James Karichu

Cost-effectiveness analysis of reflex p16/Ki-67 dual-stained cytology in HPV partial genotyping screening in Singapore

Triage testing is an integral part of high-risk human papillomavirus (HPV)-based cervical screening programs. This study assesses, from a healthcare payer perspective in Singapore, the cost-effectiveness of p16/Ki-67 dual-stained cytology (DS) compared to current standard of care (SOC). A decision-analytic Markov microsimulation model with a lifetime horizon was built to simulate the outcomes from HPV screening in Singaporean women aged 30-65 years. The intervention (primary testing with HPV genotyping followed by DS reflex test) was compared to current SOC (HPV genotyping followed by cytology) according to Singaporean clinical management guidelines. The progression through health states and associated costs and health outcomes were based on local clinical care data in Singapore. Screening impact was assessed by cost saving, number of colposcopy and quality-adjusted life years (QALYs). Compared to SOC, implementation of HPV genotyping + DS was estimated to decrease the number of screening test (-2.02 times per patient) and colposcopy (-0.16 times per patient), and reduce the overall costs to the Singaporean healthcare system by S$225.59 per patient (95% confidence interval [CI]=S$199.05 to S$249.99). The total QALYs estimates for the 2 approaches were similar (-0.0003; 95% CI=-0.0031 to 0.0022). Sensitivity analyses confirmed the robustness of expected cost-savings and that the full value of avoided colposcopies may be larger than projected in the current analysis. This economic modelling analysis projected that using DS instead of conventional cytology as the reflex test for positive test with non-HPV-16/18 subtypes significantly reduced the financial costs of cervical cancer screening in Singapore.

A prospective model of the potential clinical and economic impact of cervical cancer screening supported by a mobile phone app

Introduction Cervical cancer is a preventable and highly curable disease when detected early and adequately treated, yet it remains the leading cause of cancer-related death in women in Kenya due to low screening coverage and treatment. Implementing World Health Organization screening guidelines for human papillomavirus (HPV) is challenging due to the complex logistics of result return and follow-up requiring multiple clinic visits. Increasing the use of mobile technology can support follow-up care in cervical cancer screening programs. Methods We developed a prospective clinico-economic model to assess the potential impact of a mobile phone-based application (“app”) communicating laboratory results and recommendations to improve follow-up care for cervical cancer screening in Kenya. The model is structured to simulate a three-visit pathway for HPV-based screening used in a clinical trial of the app and based on epidemiological data, clinical guideline-based workflow, and patient-based behavioral pathways. Published literature, expert elicitation, and time-and-motion observations were used to estimate clinical data, care pathways, and visit-related costs. This analysis was conducted from a base-case healthcare system perspective with a scenario from a “limited” societal perspective. Results In a simulated cohort of women using the app-based intervention compared to conventional care, with 10,000 women in each arm, use of the app is projected to increase healthcare costs by $12.53 per enrolled woman during the trial period and to detect and treat an additional 247 women—229 with precancerous cervical lesions and 18 with cervical cancer. The incremental cost-effectiveness ratio of the app versus conventional care was $174 per case detected and treated. This would be cost-saving given the average lifetime cost per cervical cancer case of $1,000–$3,000. Conclusion Use of a mobile phone-based app is costlier than conventional screening but by improving visit compliance, it can be a cost-effective and cost-saving strategy to enhance detection and treatment in cervical cancer screening programs.