宫颈癌公共筛查策略的经济学评价

Economic Evaluation of Strategy of Public Cervical Cancer Screening

目的从卫生经济学角度对政府组织的宫颈癌公共筛查项目应用不同的策略进行评估,比较各种策略的筛查效果和疾病管理成本,为优选筛查策略提供科学依据。方法建立Markov模型,模拟在1000 000人群中对30～65岁的妇女开展两轮宫颈癌筛查,从政府角度计算不同策略的成本和效果。共纳入五种筛查策略,包括单纯细胞学检测初筛策略、细胞学初筛结合CINtec PLUS分流策略、HPV检测初筛结合细胞学分流策略、HPV检测并16/18基因分型初筛结合细胞学分流策略以及HPV检测并16/18分型初筛结合CINtec PLUS分流策略。结果在细胞学检测初筛的一组筛查策略中,加入分流方案CINtecPLUS检测,可以发现更多CIN2及以上的病变,每发现1例病变平均所需的费用更少,同时可以减少宫颈癌年发病数及死亡数。在HPV检测初筛的一组筛查策略中,进行HPV16/18分型能够发现更多CIN2及以上病变,每发现1例病变平均所需的费用更少,同时可以降低宫颈癌的年发病数和死亡数;进一步加入分流方案CINtec PLUS检测,可以发现最多CIN2及以上病变,每发现1例病变平均所需的费用最少,并可在最大程度上降低宫颈癌的年发病数及死亡数。结论通常情况下,HPV初筛相对细胞学初筛,可延长筛查间隔,在小幅降低疾病管理年总费用的同时大幅提高了筛查效果;在总预算可承受的范围内,HPV检测并16/18分型初筛结合CINtec PLUS分流方案的宫颈癌筛查效果最好,为最佳方案。

Objective The aim of this study was to evaluate the strategies for China public cervical cancer screening from the perspective of health economics and provide scientific evidence for selecting the optimal strategies by comparing the screening effectiveness and disease management cost of different strategies. Methods A Markov cohort model was established to simulate 2 rounds of cervical cancer screening in 1,000,000 women aged from 30 to 65. The cost and effectiveness of different strategies were calculated from the perspective of Chinese government. Five screening strategies were adopted, including cytology only primary screening, cytology primary screening with reflex to CINtec PLUS, HPV primary screening with reflex to cytology, HPV 16/18 genotyping primary screening with reflex to cytology, and HPV 16/18 genotyping primary screening with reflex to CINtec PLUS.Results In the strategy of cytology primary screening groups, more CIN2+ cases could be detected at less cost per case of CIN2+detected when using CINtec PLUS as reflex, which also decreased the annual incidence and mortalities of cervical cancers. In the strategy of HPV primary screening groups, introducing HPV 16/18 genotyping can detect more CIN2+ cases at less cost. per case of CIN2+ detected, further decreased the annual incidence and mortalities of cervical cancers. HPV 16/18 genotyping with reflex to CINtec PLUS screening strategy found the most CIN2+ cases at the least cost per case of CIN2+ detected and delivered the least annual incidence and mortalities of cervical cancers. Conclusion In general, compared with the cytology primary screening strategy, the HPV primary screening strategy can prolong the screening interval, which caused small decline of total annual cost and meanwhile substantially improved screening effectiveness. HPV 16/18 genotyping with reflex to CINtec PLUS screening strategy was the optimal strategy with the best screening effectiveness if the total budget was affordable.