Page 165 - Genomic Medicine in Emerging Economies

154 CHAPTER 8: E c o n omic Evaluation and Cost-Effectiveness Analysis

In an economic evaluation which was conducted in Lebanon, researchers eval-
uated cytology and HPV DNA screening for women aged 25–65 years, with
varying coverage from 20% to 70% and frequency from 1 to 5 years (Sharma
et al., 2017). In Lebanon, there is no national organized cervical cancer (CC)
screening program, and thus screening is limited only to those women who
can pay out of pocket. Hence, the study evaluated the cost-effectiveness of
increasing screening coverage and extending intervals. The model was cali-
brated to epidemiological data from Lebanon, including CC incidence and
HPV type distribution. Results showed that at 20% coverage, annual cytologic
screening reduced lifetime CC risk by 14% and had an ICER of I$80,670/year
of life saved, far exceeding Lebanon’s GDP per capita (I$17,460), a commonly
cited cost-effectiveness threshold. By comparison, increasing cytologic screen-
ing coverage to 50% and extending screening intervals to 3 and 5 years pro-
vided a greater CC reduction (26.1% and 21.4%, respectively) at lower costs,
when compared with 20% coverage with annual screening. Screening every 5
years with HPV DNA testing at 50% coverage provided greater CC reductions
than cytology at the same frequency (23.4%) and was cost-effective, assuming
a cost of I$18 per HPV test administered (I$12,210/year of life saved); HPV
DNA testing every 4 years at 50% coverage was also cost-effective at the same
cost per test (I$16,340). Increasing coverage of annual cytology was not found
to be cost-effective. The analysis concluded that the current practice of repeated
cytology in a small percentage of women is inefficient, whereas increased cov-
erage to 50% with extended screening intervals provides greater health benefits
at a reasonable cost and thus can more equitably distribute health gains. Nota-
bly, novel HPV DNA strategies offer greater CC reductions and may be more
cost-effective than cytology.

In another economic evaluation, the cost-effectiveness of different cervical
screening strategies was estimated in the Islamic Republic of Iran, a Muslim
country with a low incidence rate of invasive CC (Nahvijou et al., 2016). An
11-state Markov model was constructed, in which the parameters included
regression and progression probabilities, test characteristics, costs, and utili-
ties; these were extracted from the primary data and current literature. Compar-
ing strategies included Pap smear screening, HPV DNA testing, plus Pap smear
triaging with various starting ages and screening intervals. Model outcomes
included lifetime costs, life years gained, QALY and ICERs. It was concluded
that the prevented mortalities for the 11 strategies compared with no screening
varied from 26% to 64%. The most cost-effective strategy was HPV screening,
starting at the age of 35 years and repeated every 10 years. The ICER of this
strategy was US$8875 per QALY compared with no screening. Screening at
5-year intervals was found to be cost-effective on the basis of GDP per capita
in Iran. Overall, cervical screening with HPV DNA testing for women in Iran,
beginning at the age of 35 and repeated every 5 or 10 years was a cost-effective
and recommended treatment.