title: Cost-Effectiveness of Primary HPV Testing, Cytology and Co-testing as Cervical Cancer Screening for Women Above Age 30 Years.
abstract: Cervical cancer screening guidelines for women aged ≥30 years allow for co-testing or primary cytology testing. Our objective was to determine the test characteristics and costs associated with Cytology, HPV and Co-testing screening strategies.
  
  
  
  Retrospective cohort study of women undergoing cervical cancer screening with both cytology and HPV (Hybrid Capture 2) testing from 2004 to 2010 in an integrated health system. The electronic health record was used to identify women aged ≥30 years who had co-testing. Unsatisfactory or unavailable test results and incorrectly ordered tests were excluded. The main outcome was biopsy-proven cervical intraepithelial neoplasia grade 3 or higher (CIN3+).
  
  
  
  The final cohort consisted of 99,549 women. Subjects were mostly white (78.4 %), married (70.7 %), never smokers (61.3 %) and with private insurance (86.1 %). Overall, 5121 (5.1 %) tested positive for HPV and 6115 (6.1 %) had cytology ≥ ASCUS; 1681 had both and underwent colposcopy and 310 (0.3 %) had CIN3+. Sensitivity for CIN3+ was 91.9 % for Primary Cytology, 99.4 % for Co-testing, and 94.8 % for Primary HPV; specificity was 97.3 % for Co-testing and Primary Cytology and 97.9 % for Primary HPV. Over a 3-year screening interval, Primary HPV detected more cases of CIN3+ and was less expensive than Primary Cytology. Co-testing detected 14 more cases of CIN3+ than Primary HPV, but required an additional 100,277 cytology tests and 566 colposcopies at an added cost of $2.38 million, or $170,096 per additional case detected.
  
  
  
  Primary HPV was more effective and less expensive than Primary Cytology. Primary HPV screening appears to represent a cost-effective alternative to Co-testing.
authors.affiliation: Department of Internal Medicine, Cleveland Clinic, Cleveland, OH, USA. jinx@ccf.org.
authors.forename: Xian Wen
authors.initials: XW
authors.lastname: Jin
authors.affiliation: Department of Family Medicine, Cleveland Clinic, Cleveland, OH, USA.
authors.forename: Laura
authors.initials: L
authors.lastname: Lipold
authors.affiliation: Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, Cleveland, OH, USA.
authors.forename: Julie
authors.initials: J
authors.lastname: Foucher
authors.affiliation: Department of Internal Medicine, Cleveland Clinic, Cleveland, OH, USA.
authors.forename: Andrea
authors.initials: A
authors.lastname: Sikon
authors.affiliation: Department of Pathology, Cleveland Clinic, Cleveland, OH, USA.
authors.forename: Jennifer
authors.initials: J
authors.lastname: Brainard
authors.affiliation: Department of Obstetrics and Gynecology, Cleveland Clinic, Cleveland, OH, USA.
authors.forename: Jerome
authors.initials: J
authors.lastname: Belinson
authors.affiliation: Medicine Institute Center for Value Based Care Research, Cleveland Clinic, Cleveland, OH, USA.
authors.forename: Sarah
authors.initials: S
authors.lastname: Schramm
authors.affiliation: Medicine Institute Center for Value Based Care Research, Cleveland Clinic, Cleveland, OH, USA.|Heritage College of Osteopathic Medicine, Ohio University, Athens, OH, USA.
authors.forename: Kelly
authors.initials: K
authors.lastname: Nottingham
authors.affiliation: Department of Quantitative Health Science, Cleveland Clinic, Cleveland, OH, USA.
authors.forename: Bo
authors.initials: B
authors.lastname: Hu
authors.affiliation: Department of Internal Medicine, Cleveland Clinic, Cleveland, OH, USA.|Medicine Institute Center for Value Based Care Research, Cleveland Clinic, Cleveland, OH, USA.
authors.forename: Michael B
authors.initials: MB
authors.lastname: Rothberg
mesh_terms: D000328:Adult; D000367:Age Factors; D015331:Cohort Studies; D003362:Cost-Benefit Analysis / Q000379:methods*; D003584:Cytological Techniques / Q000191:economics / Q000379:methods; D055088:Early Detection of Cancer / Q000191:economics* / Q000379:methods*; D005260:Female; D061809:Human Papillomavirus DNA Tests / Q000191:economics / Q000379:methods; D006801:Humans; D008875:Middle Aged; D027383:Papillomaviridae / Q000235:genetics; D012189:Retrospective Studies; D002583:Uterine Cervical Neoplasms / Q000175:diagnosis* / Q000191:economics* / Q000235:genetics; D014626:Vaginal Smears / Q000191:economics / Q000379:methods