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Cost-Effectiveness of Surveillance Strategies After Treatment for High-Grade Anal Dysplasia in High-Risk Patients

Assoumou, Sabrina A. MD*; Mayer, Kenneth H. MD†‡; Panther, Lori A. MD, MPH†‡; Linas, Benjamin P. MD, MPH; Kim, Jane J. PhD

Sexually Transmitted Diseases: April 2013 - Volume 40 - Issue 4 - p 298–303
doi: 10.1097/OLQ.0b013e31827f4fe9
Original Study

Background: Anal cancer is one of the most common cancers affecting human immunodeficiency virus (HIV)–infected male patients. Currently, there is no consensus on posttreatment surveillance of HIV-infected men who have sex with men (MSM) who have been treated for high-grade intraepithelial neoplasia (HGAIN), the likely precursor to anal cancer.

Objective: The aim of this study was to assess the cost-effectiveness of a range of strategies for anal cancer surveillance in HIV-infected MSM previously treated for HGAIN.

Methods: We developed a Markov model to project quality-adjusted life expectancy, lifetime costs, and the incremental cost-effectiveness ratios of 5 strategies using high-resolution anoscopy (HRA) and/or anal cytology testing after treatment.

Results: Performing HRA alone at 6- and 12-month visits was associated with a cost-effectiveness ratio of $4446 per quality-adjusted life year gained. In comparison, combined HRA and anal cytology at both visits provided greater health benefit at a cost of $17,373 per quality-adjusted life year gained. Our results were robust over a number of scenarios and assumptions including patients’ level of immunosuppression. Results were most sensitive to test characteristics and cost, as well as progression rates of normal to HGAIN and HGAIN to cancer.

Conclusions: Our results suggest that combined HRA and anal cytology at 6 and 12 months may be a cost-effective surveillance strategy after treatment of HGAIN in HIV-infected MSM.

Results from a model-based decision analysis found that in HIV-infected men who have sex with men treated for anal dysplasia, a surveillance strategy combining high-resolution anoscopy and cytology may be cost-effective.

Form the *Department of Medicine, Section of Infectious Diseases, Boston University School of Medicine, Boston, MA; †Division of Infectious Diseases, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA; ‡The Fenway Institute, Boston, MA; §Boston University School of Public Health, Boston Medical Center, Boston University School of Medicine, Boston, MA; and ¶Department of Health Policy and Management, Harvard School of Public Health, Boston, MA

The authors thank Erika D’agata, MD, MPH, who provided guidance and critical review of the manuscript.

Supported by the Harvard Medical School Center for Excellence in Minority Health and Health Disparities (Health Disparities Post Graduate Fellowship funded by Health Resources and Services Administration, Bureau of Health Professions grant). S.A.A. was supported by the Harvard Medical School Center for Excellence in Minority Health and Health Disparities (Health Disparities Post Graduate Fellowship funded by Health Resources and Services Administration, Bureau of Health Professions grant), J.J.K. is supported, inpart, by the National Cancer Institute (1R01CA160744-01A1). B.P.L. is supported, in part, by the National Institute of Drug Abuse (R01 DA031059).

Conflicts of interest: L.A.P. has received honoraria from Merck as a member of the speakers’ bureau. K.H.M. received research support from Merck, Bristol-Myers Squibb, and Gilead. For the remaining authors, no conflicts of interest were declared.

Role of funding sources: Agencies funding this study have no role in thecollection, analysis, or interpretation of data.

Correspondence: Sabrina A. Assoumou, MD, Boston Medical Center, Boston University School of Medicine, One Boston Medical Center Place, 850 Harrison Ave, Dowling Ground, Boston, MA 02118. E-mail: sabrina.assoumou@bmc.org.

Received for publication May 30, 2012, and accepted November 21, 2012.

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© Copyright 2013 American Sexually Transmitted Diseases Association