title: Cost-effective management of women with minor cervical lesions: Revisiting the application of HPV DNA testing.
abstract: BACKGROUND
  Lack of consensus in management guidelines for women with minor cervical lesions, coupled with novel screening approaches, such as human papillomavirus (HPV) genotyping, necessitate revisiting prevention policies. We evaluated the cost-effectiveness and resource trade-offs of alternative triage strategies to inform cervical cancer prevention in Norway.
  
  
  METHODS
  We used a decision-analytic model to compare the lifetime health and economic consequences associated with ten novel candidate approaches to triage women with minor cervical lesions. Candidate strategies varied by: 1) the triage test(s): HPV testing in combination with cytology, HPV testing alone with or without genotyping for HPV-16 and -18, and immediate colposcopy, and 2) the length of time between index and triage testing (i.e., 6, 12 or 18months). Model outcomes included quality-adjusted life-years (QALYs), lifetime societal costs, and resource use (e.g., colposcopy referrals).
  
  
  RESULTS
  The current Norwegian guidelines were less effective and more costly than candidate strategies. Given a commonly-cited willingness-to-pay threshold in Norway of $100,000 per QALY gained, the preferred strategy involved HPV genotyping with immediate colposcopy referral for HPV-16 or -18 positive and repeat HPV testing at 12months for non-HPV-16 or -18 positive ($78,010 per QALY gained). Differences in health benefits among candidate strategies were small, while resource use varied substantially. More effective strategies required a moderate increase in colposcopy referrals (e.g., a 9% increase for the preferred strategy) compared with current levels.
  
  
  CONCLUSIONS
  New applications of HPV testing may improve management of women with minor cervical lesions, yet are accompanied by a trade-off of increased follow-up procedures.
authors.affiliation: Department of Health Management and Health Economics, Institute of Health and Society, University of Oslo, P.O. Box 1089 Blindern, 0317 Oslo, Norway.
authors.forename: Kine
authors.initials: K
authors.lastname: Pedersen
authors.affiliation: Department of Health Management and Health Economics, Institute of Health and Society, University of Oslo, P.O. Box 1089 Blindern, 0317 Oslo, Norway; Center for Health Decision Science, Harvard T.H. Chan School of Public Health, 718 Huntington Ave, 2nd Floor, Boston, MA 02115, USA. Electronic address: eburger@hsph.harvard.edu.
authors.forename: Emily A
authors.initials: EA
authors.lastname: Burger
authors.affiliation: Center for Health Decision Science, Harvard T.H. Chan School of Public Health, 718 Huntington Ave, 2nd Floor, Boston, MA 02115, USA.
authors.forename: Stephen
authors.initials: S
authors.lastname: Sy
authors.affiliation: Department of Health Management and Health Economics, Institute of Health and Society, University of Oslo, P.O. Box 1089 Blindern, 0317 Oslo, Norway.
authors.forename: Ivar S
authors.initials: IS
authors.lastname: Kristiansen
authors.affiliation: Center for Health Decision Science, Harvard T.H. Chan School of Public Health, 718 Huntington Ave, 2nd Floor, Boston, MA 02115, USA.
authors.forename: Jane J
authors.initials: JJ
authors.lastname: Kim
mesh_terms: D000328:Adult; D000368:Aged; D065309:Atypical Squamous Cells of the Cervix; D003362:Cost-Benefit Analysis; D055088:Early Detection of Cancer / Q000191:economics; D005260:Female; D061809:Human Papillomavirus DNA Tests / Q000379:methods*; D006801:Humans; D008875:Middle Aged; D019057:Quality-Adjusted Life Years; D065310:Squamous Intraepithelial Lesions of the Cervix / Q000628:therapy*; D014218:Triage
keywords: Cervical intraepithelial neoplasia; Cost-effectiveness; HPV testing; Human papillomavirus; Mass screening; Mathematical model