title: Cervical Cancer Screening in Partly HPV Vaccinated Cohorts - A Cost-Effectiveness Analysis.
abstract: BACKGROUND
  Vaccination against the oncogenic human papillomavirus (HPV) types 16 and 18 will reduce the prevalence of these types, thereby also reducing cervical cancer risk in unvaccinated women. This (measurable) herd effect will be limited at first, but is expected to increase over time. At a certain herd immunity level, tailoring screening to vaccination status may no longer be worth the additional effort. Moreover, uniform screening may be the only viable option. We therefore investigated at what level of herd immunity it is cost-effective to also reduce screening intensity in unvaccinated women.
  
  
  METHODS
  We used the MISCAN-Cervix model to determine the optimal screening strategy for a pre-vaccination population and for vaccinated women (~80% decreased risk), assuming a willingness-to-pay of €50,000 per quality-adjusted life year gained. We considered HPV testing, cytology testing and co-testing and varied the start age of screening, the screening interval and the number of lifetime screens. We then calculated the incremental cost-effectiveness ratio (ICER) of screening unvaccinated women with the strategy optimized to the pre-vaccination population as compared to with the strategy optimized to vaccinated women, assuming different herd immunity levels.
  
  
  RESULTS
  Primary HPV screening with cytology triage was the optimal strategy, with 8 lifetime screens for the pre-vaccination population and 3 for vaccinated women. The ICER of screening unvaccinated women 8 times instead of 3 was €28,085 in the absence of herd immunity. At around 50% herd immunity, the ICER reached €50,000.
  
  
  CONCLUSIONS
  From a herd immunity level of 50% onwards, screening intensity based on the pre-vaccination risk level becomes cost-ineffective for unvaccinated women. Reducing the screening intensity of uniform screening may then be considered.
authors.affiliation: Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands.
authors.forename: Steffie K
authors.initials: SK
authors.lastname: Naber
authors.affiliation: Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands.
authors.forename: Suzette M
authors.initials: SM
authors.lastname: Matthijsse
authors.affiliation: Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands.
authors.forename: Kirsten
authors.initials: K
authors.lastname: Rozemeijer
authors.affiliation: Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands.
authors.forename: Corine
authors.initials: C
authors.lastname: Penning
authors.affiliation: Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands.
authors.forename: Inge M C M
authors.initials: IM
authors.lastname: de Kok
authors.affiliation: Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands.
authors.forename: Marjolein
authors.initials: M
authors.lastname: van Ballegooijen
mesh_terms: D000328:Adult; D003362:Cost-Benefit Analysis; D055088:Early Detection of Cancer / Q000191:economics*; D005260:Female; D006801:Humans; D032521:Immunity, Herd; D008875:Middle Aged; D008962:Models, Theoretical; D030361:Papillomavirus Infections / Q000191:economics / Q000821:virology; D053918:Papillomavirus Vaccines / Q000191:economics*; D002583:Uterine Cervical Neoplasms / Q000175:diagnosis* / Q000191:economics / Q000517:prevention & control; D014611:Vaccination / Q000191:economics*
chemical_list: D053918:Papillomavirus Vaccines
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