title: Optimal Management Strategies for Primary HPV Testing for Cervical Screening: Cost-Effectiveness Evaluation for the National Cervical Screening Program in Australia.
abstract: Several countries are implementing a transition to HPV testing for cervical screening in response to the introduction of HPV vaccination and evidence indicating that HPV screening is more effective than cytology. In Australia, a 2017 transition from 2-yearly conventional cytology in 18-20 to 69 years to 5-yearly primary HPV screening in 25 to 74 years will involve partial genotyping for HPV 16/18 with direct referral to colposcopy for this higher risk group. The objective of this study was to determine the optimal management of women positive for other high-risk HPV types (not 16/18) ('OHR HPV').
  
  
  
  We used a dynamic model of HPV transmission, vaccination, natural history and cervical screening to determine the optimal management of women positive for OHR HPV. We assumed cytology triage testing was used to inform management in this group and that those with high-grade cytology would be referred to colposcopy and those with negative cytology would receive 12-month surveillance. For those with OHR HPV and low-grade cytology (considered to be a single low-grade category in Australia incorporating ASC-US and LSIL), we evaluated (1) the 20-year risk of invasive cervical cancer assuming this group are referred for 12-month follow-up vs. colposcopy, and compared this to the risk in women with low-grade cytology under the current program (i.e. an accepted benchmark risk for 12-month follow-up in Australia); (2) the population-level impact of the whole program, assuming this group are referred to 12-month surveillance vs. colposcopy; and (3) the cost-effectiveness of immediate colposcopy compared to 12-month follow-up. Evaluation was performed both for HPV-unvaccinated cohorts and cohorts offered vaccination (coverage ~72%).
  
  
  
  The estimated 20-year risk of cervical cancer is ≤1.0% at all ages if this group are referred to colposcopy vs. ≤1.2% if followed-up in 12 months, both of which are lower than the ≤2.6% benchmark risk in women with low-grade cytology in the current program (who are returned for 12-month follow-up). At the population level, immediate colposcopy referral provides an incremental 1-3% reduction in cervical cancer incidence and mortality compared with 12-month follow-up, but this is in the context of a predicted 24-36% reduction associated with the new HPV screening program compared to the current cytology-based program. Furthermore, immediate colposcopy substantially increases the predicted number of colposcopies, with >650 additional colposcopies required to avert each additional case of cervical cancer compared to 12-month follow-up. Compared to 12-month follow-up, immediate colposcopy has an incremental cost-effectiveness ratio (ICER) of A$104,600/LYS (95%CrI:A$100,100-109,100) in unvaccinated women and A$117,100/LYS (95%CrI:A$112,300-122,000) in cohorts offered vaccination [Indicative willingness-to-pay threshold: A$50,000/LYS].
  
  
  
  In primary HPV screening programs, partial genotyping for HPV16/18 or high-grade triage cytology in OHR HPV positive women can be used to refer the highest risk group to colposcopy, but 12-month follow-up for women with OHR HPV and low-grade cytology is associated with a low risk of developing cervical cancer. Direct referral to colposcopy for this group would be associated with a substantial increase in colposcopy referrals and the associated harms, and is also cost-ineffective; thus, 12-month surveillance for women with OHR HPV and low-grade cytology provides the best balance between benefits, harms and cost-effectiveness.
authors.affiliation: Cancer Research Division, Cancer Council NSW, Sydney, New South Wales, Australia.|Prince of Wales Clinical School, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia.
authors.forename: Kate T
authors.identifier: 0000-0003-2568-7956
authors.initials: KT
authors.lastname: Simms
authors.affiliation: Cancer Research Division, Cancer Council NSW, Sydney, New South Wales, Australia.|Prince of Wales Clinical School, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia.
authors.forename: Michaela
authors.initials: M
authors.lastname: Hall
authors.affiliation: Cancer Research Division, Cancer Council NSW, Sydney, New South Wales, Australia.|Prince of Wales Clinical School, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia.|School of Public Health, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia.
authors.forename: Megan A
authors.identifier: 0000-0002-0401-2653
authors.initials: MA
authors.lastname: Smith
authors.affiliation: Cancer Research Division, Cancer Council NSW, Sydney, New South Wales, Australia.|Prince of Wales Clinical School, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia.
authors.forename: Jie-Bin
authors.initials: JB
authors.lastname: Lew
authors.affiliation: Cancer Research Division, Cancer Council NSW, Sydney, New South Wales, Australia.
authors.forename: Suzanne
authors.initials: S
authors.lastname: Hughes
authors.affiliation: Cancer Research Division, Cancer Council NSW, Sydney, New South Wales, Australia.
authors.forename: Susan
authors.initials: S
authors.lastname: Yuill
authors.affiliation: Steering Committee for the Renewal Implementation Project, National Cervical Screening Program, Department of Health, Canberra, Australian Capital Territory, Australia.|School of Women's and Infants' Health, University of Western Australia, Perth, Western Australia, Australia.
authors.forename: Ian
authors.initials: I
authors.lastname: Hammond
authors.affiliation: Victorian Cytology Service, Victoria, Australia.|Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Victoria, Australia.
authors.forename: Marion
authors.initials: M
authors.lastname: Saville
authors.affiliation: Cancer Research Division, Cancer Council NSW, Sydney, New South Wales, Australia.|Prince of Wales Clinical School, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia.|School of Public Health, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia.
authors.forename: Karen
authors.initials: K
authors.lastname: Canfell
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001315:Australia; D002648:Child; D003127:Colposcopy; D003362:Cost-Benefit Analysis; D003581:Cytodiagnosis; D004279:DNA, Viral / Q000235:genetics; D019468:Disease Management; D055088:Early Detection of Cancer / Q000191:economics*; D005260:Female; D005838:Genotype; D006801:Humans; D008875:Middle Aged; D009313:National Health Programs; D027383:Papillomaviridae / Q000235:genetics; D030361:Papillomavirus Infections / Q000150:complications / Q000175:diagnosis* / Q000821:virology; D002583:Uterine Cervical Neoplasms / Q000175:diagnosis / Q000191:economics* / Q000821:virology; D014626:Vaginal Smears / Q000191:economics; D055815:Young Adult; D002578:Uterine Cervical Dysplasia / Q000175:diagnosis / Q000191:economics* / Q000453:epidemiology / Q000821:virology
chemical_list: D004279:DNA, Viral