Costs and Effectiveness of Alternative Strategies for Cervical Cancer Screening in Military Beneficiaries

Maxwell, G. Larry MD; Carlson, Jay W. MC; Ochoa, Mark MC; Krivak, Tom MC; Rose, G. Scott MC; Myers, Evan R. MD, MPH

Obstetrics & Gynecology:
Original Research

OBJECTIVE: To estimate the potential effects, on costs and outcomes, of changes in sensitivity and specificity associated with new screening methods for cervical cancer in the military.

METHODS: A Markov model of the natural history of cervical cancer was created to simulate a cohort of 100,000 military beneficiaries aged 18–85. Probability estimates for various outcomes and the accuracy of screening tests were obtained from the literature. Cost estimates were obtained from military sources where available; otherwise, civilian costs were used. The outcomes and costs of conventional cytology, liquid‐based cytology, and liquid‐based cytology with human papillomavirus (HPV) triage were compared at 1‐, 2‐, and 3‐year screening frequencies.

RESULTS: Marginal reductions in the incidence of cervical cancer from increasing screening sensitivity are greater than reductions in cancer mortality at every screening interval. Incremental improvements in both cancer incidence and mortality are higher at less frequent screening intervals. Increases in the ratio of low‐ to high‐grade lesions result from increasing the sensitivity of the screening test or shortening the screening interval. Both liquid‐based cytology and liquid‐based cytology with HPV testing are cost effective (less than $50,000 per life‐year saved) when performed at 3‐year screening intervals. However, neither strategy is cost‐effective when performed more frequently than every 3 years.

CONCLUSION: Use of a more sensitive cervical cancer screening test increases costs. However, a more sensitive test performed less frequently may be more effective and less expensive than conventional cytology done annually. In the military setting, this has significant implications for both expense reduction and readiness enhancement.

In Brief

More sensitive cervical cancer screening performed less frequently may be more effective and less expensive than the conventional cytology done annually.

Author Information

Division of Gynecologic Oncology, Walter Reed Army Medical Center, Washington, District of Columbia; and Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, North Carolina.

Address reprint requests to: Evan R. Myers, MD, MPH, Duke University Medical Center, Department of Obstetrics and Gynecology, Durham, NC 27710.

ERM has received unrestricted grant funding in the past from Digene Inc. for the evaluation of economic issues surrounding human papillomavirus testing. JWC authored the decision brief that led to the implementation of liquid‐based cytology and reflex human papillomavirus testing, utilizing ThinPrep and HC2, at all Army medical facilities worldwide.

Data reported here were presented at the 33rd Annual Meeting of the Society of Gynecologic Oncologists, Miami, Florida, March 2–7, 2002.

Received November 27, 2001. Received in revised form March 26, 2002. Accepted April 18, 2002.

© 2002 by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.