Cervical Cancer Screening in Low Resource Settings: A Cost Effectiveness Analysis in Nepalese Context
Year: 2017
Type: dissertation
Abstract: Background: Cervical cancer is a leading cause of cancer related mortality among women all over the world, with particularly high incidence in developing countries. It is the most common cancer among women in Nepal. Cervical cancer screening can be effective in reducing incidence and mortality due to cervical cancer. However, expansion of screening to low income settings remains a challenge. At present, there is no organized screening program in Nepal, but recently government announced that Pap smear tests will be made available free of cost in public hospitals. Studies from other countries indicate that Pap smear may not be the most cost effective strategy, especially in low resource settings. There is growing focus on Visual Inspection with Acetic Acid (VIA) and Human Papilloma Virus (HPV) Tests as more cost effective alternatives for Pap smear. Objective: To compare cost effectiveness of three screening strategies VIA, Pap smear and HPV DNA test for cervical cancer screening in Nepal. Method: A probabilistic decision tree model for one time screening of women at 30 years age was constructed where outcome was number of CIN2+ detected. Cost effectiveness analysis was carried out from societal perspective and hence both direct and indirect costs were included in analysis. The epidemiological data was obtained from literature. Uncertainty was explored by one-way, two-way and probabilistic sensitivity analysis. In addition, harm to benefit analysis was carried out to explore the additional number of colposcopy required per additional CIN 2+ detected. Budget impact analysis was carried out to explore the financial implication of implementing the screening program in Nepal from provider’s perspective. Results: Among the three screening strategies, Pap smear was found to be not cost effective at any WTP threshold. VIA was found to be cost effective for WTP threshold below NRS 500,000 per CIN2+ detected and HPV Test was found to be cost effective for WTP threshold above NRS 500,000 per CIN2+ detected. In harms to benefit analysis, VIA was found to be least acceptable, whereas Pap smear was most acceptable strategy. In terms of budget impact, HPV test and VIA was found to be most costly and least costly strategies respectively. Conclusion: Given the resource constraints, this study indicates that Pap smear may not be the right choice of screening strategy. VIA has more favourable outcomes, but there is need for more research as there is presence of a considerable decision uncertainty.
Author: Aastha Bajracharya
Language: English
Subfield: Epidemiology
Field: Medicine
Domain: Health Sciences
Open Access status: green
OpenAlex ID: W2746412034