Potential cost‐effectiveness of the nonavalent human papillomavirus (HPV) vaccine

Randomized clinical trials are currently examining the efficacy of a nonavalent human papillomavirus (HPV) vaccine, including HPV‐types 6/11/16/18/31/33/45/52/58. Evidence on the cost‐effectiveness of the nonavalent is required for timely policy‐decisions. We compared the potential cost‐effectiveness of the nonavalent and quadrivalent HPV vaccines. We used a multi‐type individual‐based transmission‐dynamic model of HPV infection and diseases, 70‐year time‐horizon, 3% discount rate and healthcare payer perspective. We calibrated the model to Canadian sexual behavior and epidemiologic data, and estimated Quality‐Adjusted Life‐Years (QALYs) lost and costs ($CAN 2010) from the literature. Under base‐case assumptions (vaccinating 10‐year‐old girls, 80% coverage, 95$/dose, vaccine‐type efficacy = 95%, cross‐protection for the quadrivalent vaccine, duration of vaccine‐type protection (cross‐protection) = 20 (10) years), using the quadrivalent and nonavalent vaccines is estimated to cost $15,528 [12,056; 19,140] and $12,203 [9,331; 17,292] per QALY‐gained, respectively. At equal price, the nonavalent vaccine is more cost‐effective than the quadrivalent vaccine, even when assuming both shorter duration of protection (nonavalent = 20 years vs. quadrivalent = lifelong) and lower vaccine‐type efficacy (nonavalent = 85% vs. quadrivalent = 95%). However, the additional cost per dose of the nonavalent vaccine should not exceed $11 to remain more cost‐effective than the quadrivalent vaccine, and $24 to represent a cost‐effective alternative to the quadrivalent vaccine (using a $40,000/QALY‐gained threshold). The nonavalent vaccine can be a cost‐effective alternative to the quadrivalent vaccine, even in scenarios where nonavalent vaccine efficacy is 85%. However, because most cervical cancers are caused by HPV‐16/18, it is unlikely that the nonavalent would be used if its efficacy against these types is lower than current HPV vaccines.     

Cost‐effectiveness analysis of cervical cancer prevention based on a rapid human papillomavirus screening test in a high‐risk region of China

This study assessed the cost‐effectiveness of a new, rapid human papillomavirus (HPV)‐DNA screening test for cervical cancer prevention in the high‐risk region of Shanxi, China. Using micro‐costing methods, we estimated the resources needed to implement preventive strategies using cervical cytology or HPV‐DNA testing, including the Hybrid Capture 2 (hc2) test (QIAGEN Corp., Gaithersburg, MD) and the rapid HPV‐DNA careHPV? test (QIAGEN). Data were used in a previously published model and empirically calibrated to country‐specific epidemiological data. Strategies differed by initial test, targeted age, frequency of screening, number of clinic visits required (1, 2 or 3) and service delivery setting (national, county and township levels). Outcomes included lifetime risk of cancer, years of life saved (YLS), lifetime costs and incremental cost‐effectiveness ratios (cost per YLS). For all screening frequencies, the most efficient strategy used 2‐visit rapid HPV‐DNA testing at the county level, including screening and diagnostics in the first visit, and treatment in the second visit. Screening at ages 35, 40 and 45 reduced cancer risk by 50% among women compliant with all 3 screening rounds, and was US$ 150 per YLS, compared with this same strategy applied twice per lifetime. This would be considered very cost‐effective evaluated against China's per‐capita gross domestic product (US$ 1,702). By enhancing the linkage between screening and treatment through a reduced number of visits, rapid HPV‐DNA testing 3 times per lifetime is more effective than traditional cytology, and is likely to be cost‐effective in high‐risk regions of China.     

Colorectal cancer screening comparing no screening,immunochemical and guaiac fecal occult blood tests: A cost‐effectiveness analysis

Comparability of cost‐effectiveness of colorectal cancer (CRC) screening strategies is limited if heterogeneous study data are combined. We analyzed prospective empirical data from a randomized‐controlled trial to compare cost‐effectiveness of screening with either one round of immunochemical fecal occult blood testing (I‐FOBT; OC‐Sensor®), one round of guaiac FOBT (G‐FOBT; Hemoccult‐II®) or no screening in Dutch aged 50 to 75 years, completed with cancer registry and literature data, from a third‐party payer perspective in a Markov model with first‐ and second‐order Monte Carlo simulation. Costs were measured in Euros (€), effects in life‐years gained, and both were discounted with 3%. Uncertainty surrounding important parameters was analyzed. I‐FOBT dominated the alternatives: after one round of I‐FOBT screening, a hypothetical person would on average gain 0.003 life‐years and save the health care system €27 compared with G‐FOBT and 0.003 life years and €72 compared with no screening. Overall, in 4,460,265 Dutch aged 50–75 years, after one round I‐FOBT screening, 13,400 life‐years and €320 million would have been saved compared with no screening. I‐FOBT also dominated in sensitivity analyses, varying uncertainty surrounding important effect and cost parameters. CRC screening with I‐FOBT dominated G‐FOBT and no screening with or without accounting for uncertainty.     

Cost‐effectiveness analysis of intensity‐modulated radiation therapy with normal and hypofractionated schemes for the treatment of localised prostate cancer

The aim of our analysis was to compare the cost‐effectiveness of high‐dose intensity‐modulated radiation therapy (IMRT) and hypofractionated intensity‐modulated radiation therapy (HF‐IMRT) versus conventional dose three‐dimensional radiation therapy (3DCRT) for the treatment of localised prostate cancer. A Markov model was constructed to calculate the incremental quality‐adjusted life years and costs. Transition probabilities, adverse events and utilities were derived from relevant systematic reviews. Microcosting in a large university hospital was applied to calculate cost vectors. The expected mean lifetime cost of patients undergoing 3DCRT, IMRT and HF‐IMRT were 7,160 euros, 6,831 euros and 6,019 euros respectively. The expected quality‐adjusted life years (QALYs) were 5.753 for 3DCRT, 5.956 for IMRT and 5.957 for HF‐IMRT. Compared to 3DCRT, both IMRT and HF‐IMRT resulted in more health gains at a lower cost. It can be concluded that high‐dose IMRT is not only cost‐effective compared to the conventional dose 3DCRT but, when used with a hypofractionation scheme, it has great cost‐saving potential for the public payer and may improve access to radiation therapy for patients.     

Cost‐effectiveness of the Norwegian breast cancer screening program

The Norwegian Breast Cancer Screening Programme (NBCSP) has a nation‐wide coverage since 2005. All women aged 50–69 years are invited biennially for mammography screening. We evaluated breast cancer mortality reduction and performed a cost‐effectiveness analysis, using our microsimulation model, calibrated to most recent data. The microsimulation model allows for the comparison of mortality and costs between a (hypothetical) situation without screening and a situation with screening. Breast cancer incidence in Norway had a steep increase in the early 1990s. We calibrated the model to simulate this increase and included recent costs for screening, diagnosis and treatment of breast cancer and travel and productivity loss. We estimate a 16% breast cancer mortality reduction for a cohort of women, invited to screening, followed over their complete lifetime. Cost‐effectiveness is estimated at NOK 112,162 per QALY gained, when taking only direct medical costs into account (the cost of the buses, examinations, and invitations). We used a 3.5% annual discount rate. Cost‐effectiveness estimates are substantially below the threshold of NOK 1,926,366 as recommended by the WHO guidelines. For the Norwegian population, which has been gradually exposed to screening, breast cancer mortality reduction for women exposed to screening is increasing and is estimated to rise to ～30% in 2020 for women aged 55–80 years. The NBCSP is a highly cost‐effective measure to reduce breast cancer specific mortality. We estimate a breast cancer specific mortality reduction of 16–30%, at the cost of 112,162 NOK per QALY gained.