
JJ
D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002648:Child; D003362:Cost-Benefit Analysis; D003584:Cytological Techniques / Q000191:economics; D005260:Female; D052162:Human papillomavirus 16; D052161:Human papillomavirus 18; D006801:Humans; D015994:Incidence; D008403:Mass Screening / Q000191:economics / Q000379:methods; D008875:Middle Aged; D030361:Papillomavirus Infections / Q000191:economics* / Q000453:epidemiology / Q000517:prevention & control; D053918:Papillomavirus Vaccines / Q000191:economics*; D019057:Quality-Adjusted Life Years; D012307:Risk Factors; D013030:Spain / Q000453:epidemiology; D002583:Uterine Cervical Neoplasms / Q000191:economics* / Q000453:epidemiology / Q000517:prevention & control; D014611:Vaccination / Q000191:economics / Q000379:methods; D055815:Young Adult; D002578:Uterine Cervical Dysplasia / Q000191:economics* / Q000453:epidemiology / Q000517:prevention & control
D053918:Papillomavirus Vaccines