Cost-effectiveness analysis of human papillomavirus-vaccination programs to prevent cervical cancer in Austria
Introduction
It has been demonstrated that infection with certain types of human papillomavirus (HPV) can cause cervical cancer. Worldwide, cervical cancer is responsible for 9% of total cancer related mortality. However, 80% of the cases concern the so-called developing countries. In Europe there are approximately 34,000 new cases of cervical cancer each year. Around 14,000 women die each year [1]. In Austria there were 473 new cases of cervical carcinoma in 2003 and 169 women died from cervical cancer, representing a 2.8% share of the total cancer incidence and a 2% share of the total cancer mortality [2].
For the past decades incidence and mortality of cervical carcinoma have been clearly decreasing in Western countries, including Austria. This is explained by the introduction of cytological screening (pap smear). However, in comparison with other European countries, the age-adjusted incidence and mortality rates are high in Austria [1]. In Finland, which is the European country with the lowest age-adjusted incidence and mortality rate, in 2002, 6.6 fewer women per 100,000 had developed the disease than in Austria, and 2.3 fewer women per 100,000 died from it [1]. Overall, in Austria screening is opportunistic rather than organised. Potential for improvement exists in terms of screening attendance rates, particularly among women from underprivileged groups, and in terms of screening quality. Although screening is publicly financed, available data have shown an annual screening participation rate of only 30% in 2005. In a three-year time interval (2003–2006), about 50% of women participated in cervical cancer screening. Participation decreases with increasing age [3].
In addition to successful screening programs, the possibility of immunisation against high-risk HPV genotypes has recently been introduced. Both of the two available HPV vaccines prevent infection from two out of 15 identified high-risk HPV genotypes (16 and 18, detected in about 70% of cancer cases), one additionally protects against two low-risk types (6 and 11) which are related to further diseases such as genital warts. As has been shown in systematic literature reviews, clinical studies have demonstrated that in the specific subgroup of HPV-naive females aged 15–26 the vaccines have shown high efficacy in preventing HPV-type-specific infections and precancerous lesions, the latter being intermediate parameters for cervical carcinoma [4], [5], [6]. There is hope that through vaccination the number of new cervical cancers will decrease substantially. However, several important uncertainties remain such as duration of protection, possible changes in the virus dynamics or overall reduction of precancerous lesions and invasive carcinomas, regardless of HPV-type and subgroups studied. Thus, efficacy data on HPV vaccines are still limited.
To support rational decision making under uncertainty regarding the decision whether to finance HPV-vaccination publicly, decision analytic modelling [7] and economic evaluations are a useful tool. Such economic evaluations have been conducted for several countries [4], [8], [9], [10], [11], [12], [13], [14], [15], [16], [17], [18], [19], [20]. However, transferability from one country to another is usually limited [21], [22]. Thus, country-specific evaluations are required that take into account country-specific features such as screening policy, epidemiology of cervical cancer, service patterns or unit costs. Therefore, the aim of our study was to evaluate the long-term effectiveness and cost-effectiveness of HPV-vaccination programs to prevent cervical cancer in comparison to screening only in an Austrian health care system context.
Section snippets
Prevention strategies and outcomes
We compared three different prevention strategies: (a) ‘screening only’ (the current standard treatment); (b) vaccination of 12-year-old girls in addition to screening (HPV F); (c) vaccination of 12-year-old girls and boys in addition to screening (HPV F + M). Because many of the vaccine benefits will occur in the long-term, a mathematical model was used to predict the impact of the vaccination beyond the time-horizon of clinical vaccine trials. The outcome parameters of interest for the
Model validity
Model outputs for cervical carcinoma incidence and mortality are in accordance with Austrian epidemiological data. Overall, incidence and mortality rates between 2001 and 2006 in the model do not differ more than 15% from the observed rates in Austria. If at all, the model slightly overestimates the rates. However, as Austrian cervical carcinoma epidemiological data seem to slightly underestimate the true burden of the disease, this in fact supports validity of the model outputs. Fig. 2
Discussion
This study aimed at evaluating the long-term cost-effectiveness of different HPV-vaccination programmes to reduce cervical cancer in comparison with screening only in Austria. The calculation was based on a dynamic transmission model for the strategies of (a) screening only, (b) vaccinating 12-year-old girls only and (c) vaccinating girls and boys. From a health care system perspective, base case results showed a cost-effectiveness ratio of 64,000 Euros per LYG for vaccinating 12-year-old girls
Conclusion
There is hope that the introduction of a population-wide HPV-vaccination programme will further decrease cervical cancer incidence and mortality in Austria. The cost-effectiveness of HPV-vaccination depends strongly on the framework of the analysis: when considering longer time-horizons and a societal perspective, vaccination of girls should be cost-effective when compared to other well-accepted interventions in health and medicine in Austria, whereas for a shorter time span and from a payer's
Acknowledgements
The article is based on the results of the report entitled ‘Economic evaluation of HPV-vaccination in Austria’ which was funded by the Austrian Ministry of Health. We are grateful to the people from various Austrian institutions (Statistics Austria, Ministry of Health, Federation of the Austrian Social Insurance Institutions, Tyrolean hospital association) who provided the numerous data required, to the medical experts who supported us with their advice and expertise and to our colleagues
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2018, VaccineCitation Excerpt :Seventeen studies [24,26,27,35–48] explored the economic impact of multiple age cohort immunization, whereby three studies extended their cost-effectiveness analyses by including both gender in the multicohort immunization strategy [24,26,27] (see Table 2). Among all included studies, majority studies (28/34) were conducted in high income countries [15,17–25,27,29–31,33–39,42–48], four studies in upper-middle income countries [26,28,40,41] and two studies in low-middle income countries [16,32]. Majority studies (21/34) were funded by vaccine manufacturers (e.g. Merck, Sharp & Dome; Sanofi Pasteur MSD and GlaxoSmith Kline) [17,21,23–27,30,31,35–42,45–48] while elven studies were funded by not-for-profit funders [15,16,18,19,28,29,32–34,43,44].
Cost-Effectiveness Analysis of Universal Human Papillomavirus Vaccination Using a Dynamic Bayesian Methodology: The BEST II Study
2015, Value in HealthCitation Excerpt :They all use a deterministic methodology, with the exception of Kim and Goldie [11], in which sexual mating continues to be modeled in a deterministic way. In all but two publications showing lack of cost-effectiveness [10,11], the ICERs only account for HPV-induced diseases related to the cervix [47,127], and in some cases also for anogenital warts [123–126]. In contrast, universal vaccination is estimated to be cost-effective according to seven studies [12,19–23,128], with ICER values ranging from €4,470 [128] to €31,240 [19] compared with screening-only and €93 [20] to €21,677 [12] compared with female-only vaccination, respectively (across a large range of scenarios).
Mind the gaps: What's missing from current economic evaluations of universal HPV vaccination?
2014, VaccineCitation Excerpt :Six studies included HRQoL effects for cancer survivors [57–60,62,64] but no study included the indirect effects experienced by patients who have recovered from HPV-related conditions, such as impacts on fertility or emotional sequelae such as anxiety and distress. Seven studies expressed the ICER in terms of QALYs gained, while one estimated life-years gained, which ignores the value of preventing HPV-related morbidity [61]. However, a number of limitations were identified with the approaches used to estimate utility.