title: Cost-effectiveness of cervical cancer screening methods in low- and middle-income countries: A systematic review.
abstract: The incidence of cervical cancer in low- and middle-income countries (LMICs) is five times higher than that observed in high-income countries (HICs). This discrepancy is largely attributed to the implementation of cytology-based screening programmes in HICs. However, due to reduced health system infrastructure requirements, HPV testing (self- and provider-collected) and visual inspection with acetic acid (VIA) have been proposed as alternatives that may be better suited to LMICs. Knowing the relative value of different screening options can inform policy and the development of sustainable prevention programs. We searched MEDLINE and EMBASE for English language publications detailing model-based cost-effectiveness analyses of cervical cancer screening methods in LMICs from 2000 to 2016. The main outcome of interest was the incremental cost-effectiveness ratio (ICER). Quantitative data were extracted to compare commonly evaluated screening methods and a descriptive review was conducted for each included study. Of the initial 152 articles reviewed, 19 met inclusion criteria. Generally, cytology-based screening was shown to be the least effective and most costly screening method. Whether provider-collected HPV testing or VIA was the more efficient alternative depended on the cost of the HPV test, loss to follow-up and VIA test performance. Self-collected HPV testing was cost-effective when it yielded population coverage gains over other screening methods. We conclude that HPV testing and VIA are more cost-effective screening methods than cytology in LMICs. Policy makers should consider HPV testing with self-collection of samples if it yields gains in population coverage.
authors.affiliation: Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada.
authors.forename: Alex K
authors.initials: AK
authors.lastname: Mezei
authors.affiliation: Women's Health Research Institute, BC Women's Hospital, Vancouver, BC, Canada.
authors.forename: Heather L
authors.initials: HL
authors.lastname: Armstrong
authors.affiliation: Women's Health Research Institute, BC Women's Hospital, Vancouver, BC, Canada.
authors.forename: Heather N
authors.initials: HN
authors.lastname: Pedersen
authors.affiliation: Department of Health Policy and Management, Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, MA.
authors.forename: Nicole G
authors.initials: NG
authors.lastname: Campos
authors.affiliation: Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, BC, Canada.
authors.forename: Sheona M
authors.initials: SM
authors.lastname: Mitchell
authors.affiliation: Department of Obstetrics and Gynecology, Makerere University/Mulago National Referral Hospital, Kampala, Uganda.
authors.forename: Musa
authors.initials: M
authors.lastname: Sekikubo
authors.affiliation: Department of Obstetrics and Gynecology, Makerere University/Mulago National Referral Hospital, Kampala, Uganda.
authors.forename: Josaphat K
authors.initials: JK
authors.lastname: Byamugisha
authors.affiliation: Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, BC, Canada.
authors.forename: Jane J
authors.initials: JJ
authors.lastname: Kim
authors.affiliation: Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, BC, Canada.
authors.forename: Stirling
authors.initials: S
authors.lastname: Bryan
authors.affiliation: Women's Health Research Institute, BC Women's Hospital, Vancouver, BC, Canada.
authors.forename: Gina S
authors.identifier: 0000-0001-5783-4493
authors.initials: GS
authors.lastname: Ogilvie
mesh_terms: D003362:Cost-Benefit Analysis; D003906:Developing Countries; D055088:Early Detection of Cancer / Q000191:economics*; D005260:Female; D006801:Humans; D002583:Uterine Cervical Neoplasms / Q000175:diagnosis / Q000191:economics* / Q000517:prevention & control
keywords: cervical cancer; cost-effectiveness analysis; human papillomavirus; low- and middle-income countries; screening