title: Cost-effectiveness of primary HPV screening for cervical cancer in Germany--a decision analysis.
abstract: OBJECTIVE
  To systematically evaluate the long-term effectiveness and cost-effectiveness of HPV-based primary cervical cancer screening in the German health care context using a decision-analysis approach.
  
  
  METHODS
  A Markov-model for HPV-infection and cervical cancer was developed for the German health care context, and applied to evaluate various screening strategies that differ by screening interval and test algorithms, including HPV-testing alone or in combination with cytology. German clinical, epidemiological, and economic data, and test accuracy data from international meta-analyses were used. Outcomes predicted included the reduction in cervical cancer cases and deaths, life expectancy and discounted incremental cost-effectiveness ratios (ICER). The analysis was performed from the perspective of the healthcare system adopting a 3% annual discount rate for costs and outcomes. Extensive sensitivity analyses were performed.
  
  
  RESULTS
  HPV-based screening is more effective than cytology alone. It results in a 71-97% reduction in cervical cancer cases as compared to 53-93% for cytology alone. The ICER range from 2600 Euro/LYG (cytology, 5-year-interval) to 155,500 Euro/LYG (annual HPV-testing starting at age 30 years, cytology age 20-29 years). Annual cytology alone, the current recommended screening strategy in Germany, is dominated by HPV-strategies. Increasing the age at screening initiation from 20 to 25 years does not result in a relevant loss in effectiveness but results in lower costs.
  
  
  CONCLUSIONS
  Based on our analyses, HPV-based cervical cancer screening is more effective than cytology alone and could be cost-effective if performed at intervals of two years or longer. In the German context, an optimal screening strategy may be biennial HPV screening starting at age 30 years preceded by biennial cytology for women aged 25-29 years. Longer screening intervals may be considered in low-risk women with good screening adherence and in populations with low HPV-incidence.
authors.affiliation: Department of Public Health and Health Technology Assessment, UMIT - University for Health Sciences, Medical Informatics and Technology, Eduard Wallnoefer Center I, A-6060 Hall iT, Austria.
authors.forename: G
authors.initials: G
authors.lastname: Sroczynski
authors.forename: P
authors.initials: P
authors.lastname: Schnell-Inderst
authors.forename: N
authors.initials: N
authors.lastname: Mühlberger
authors.forename: K
authors.initials: K
authors.lastname: Lang
authors.forename: P
authors.initials: P
authors.lastname: Aidelsburger
authors.forename: J
authors.initials: J
authors.lastname: Wasem
authors.forename: T
authors.initials: T
authors.lastname: Mittendorf
authors.forename: J
authors.initials: J
authors.lastname: Engel
authors.forename: P
authors.initials: P
authors.lastname: Hillemanns
authors.forename: K U
authors.initials: KU
authors.lastname: Petry
authors.forename: A
authors.initials: A
authors.lastname: Krämer
authors.forename: U
authors.initials: U
authors.lastname: Siebert
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003362:Cost-Benefit Analysis; D003661:Decision Support Techniques; D055088:Early Detection of Cancer; D005260:Female; D006801:Humans; D008390:Markov Chains; D008403:Mass Screening / Q000379:methods; D008495:Medical Oncology / Q000379:methods; D008875:Middle Aged; D017063:Outcome Assessment, Health Care; D015995:Prevalence; D012680:Sensitivity and Specificity; D002583:Uterine Cervical Neoplasms / Q000175:diagnosis* / Q000191:economics*