There are 33,230 to 63,965 new cases of high-grade cervical precancerous lesions (cervical intraepithelial neoplasia, CIN2+) every year in the UK.[1] Even for lower grades, the psychological effect and economic impact of CIN diagnosis are substantial.[1] A nonavalent HPV vaccine is now licensed in Europe with the potential to prevent close to 90% of cervical cancers and approximately 50% of CIN1 and 80% of CIN2+.[1] Although there have been some published estimates of the costs associated with CIN, few data closely reflect current management guidelines in the UK.[2] With HPV triage recently recommended for cases of borderline and low-grade dyskaryosis, the management pathway continues to evolve and is increasingly branched, complicating the estimation of the economic burden. To address this limitation, this study aimed to understand the pathway and determine the costs associated with the management of HPV-related CIN1 and CIN2/3 in current UK practice.
A probabilistic decision tree was constructed according to current UK guidelines to simulate the management pathway of a woman diagnosed with CIN. An expert clinician validated the pathway to ensure that it reflected current clinical practice. The episode of care extended from the initial abnormal cytology up to either the progression of the lesion to cervical cancer or the resolution of the case and discharge of the woman to routine recall. All attributable treatment and follow up events were modelled, but long-term maternal consequences, such as preterm birth and neonatal morbidity were not considered. Unit costs associated with consultations, screening and diagnostic tests, and treatment were collected from national sources, as were epidemiological probabilities. Costs were also reported by pathway stages (i.e., screening, diagnosis, treatment, and follow-up) and by initial cytology (smear test) result.
In the base case scenario, the average cost of care per episode was £759.47 for CIN 1 and £788.52 for CIN 2/3. Distribution of costs were similar across diagnosis, treatment, and follow-up stages for CIN 1 (£224.00, £209.96, £240.88), while treatment was responsible for 44% of costs in CIN 2/3 management. Stratified by initial smear test result, the average episode cost for a high grade smear (i.e. moderate to severe dyskaryosis) was £557.93, compared to £398.50 for a low grade smear (i.e. borderline to mild dyskaryosis).
Costs associated with an episode of care for CIN were reappraised according to current management algorithms, and found to be higher than a prior, regularly cited estimate.[3]
[1] Hartwig, S., et al., Estimation of the epidemiological burden of HPV-related anogenital cancers, precancerous lesions, and genital warts in women and men in Europe: Potential additional benefit of a nine-valent second generation HPV vaccine compared to first generation HPV vaccines. Papillomavirus Research, 2015. 1: p. 90-100.
[2] NHS Cancer Screening Programmes, NHS Cervical Screening Programme Screening Protocol Algorithm for HPV Triage and TOC 2014.
[3] Martin-Hirsch, P., et al., Management of women with abnormal cervical cytology: treatment patterns and associated costs in England and Wales. BJOG., 2007. 114(4): p. 408-415.