title: The cost-utility of integrated cervical cancer prevention strategies in the Ontario setting - Can we do better?
abstract: BACKGROUND
  A universal, publicly funded, school-based human papillomavirus (HPV) vaccination program in grade eight girls was initiated in Ontario in 2007. We present a cost-utility analysis of integrated cervical cancer prevention programs from the healthcare payer perspective.
  
  
  METHODS
  Our analysis was based on linked HPV transmission and disease history models. We obtained data from the literature, provincial surveys and Ontario population-based linked health administrative datasets. We modeled combinations of vaccination and screening strategies. We considered vaccination based on the Ontario experience, as well as conservative and optimistic scenarios, varying coverage, vaccine effectiveness and duration of protection. We considered 900 screening scenarios (screening start age: 21-70 years, screening interval: 3-20 years; 1-year time steps). The current schedule screens every 3 years starting at age 21 years. We examined (1) first vaccinated cohort (low herd-immunity), and (2) steady state, i.e. all cohorts were vaccinated (high herd-immunity).
  
  
  RESULTS
  Adding vaccination to the current screening schedule was cost-effective (<C$10,000/quality-adjusted life year (QALY)) across all scenarios. Delaying screening start and/or extending screening intervals increased both expected QALYs and cost, and increased overall NHB for screening schedules with a start age of 25-35 years and 3-10-year intervals for most scenarios.
  
  
  CONCLUSIONS
  Delaying screening start age and/or extending screening intervals in vaccinated cohorts is likely to be cost-effective. Consideration should be given to both the short- and long-term implications of health policy decisions, particularly for infectious disease interventions that require long time intervals to reach steady state.
authors.affiliation: Public Health Ontario, Canada; University of Toronto, Canada; Institute for Clinical Evaluative Sciences, Toronto, Canada; Toronto Health Economics and Technology Assessment Collaborative, Canada. Electronic address: beate.sander@oahpp.ca.
authors.forename: Beate
authors.initials: B
authors.lastname: Sander
authors.affiliation: University of Toronto, Canada; Toronto Health Economics and Technology Assessment Collaborative, Canada.
authors.forename: William W L
authors.initials: WW
authors.lastname: Wong
authors.affiliation: Public Health Ontario, Canada.
authors.forename: Man Wah
authors.initials: MW
authors.lastname: Yeung
authors.affiliation: Toronto Health Economics and Technology Assessment Collaborative, Canada.
authors.forename: Orges
authors.initials: O
authors.lastname: Ormanidhi
authors.affiliation: Cancer Care Ontario, Canada.
authors.forename: Karen
authors.initials: K
authors.lastname: Atkin
authors.affiliation: University of Toronto, Canada; Cancer Care Ontario, Canada; University Health Network, Toronto, Canada.
authors.forename: Joan
authors.initials: J
authors.lastname: Murphy
authors.affiliation: University of Toronto, Canada; Institute for Clinical Evaluative Sciences, Toronto, Canada; Toronto Health Economics and Technology Assessment Collaborative, Canada; University Health Network, Toronto, Canada.
authors.forename: Murray
authors.initials: M
authors.lastname: Krahn
authors.affiliation: Public Health Ontario, Canada; University of Toronto, Canada.
authors.forename: Shelley L
authors.initials: SL
authors.lastname: Deeks
mesh_terms: D000328:Adult; D000368:Aged; D003362:Cost-Benefit Analysis; D055088:Early Detection of Cancer / Q000191:economics*; D005260:Female; D006801:Humans; D008403:Mass Screening / Q000191:economics*; D008875:Middle Aged; D018803:Models, Economic; D009864:Ontario; D030361:Papillomavirus Infections / Q000517:prevention & control* / Q000635:transmission; D053918:Papillomavirus Vaccines / Q000191:economics* / Q000627:therapeutic use; D019057:Quality-Adjusted Life Years; D002583:Uterine Cervical Neoplasms / Q000517:prevention & control*; D014611:Vaccination / Q000191:economics*; D055815:Young Adult
chemical_list: D053918:Papillomavirus Vaccines
keywords: Cervical cancer; Cost-effectiveness analysis; Human papilloma virus; Screening; Vaccination