Cost-effectiveness of human papillomavirus vaccination and screening in Spain.

European journal of cancer (Oxford, England : 1990) 2010 Jul 16; In press

Diaz M, de Sanjose S, Ortendahl J, O'Shea M, Goldie S SJ, Bosch F FX, Kim J JJ

Unit of Infections and Cancer (UNIC), Cancer Epidemiology Research Program, Catalan Institute of Oncology (ICO), IDIBELL, Av. Gran Via 199-203, 08907 L'Hospitalet de Llobregat, Barcelona, Spain.

BACKGROUND: In Spain, prophylactic vaccination against human papillomavirus (HPV) types 16 and 18 is being offered free-of-charge to one birth cohort of girls aged 11-14. Screening is opportunistic (annual/biannual) contributing to social and geographical disparities. METHODS: A multi-HPV-type microsimulation model was calibrated to epidemiologic data from Spain utilising likelihood-based methods to assess the health and economic impact of adding HPV vaccination to cervical cancer screening. Strategies included (1) screening alone of women over age 25, varying frequency (every 1-5years) and test (cytology, HPV DNA testing); (2) HPV vaccination of 11-year-old girls combined with screening. Outcomes included lifetime cancer risk, life expectancy, lifetime costs, number of clinical procedures and incremental cost-effectiveness ratios. RESULTS: After the introduction of HPV vaccination, screening will need to continue, and strategies that incorporated HPV testing are more effective and cost-effective than those with cytology alone. For vaccinated girls, 5-year organised cytology with HPV testing as triage from ages 30 to 65 costs 24,350euro per year of life saved (YLS), assuming life-long vaccine immunity against HPV-16/18 by 3 doses with 90% coverage. Unvaccinated girls would benefit from organised cytology screening with HPV testing as triage; 5-year screening from ages 30 to 65 costs 16,060euro/YLS and 4-year screening from ages 30 to 85 costs 38,250euro/YLS. Interventions would be cost-effective depending on the cost-effectiveness threshold and the vaccine price. CONCLUSIONS: In Spain, inequitable coverage and overuse of cytology make screening programmes inefficient. If high vaccination coverage among pre-adolescent girls is achieved, organised cytology screening with HPV triage starting at ages 30 to at least 65 every 4-5years represents the best balance between costs and benefits.

Keywords: papillomavirus Spain vaccine