About 80% of all cervical cancers occur in developing countries, including Latin America, sub-Saharan Africa, and Southeast Asia. In these countries, cervical cancer screening programs must compete with other health problems for funding. While the Pap smear has been the traditional screening approach for cervical cancer, studies have suggested that, in developing countries, visual inspection of the cervix with acetic acid (VIA) and human papillomavirus (HPV) DNA testing may be less expensive alternatives for cervical cancer screening.
VIA involves swabbing the cervix with diluted vinegar and looking for abnormal tissue. HPV DNA testing involves testing for DNA from the HPV virus, which has been strongly linked to cervical cancer.
In this study, Jeanne S. Mandelblatt, M.D., of the Georgetown University School of Medicine, Lombardi Cancer Center, and her colleagues used a computer model to simulate the societal costs and benefits of cervical cancer screening, diagnosis, and treatment in Thailand, a country with high rates of cervical cancer and no organized infrastructure for Pap testing. The researchers then compared the costs and benefits of 42 combinations of seven different screening strategies using one or more of the three screening tests performed at various intervals.
The screening strategies included Pap smear screening, HPV DNA testing, Pap smear and HPV DNA testing, VIA and immediate treatment of abnormal tissue, VIA with referral of women with abnormal results to a regional hospital, and VIA followed by HPV DNA testing.
Compared with no screening, all strategies reduced the incidence and mortality of cervical cancer at a cost of between $121 to $6,720 per life-year saved. VIA, performed every 5 years in women ages 35 to 55, with immediate treatment if abnormalities were found, was the least expensive approach and saved the most lives. Their model projects that in Thailand the total annual cost of a VIA screening program with immediate treatment for the female population aged 33 to 55 years every 5 years would be $0.79 per woman, or $4.7 million annually. Such a screening program would increase Thailand's overall national per capita health expenditure by less than 0.1%, the researchers write.
HPV testing resulted in similar costs and benefits, if the test cost is $5 and if 90% of women undergo follow-up after an abnormal screen. The Pap smear was a reasonable alternative if it picked up at least 80% of the abnormalities and if 90% of women undergo follow-up after an abnormal screen. Overall, strategies that involved screening at regular intervals were more effective than those that involved screening just once or twice.
The authors say that these findings may be useful on helping resource-poor countries make decisions about which screening strategy may be best for a given region. However, "regardless of the strategy chosen, community education will be key to ensuring compliance with screening and follow-up recommendations," the authors point out. "These costs will need to be considered when evaluating initial costs of building and maintaining any screening infrastructure."
Contact: Beth Porter, Lombardi Cancer Center, 202-687-4699; fax: 202-687-5213, bap2@georgetown.edu
Mandelblatt J, Lawrence W, Gaffikin L, Limpahayom K, Lumbiganon P, Warakamin S, et al. Costs and benefits of different strategies to screen for cervical cancer in less-developed countries. J Natl Cancer Inst 2002;94:1469–83.
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JNCI Journal of the National Cancer Institute