In Europe, cervical cancer screening varies substantially regarding age at screening start and end, frequency, type of primary test and follow-up algorithm for screen-positive women. Risk-based screening and follow-up strategies may have the potential to improve both, the benefit-harm balance of the screening program and its cost-effectiveness. We systematically reviewed current evidence on long-term effectiveness and cost-effectiveness of cervical cancer screening in Europe with specific interest on risk-adapted strategies.
Relevant databases (Medline/Embase/Cochrane Library/CRD/EconLit) were systematically searched for decision-analytic studies evaluating the cost-effectiveness of cervical cancer screening strategies in Europe. Study characteristics and results including the incremental cost-effectiveness ratios (ICER) in cost per quality-adjusted life year (QALY) or life year gained (LYG) were extracted into standardized evidence tables. Economic results were converted to 2015 Euros.
Fourteen studies were included, comprising eleven analyses for countries with population-based organized screening, one for an opportunistic screening, and two for countries where, depending on the region, the screening is organized or opportunistic. Three studies evaluated screening for multiple European countries.
HPV-based screening was reported to be more effective in terms of patient-relevant outcomes compared to cytology alone in both non-vaccinated and vaccinated women. Overall, HPV-based screening strategies were considered to be cost-effective at a willingness-to-pay threshold of 50,000 Euro/QALY or LYG conditional on screening intervals of at least three years in non-vaccinated women and at least five years in vaccinated women. Most studies recommended starting screening at age 25 with HPV-based screening at age 30 years or older. HPV screening was mostly accompanied with a triage test for HPV-positive women. The upper age limit for screening varied with most studies ending screening at age 65 years.
In conclusion, the evidence from decision-analytic modeling studies suggests that HPV-based screening is more effective compared to cytology alone, and can be considered cost-effective at screening intervals of at least 3 years in non-vaccinated and at least 5 years in vaccinated women. Current risk-tailored screening programs are based on restrictions to a specific age and using triage or follow-up tests for HPV-positive women before referring to colposcopy directed biopsy. In future research, predictive biomarker for risk-based management of screen-positives should be considered.