title: The comparative and cost-effectiveness of HPV-based cervical cancer screening algorithms in El Salvador.
abstract: Cervical cancer is the leading cause of cancer death among women in El Salvador. Utilizing data from the Cervical Cancer Prevention in El Salvador (CAPE) demonstration project, we assessed the health and economic impact of HPV-based screening and two different algorithms for the management of women who test HPV-positive, relative to existing Pap-based screening. We calibrated a mathematical model of cervical cancer to epidemiologic data from El Salvador and compared three screening algorithms for women aged 30-65 years: (i) HPV screening every 5 years followed by referral to colposcopy for HPV-positive women (Colposcopy Management [CM]); (ii) HPV screening every 5 years followed by treatment with cryotherapy for eligible HPV-positive women (Screen and Treat [ST]); and (iii) Pap screening every 2 years followed by referral to colposcopy for Pap-positive women (Pap). Potential harms and complications associated with overtreatment were not assessed. Under base case assumptions of 65% screening coverage, HPV-based screening was more effective than Pap, reducing cancer risk by ∼ 60% (Pap: 50%). ST was the least costly strategy, and cost $2,040 per year of life saved. ST remained the most attractive strategy as visit compliance, costs, coverage, and test performance were varied. We conclude that a screen-and-treat algorithm within an HPV-based screening program is very cost-effective in El Salvador, with a cost-effectiveness ratio below per capita GDP.
authors: Center for Health Decision Science, Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA.
authors: Nicole G
authors: NG
authors: Campos
authors: Basic Health International, San Salvador, El Salvador.
authors: Mauricio
authors: M
authors: Maza
authors: Basic Health International, San Salvador, El Salvador.
authors: Karla
authors: K
authors: Alfaro
authors: Department of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD.
authors: Julia C
authors: JC
authors: Gage
authors: Global Coalition against Cervical Cancer, Arlington, VA.|Department of Epidemiology & Population Health, Albert Einstein College of Medicine, Bronx, NY.
authors: Philip E
authors: PE
authors: Castle
authors: Department of Pathology, Keck School of Medicine of University of Southern California, Los Angeles, CA.
authors: Juan C
authors: JC
authors: Felix
authors: Basic Health International, San Salvador, El Salvador.|Obstetrics, Gynecology & Women's Health Institute, Cleveland Clinic, Cleveland, OH.
authors: Miriam L
authors: ML
authors: Cremer
authors: Center for Health Decision Science, Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA.
authors: Jane J
authors: JJ
authors: Kim
mesh_terms: D000328:Adult; D003127:Colposcopy; D003362:Cost-Benefit Analysis; D055088:Early Detection of Cancer; D004544:El Salvador; D005260:Female; D006801:Humans; D008403:Mass Screening; D008875:Middle Aged; D008962:Models, Theoretical; D027383:Papillomaviridae / Q000472:pathogenicity*; D030361:Papillomavirus Infections / Q000453:epidemiology* / Q000473:pathology / Q000821:virology; D011247:Pregnancy; D002583:Uterine Cervical Neoplasms / Q000453:epidemiology* / Q000473:pathology / Q000821:virology; D014626:Vaginal Smears
keywords: El Salvador; HPV DNA tests; cancer screening; decision analysis; human papillomavirus (HPV); mathematical model; uterine cervical neoplasms