Overtreatment and Cost-Effectiveness of the See-and-Treat Strategy for Managing Cervical Precancer

• Published in: Cancer epidemiology, biomarkers & prevention Vol. 25; no. 5; pp. 807 - 814
• Main Authors: Nghiem, Van T, Davies, Kalatu R, Beck, J Robert, Follen, Michele, Cantor, Scott B
• Format: Journal Article
• Language: English
• Published: United States 01-05-2016
• Subjects: Adult; Cohort Studies; Colposcopy - methods; Cost-Benefit Analysis; Female; Humans; Medical Overuse; Uterine Cervical Neoplasms - economics; Uterine Cervical Neoplasms - pathology
• ISSN: 1055-9965; 1538-7755
• DOI: 10.1158/1055-9965.EPI-15-1044

See-and-treat using loop electrosurgical excision procedure (LEEP) has been recommended as an alternative in managing high-grade cervical squamous intraepithelial lesions, but existing literature lacks evidence of the strategy's cost-effectiveness. We evaluated the overtreatment and cost-effectiveness of the see-and-treat strategy compared with usual care.
We modeled a hypothetical cohort of 40-year-old females who had not been screened for cervical cancer and followed them through their lifetimes using a Markov model. From a U.S. health-system perspective, the analysis was conducted in 2012 dollars and measured effectiveness in quality-adjusted life-years (QALY). We estimated incremental cost-effectiveness ratios (ICER) using a willingness-to-pay threshold of $50,000/QALY. The robustness of the see-and-treat strategy's cost-effectiveness and its overtreatment rates were further examined in various sensitivity analyses.
In the base-case, the see-and-treat strategy yielded an ICER of $70,774/QALY compared with usual care. For most scenarios in the deterministic sensitivity analysis, this strategy had ICERs larger than $50,000/QALY, and its cost-effectiveness was sensitive to the disutility of LEEP treatment and biopsy-directed treatment adherence under usual care. Probabilistic sensitivity analysis showed that the see-and-treat strategy had a 50.1% chance to be cost-effective. It had an average overtreatment rate of 7.1% and a 78.8% chance to have its overtreatment rate lower than the 10% threshold.
The see-and-treat strategy induced an acceptable overtreatment rate. Its cost-effectiveness, compared with usual care, was indiscriminating at the chosen willingness-to-pay threshold but much improved when the threshold increased.
The see-and-treat strategy was reasonable for particular settings, that is, those with low treatment adherence. Cancer Epidemiol Biomarkers Prev; 25(5); 807-14. ©2016 AACR.