For Cervical Cancer, Two Tests Are Better Than One

Consensus United States cervical cancer screening guidelines recommend the use of combination Pap plus human papillomavirus (HPV) testing for women aged 30 to 65 years, while Pap testing is recommended for women aged 21 to 30 years. However, an HPV test has been approved for primary cervical cancer screening in women aged 25 years or older.

In order to test the effectiveness and efficiency of co-testing with Pap plus HPV versus single testing for HPV only, researchers led by Juan C Felix, MD, developed a health state transition (Markov) model with 1-year cycling using epidemiologic, clinical, and economic data from health care databases and published literature. Comprehensive sensitivity analyses were performed on a hypothetical cohort of 1 million women aged 30 years who received triennial cervical cancer screening and modeled up to age 70 years.

Outcomes of the study included total and incremental differences in costs, invasive cervical cancer (ICC) cases, ICC deaths, number of colposcopies, and quality-adjusted life years (QALYs) for cost-effectiveness calculations, which were summed during each year over the course of 40 years. The primary outcome measure was total direct medical costs per woman screened. 

The model predicted that screening with HPV primary testing instead of co-testing could lead to as many as 2141 more ICC cases and 2041 more ICC deaths (J Women’s Health. 2016; 25(6):606-616). During the simulation, co-testing demonstrated a greater number of lifetime QALYs and yielded $39 million in savings compared with HPV primary. Lifetime cumulative costs of screening and management per patient equaled $2326 for co-testing and $2365 for HPV primary. For co-testing, screening and diagnosis costs were $1319 and $1007, respectively, while for HPV primary, they equaled $1129 and $1236, respectively. Therefore, there are lower costs associated with co-testing. 

Additionally, co-testing resulted in more accurate colposcopies per woman compared with HPV positive (0.127 vs 0.122) and fewer false positive colposcopies (2.101 vs 2.111). This data represents 5206 more true results and 9763 fewer false positive results across the entire cohort.

Because ICC remains a significant public health burden, effective screening methods need to be utilized. The results of this model show that co-testing has the potential to provide improved outcomes.—Nina Farrell