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5 A systematic review of cost-effectiveness analysis in cervical cancer screening: how can overdiagnosis be included in cost-effectiveness analysis?
  1. Chisato Hamashima1,
  2. Takafumi Katayma2,
  3. Satoyo Hosono3,
  4. Teruhiko Terasawa4,
  5. Keika Hoshi5,
  6. Seijyu Sasaki6
  1. 1Teikyo University, Tokyo, Japan
  2. 2Hyogo Prefecture University, Akashi, Japan
  3. 3Nagoya City Unuversity, Nagoya, Japan
  4. 4Fujita Medical University, Nagoya, Japan
  5. 5National Institute of Public Health, Wako, Japan
  6. 6St.Luka International Hospital, Tokyo, Japan


Objectives Cervical cancer screening is a common strategy for cancer control worldwide. Although its real target is invasive cancer, precancerous lesions have become the actual target of cervical cancer screening. These is possibility that there is a high degree of overdiagnosis among the detected cancers. How overdiagnosis can be incorporated in cost-effectiveness analysis (CEA) of cervical cancer screening was investigated.

Method CEA for cervical cancer screening was searched using PubMed before 2017, and then how to apply overdiagnosis in CEA was investigated.

Results Of 152 studies identified, 17 studies analyzed the cost-effectiveness of HPV testing or co-testing compared with cytology. Of these articles, 4 studies analyzed the cost-effectiveness of both tests. These models were developed based on the natural history from precursor lesion to invasive cancer. The time horizon of these studies was lifetime, and they included all diagnosis and treatment cost. However, cancers detected by cancer screening were not divided into overdiagnosis or not. Therefore, the quality adjusted life years (QALYs) were equal in these models between overdiagnosis or not. All models for CEA of cervical cancer screening did not consider overdiagnosis of cervical cancer screening.

Conclusions In the models, all detected precursor lesions were assumed to progress to invasive cancer. However, there is a huge amount of overdiagnosis of precursor lesions and it cannot be ignored. When a precursor lesion is diagnosed, most lesion are treated based on the assumption of progression to invasive cancer. If patients know the possibility of overdiagnosis in cervical cancer screening and its frequency cannot be ignored, the value of cervical cancer screening and patients’ choice for treatment might change. Since these models ignored overdiagnosis, the value was overestimated. CEA of cancer screening has been commonly reported, and the results are used for political decision-making. Overdiagnosis of cancer screening causes serious harm and must be reduced. To clarify the true efficiency of cancer screening, overdiagnosis should be included in the CEA model of cancer screening.

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