Cost-Effectiveness of Different Cervical Screening Strategies in Islamic Republic of Iran: A Middle-Income Country with a Low Incidence Rate of Cervical Cancer.
OBJECTIVE
Invasive cervical cancer (ICC) is the fourth most common cancer among women worldwide. Cervical screening programs have reduced the incidence and mortality rates of ICC. We studied the cost-effectiveness of different cervical screening strategies in the Islamic Republic of Iran, a Muslim country with a low incidence rate of ICC.


METHODS
We constructed an 11-state Markov model, in which the parameters included regression and progression probabilities, test characteristics, costs, and utilities; these were extracted from primary data and the literature. Our strategies included Pap smear screening and human papillomavirus (HPV) DNA testing plus Pap smear triaging with different starting ages and screening intervals. Model outcomes included lifetime costs, life years gained, quality-adjusted life years (QALY), and incremental cost-effectiveness ratios (ICERs). One-way sensitivity analysis was performed to examine the stability of the results.


RESULTS
We found that the prevented mortalities for the 11 strategies compared with no screening varied from 26% to 64%. The most cost-effective strategy was HPV screening, starting at age 35 years and repeated every 10 years. The ICER of this strategy was $8,875 per QALY compared with no screening. We found that screening at 5-year intervals was also cost-effective based on GDP per capita in Iran.


CONCLUSIONS
We recommend organized cervical screening with HPV DNA testing for women in Iran, beginning at age 35 and repeated every 10 or 5 years. The results of this study could be generalized to other countries with low incidence rates of cervical cancer.
Cancer Research Center, Cancer Institute of Iran, Tehran University of Medical Sciences, Tehran, I. R. Iran.
Azin
A
Nahvijou
Department of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, I. R. Iran.
Rajabali
R
Daroudi
Cancer Research Center, Cancer Institute of Iran, Tehran University of Medical Sciences, Tehran, I. R. Iran.
Mamak
M
Tahmasebi
Cancer Research Center, Cancer Institute of Iran, Tehran University of Medical Sciences, Tehran, I. R. Iran.
Farnaz
F
Amouzegar Hashemi
Institute of Health & Wellbeing Health Economics & Health Technology Assessment University of Glasgow, Scotland, United Kingdom.
Mohsen
M
Rezaei Hemami
Department of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, I. R. Iran.
Ali
A
Akbari Sari
Department of Health Services Management, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, I. R. Iran.
Ahmad
A
Barati Marenani
Cancer Model Research Center, Cancer Institute of Iran, Tehran University of Medical Sciences, Tehran, I. R. Iran.
Kazem
K
Zendehdel
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003365:Costs and Cost Analysis; D005260:Female; D006801:Humans; D015994:Incidence; D007492:Iran / Q000453:epidemiology; D008403:Mass Screening / Q000191:economics*; D008875:Middle Aged; D018803:Models, Economic; D065006:Papanicolaou Test / Q000191:economics*; D002583:Uterine Cervical Neoplasms / Q000175:diagnosis / Q000191:economics / Q000401:mortality