Surveillance after treatment for cervical intraepithelial neoplasia: outcomes, costs, and cost-effectiveness.
OBJECTIVE
To estimate outcomes and costs of surveillance strategies after treatment for high-grade cervical intraepithelial neoplasia (CIN).


METHODS
A hypothetical cohort of women was evaluated after treatment for CIN 2 or 3 using a Markov model incorporating data from a large study of women treated for CIN, systematic reviews of test accuracy, and individual preferences. Surveillance strategies included initial conventional or liquid-based cytology, human papillomavirus testing, or colposcopy 6 months after treatment, followed by annual or triennial cytology. Estimated outcomes included CIN, cervical cancer, cervical cancer deaths, life expectancy, costs, cost per life-year, and cost per quality-adjusted life-year.


RESULTS
Conventional cytology at 6 and 12 months, followed by triennial cytology, was least costly. Compared with triennial cytology, annual cytology follow-up reduced expected cervical cancer deaths by 73% to 77% and had an average incremental cost per life-year gained of $69,000 to $81,000. For colposcopy followed by annual cytology, the incremental cost per life-year gained ranged from $70,000 to more than $1 million, depending on risk. Between-strategy differences in mean additional life expectancy per woman were less than 4 days; differences in mean incremental costs per woman were as high as $822. In the cost-utility analysis, colposcopy at 6 months followed by annual cytology had an incremental cost per quality-adjusted life-year of less than $5,500. Human papillomavirus testing or liquid-based cytology added little to no improvement to life-expectancy with higher costs.


CONCLUSIONS
Annual conventional cytology surveillance reduced cervical cancers and cancer deaths compared with triennial cytology. For high risk of recurrence, a strategy of colposcopy at 6 months increased life expectancy and quality-adjusted life expectancy. Human papillomavirus testing and liquid-based cytology increased costs, but not effectiveness, compared with traditional approaches.
Melnikow
Joy
J
Department of Economics, Center for Healthcare Policy and Research, University of California, Davis, California 95817, USA. jamelnikow@ucdavis.edu
Kulasingam
Shalini
S
Slee
Christina
C
Helms
L Jay
LJ
Kuppermann
Miriam
M
Birch
Stephen
S
McGahan
Colleen E
CE
Coldman
Andrew
A
Chan
Benjamin K S
BK
Sawaya
George F
GF
D000328:Adult; D003127:Colposcopy / Q000191:economics; D019092:Conization; D003362:Cost-Benefit Analysis; D003452:Cryosurgery; D003581:Cytodiagnosis / Q000191:economics; D005189:False Positive Reactions; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008390:Markov Chains; D027383:Papillomaviridae / Q000302:isolation & purification; D030361:Papillomavirus Infections / Q000150:complications / Q000175:diagnosis / Q000191:economics; D002583:Uterine Cervical Neoplasms / Q000175:diagnosis / Q000191:economics / Q000601:surgery* / Q000821:virology; D002578:Uterine Cervical Dysplasia / Q000175:diagnosis / Q000191:economics / Q000601:surgery* / Q000821:virology