title: Evaluation of primary HPV-DNA testing in relation to visual inspection methods for cervical cancer screening in rural China: an epidemiologic and cost-effectiveness modelling study.
abstract: BACKGROUND
  A new lower-cost rapid-throughput human papillomavirus (HPV) test (careHPV, Qiagen, Gaithersburg, USA) has been shown to have high sensitivity for the detection of high grade cervical intraepithelial neoplasia.
  
  
  METHODS
  We assessed the outcomes and cost-effectiveness of careHPV screening in rural China, compared to visual inspection with acetic acid, when used alone (VIA) or in combination with Lugol's iodine (VIA/VILI). Using data on sexual behaviour, test accuracy, diagnostic practices and costs from studies performed in rural China, we estimated the cost-effectiveness ratio (CER) and associated lifetime outcomes for once-lifetime and twice-lifetime screening strategies, and for routine screening at 5-yearly, 10-yearly and IARC-recommended intervals. The optimal age range for once-lifetime screening was also assessed.
  
  
  RESULTS
  For all strategies, the relative ordering of test technologies in reducing cervical cancer incidence and mortality was VIA (least effective); VIA/VILI; careHPV@1.0 pg/ml and careHPV@0.5 pg/ml (most effective). For once-lifetime strategies, maximum effectiveness was achieved if screening occurred between 35-50 years. Assuming a participation rate of ~70%, once-lifetime screening at age 35 years would reduce cancer mortality by 8% (for VIA) to 12% (for careHPV@0.5) over the long term, with a CER of US$557 (for VIA) to $959 (for careHPV@1.0) per life year saved (LYS) compared to no intervention; referenced to a 2008 GDP per capita in Shanxi Province of $2,975. Correspondingly, regular screening with an age-standardised participation rate of 62% (which has been shown to be achievable in this setting) would reduce cervical cancer mortality by 19-28% (for 10-yearly screening) to 43-54% (using IARC-recommended intervals), with corresponding CERs ranging from $665 (for 10-yearly VIA) to $2,269 (for IARC-recommended intervals using careHPV@1.0) per LYS.
  
  
  CONCLUSIONS
  This modelled analysis suggests that primary careHPV screening compares favourably to visual inspection screening methodologies in rural China, particularly if used as part of a regular screening program.
authors.affiliation: Department of Cancer Epidemiology, Cancer Institute, Chinese Academy of Medical Sciences, Peking Union Medical College, 17, South Panjiayuan LN, PO Box 2258, Beijing 100021, China.
authors.forename: Ju-Fang
authors.initials: JF
authors.lastname: Shi
authors.forename: Karen
authors.initials: K
authors.lastname: Canfell
authors.forename: Jie-Bin
authors.initials: JB
authors.lastname: Lew
authors.forename: Fang-Hui
authors.initials: FH
authors.lastname: Zhao
authors.forename: Rosa
authors.initials: R
authors.lastname: Legood
authors.forename: Yan
authors.initials: Y
authors.lastname: Ning
authors.forename: Leonardo
authors.initials: L
authors.lastname: Simonella
authors.forename: Li
authors.initials: L
authors.lastname: Ma
authors.forename: Yoon-Jung
authors.initials: YJ
authors.lastname: Kang
authors.forename: Yong-Zhen
authors.initials: YZ
authors.lastname: Zhang
authors.forename: Megan A
authors.initials: MA
authors.lastname: Smith
authors.forename: Jun-Feng
authors.initials: JF
authors.lastname: Chen
authors.forename: Xiang-Xian
authors.initials: XX
authors.lastname: Feng
authors.forename: You-Lin
authors.initials: YL
authors.lastname: Qiao
mesh_terms: D019342:Acetic Acid; D000328:Adult; D002681:China / Q000453:epidemiology; D004396:Coloring Agents; D003198:Computer Simulation; D003362:Cost-Benefit Analysis; D015344:DNA Probes, HPV; D004279:DNA, Viral / Q000032:analysis*; D055088:Early Detection of Cancer / Q000191:economics / Q000379:methods*; D005260:Female; D017048:Health Care Costs; D057166:High-Throughput Screening Assays / Q000191:economics; D006801:Humans; D007454:Iodides; D008403:Mass Screening / Q000191:economics / Q000379:methods*; D008875:Middle Aged; D008962:Models, Theoretical; D030361:Papillomavirus Infections / Q000175:diagnosis* / Q000191:economics / Q000453:epidemiology / Q000635:transmission / Q000821:virology; D010808:Physical Examination / Q000191:economics / Q000379:methods*; D012424:Rural Population; D012725:Sexual Behavior; D013997:Time Factors; D002583:Uterine Cervical Neoplasms / Q000175:diagnosis* / Q000191:economics / Q000453:epidemiology / Q000517:prevention & control / Q000821:virology; D002578:Uterine Cervical Dysplasia / Q000175:diagnosis* / Q000191:economics / Q000453:epidemiology / Q000821:virology
chemical_list: D004396:Coloring Agents; D015344:DNA Probes, HPV; D004279:DNA, Viral; D007454:Iodides; D019342:Acetic Acid; C010389:Lugol's solution