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Cost-Effectiveness Analysis of Different Management Strategies for Detection CIN2+ of Women with Atypical Squamous Cells of Undetermined Significance (ASC-US) Pap Smear in Thailand

  • Tantitamit, Tanitra (Department of Obstetrics and Gynecology, Faculty of Medicine, King Chulalongkorn Memorial Hospital) ;
  • Termrungruanglert, Wichai (Department of Obstetrics and Gynecology, Faculty of Medicine, King Chulalongkorn Memorial Hospital) ;
  • Oranratanaphan, Shina (Department of Obstetrics and Gynecology, Faculty of Medicine, King Chulalongkorn Memorial Hospital) ;
  • Niruthisard, Somchai (Department of Obstetrics and Gynecology, Faculty of Medicine, King Chulalongkorn Memorial Hospital) ;
  • Tanbirojn, Patuou (Department of Obstetrics and Gynecology, Faculty of Medicine, King Chulalongkorn Memorial Hospital) ;
  • Havanond, Piyalamporn (College of Public Health Science, Chulalongkorn University)
  • Published : 2015.11.04

Abstract

Background: To identify the optimal cost effective strategy for the management of women having ASC-US who attended at King Chulalongkorn Memorial Hospital (KMCH). Design: An Economical Analysis based on a retrospective study. Subject: The women who were referred to the gynecological department due to screening result of ASC-US at King Chulalongkorn Memorial Hospital, a general and tertiary referral center in Bangkok Thailand, from Jan 2008 - Dec 2012. Materials and Methods: A decision tree-based was constructed to evaluate the cost effectiveness of three follow up strategies in the management of ASC-US results: repeat cytology, triage with HPV testing and immediate colposcopy. Each ASC-US woman made the decision of each strategy after receiving all details about this algorithm, advantages and disadvantages of each strategy from a doctor. The model compared the incremental costs per case of high-grade cervical intraepithelial neoplasia (CIN2+) detected as measured by incremental cost-effectiveness ratio (ICER). Results: From the provider's perspective, immediate colposcopy is the least costly strategy and also the most effective option among the three follow up strategies. Compared with HPV triage, repeat cytology triage is less costly than HPV triage, whereas the latter provides a more effective option at an incremental cost-effectiveness ratio (ICER) of 56,048 Baht per additional case of CIN 2+ detected. From the patient's perspective, the least costly and least effective is repeat cytology triage. Repeat colposcopy has an incremental cost-effectiveness (ICER) of 2,500 Baht per additional case of CIN2+ detected when compared to colposcopy. From the sensitivity analysis, immediate colposcopy triage is no longer cost effective when the cost exceeds 2,250 Baht or the cost of cytology is less than 50 Baht (1USD = 31.58 THB). Conclusions: In women with ASC-US cytology, colposcopy is more cost-effective than repeat cytology or triage with HPV testing for both provider and patient perspectives.

Keywords

ASC-US;cost effectiveness;PAP smear;colposcopy;HPV testing;ICER

References

  1. Arbyn M, Roelens J, Simoens C, et al (2013). Human papillomavirus testing versus repeat cytology for triage of minor cytological cervical lesions. Cochrane Database Syst Rev, 3, 8054.
  2. Chichareon SB, Tocharoenvanich ST (2002). Situation analysis of atypical squamous cells of undetermined significance smears in Songklanagarind Hospital. J Obstet Gynaecol Res, 28, 269-73. https://doi.org/10.1046/j.1341-8076.2002.00054.x
  3. Chichareon SB, Tassee S, Wootipoom V, et al (2005). Situation analysis for management of abnormal Pap smears in the lower southern Thailand. Asian Pac J Cancer Prev, 6, 286-94.
  4. Kantathavorn N, Kietpeerakool C, Suprasert P, et al (2008). Clinical relevance of atypical squamous cells of undetermined significance by the 2001 bethesda system: experience from a cervical cancer high incidence region. Asian Pac J Cancer Prev, 9, 785-8.
  5. Katki HA, Schiffman M, Castle PE, et al (2013). Benchmarking CIN 3+ risk as the basis for incorporating HPV and Pap cotesting into cervical screening and management guidelines. J Low Genit Tract Dis, 17, 28-35. https://doi.org/10.1097/LGT.0b013e318258bf5b
  6. Katki HA, Schiffman M, Castle PE, et al (2013). Five-year risks of CIN 3+ and cervical cancer among women who test Pap-negative but are HPV-positive. J Low Genit Tract Dis, 17, 56-63. https://doi.org/10.1097/LGT.0b013e318285437b
  7. Kim JJ, Wright TC, Goldie SJ (2002). Cost-effectiveness of alternative triage strategies for atypical squamous cells of undetermined significance. JAMA, 287, 2382-90. https://doi.org/10.1001/jama.287.18.2382
  8. Kulasingam SL, Kim JJ, Lawrence WF, et al (2006). Costeffectiveness analysis based on the atypical squamous cells of undetermined significance/low-grade squamous intraepithelial lesion triage study (ALTS). J Natl Cancer Inst, 98, 92-100. https://doi.org/10.1093/jnci/djj009
  9. Limpvanuspong B, Tangjitgamol S, Manusirivithaya S, et al (2008). Prevalence of high grade squamous intraepithelial lesions (HSIL) and invasive cervical cancer in patients with atypical squamous cells of undetermined significance (ASCUS) from cervical pap smears. Southeast Asian J Trop Med Public Health, 39, 737-44.
  10. Lytwyn A, Sellors JW, Mahony JB, et al (2000). Comparison of human papillomavirus DNA testing and repeat papanicolaou test in women with low-grade cervical cytologic abnormalities: a randomized trial. HPV Effectiveness in Lowgrade Paps (HELP) Study No. 1 Group. CMAJ, 163, 701-7.
  11. Ostensson E, Froberg M, Hjerpe A, et al (2010). Economic analysis of human papillomavirus triage, repeat cytology, and immediate colposcopy in management of women with minor cytological abnormalities in Sweden. Acta Obstet Gynecol Scand, 89, 1316-25. https://doi.org/10.3109/00016349.2010.512066
  12. Poomtavorn Y, Suwannarurk K, Thaweekul Y, et al (2011). Risk factors for high-grade cervical intraepithelial neoplasia in patients with atypical squamous cells of undetermined significance (ASC-US) Papanicolaou smears. Asian Pac J Cancer Prev, 12, 235-8.
  13. Sheriff SK, Petry KU, Ikenberg H, et al (2007). An economic analysis of human papillomavirus triage for the management of women with atypical and abnormal Pap smear results in Germany. Eur J Health Econ, 8, 153-60. https://doi.org/10.1007/s10198-007-0038-5
  14. Solomon D, Schiffman M, Tarone R (2001). Comparison of three management strategies for patients with atypical squamous cells of undetermined significance: baseline results from a randomized trial. J Natl Cancer Inst, 93, 293-9. https://doi.org/10.1093/jnci/93.4.293
  15. Suntornlimsiri W (2010). Women in a region with high incidence of cervical cancer warrant immediate colposcopy for atypical squamous cells of undetermined significance on cervical cytology. J Med Assoc Thai, 93, 676-81.
  16. Vanni T, Legood R, Franco EL, et al (2011). Economic evaluation of strategies for managing women with equivocal cytological results in Brazil. Int J Cancer, 129, 671-9. https://doi.org/10.1002/ijc.25708
  17. WHO/ICO Information Centre on HPV and Cervical Cancer (2010). Human papillomavirus and related cancers in thailand. summary report 2010. [Date accessed].
  18. Wright TC, Jr., Massad LS, Dunton CJ, et al (2007). 2006 consensus guidelines for the management of women with abnormal cervical screening tests. J Low Genit Tract Dis, 11, 201-22. https://doi.org/10.1097/LGT.0b013e3181585870
  19. Yarandi F, Shojaei H, Eftekhar Z, et al (2009). Comparison of three management strategies for patients with atypical squamous cells of undetermined significance, after six months delay: a three-year experience in an Iranian university hospital. Aust N Z J Obstet Gynaecol, 49, 207-10. https://doi.org/10.1111/j.1479-828X.2009.00960.x