Scale-up of radiotherapy for cervical cancer in the era of human papillomavirus vaccination in low-income and middle-income countries: a model-based analysis of need and economic impact (original) (raw)
Clinical Oncology, 2019
Aims: Among all malignancies, the use of radiotherapy incurs the highest survival benefit within cervical cancers. Radiotherapy, however, remains underutilised for cervical cancers within the Brazilian public health system (BPHS). The objective of this study was to estimate the potential health and monetary benefits for universal access to radiotherapy and chemoradiotherapy (CRT) for untreated cervical cancer patients in the BPHS. Materials and methods: Using 2016 data on Brazilian cervical cancer incidence and availability of radiotherapy/CRT in the BPHS, the number of cancer deaths due to radiotherapy/CRT underutilisation was estimated. The incremental effectiveness was calculated by life-year gain. The indirect costs from mortalityrelated productivity loss (MRPL) were estimated based on life expectancy, wage and labour force participation rate. MRPL was compared with direct medical costs after being adjusted to 2016 US dollars. This study was conducted from the payer's perspective; both costs and effectiveness were discounted at a rate of 3%. The incremental cost-effectiveness ratio (ICER) was calculated to determine the cost-effectiveness of radiotherapy for cervical cancer in Brazil. One-way sensitivity analyses were carried out to assess the robustness of the model.
2021
High out-of-pocket (OOP) medical expenses for cervical cancer (CC) can lead to catastrophic health expenditures (CHEs) and medical impoverishment in many low-resource settings. There are 32 million women at risk for CC in Ethiopia, where CC screening is extremely limited. An evaluation of the population health and financial risk protection benefits, and their distributional consequences across socioeconomic groups, from human papillomavirus (HPV) vaccination will be critical to support CC prevention efforts in this setting. We used a static cohort model that captures the main features of HPV vaccines and population demographics to project health and economic outcomes associated with routine HPV vaccination in Ethiopia. Health outcomes included the number of CC cases, and costs included vaccination and operational costs in 2015 US dollars over the years 2019–2118 and CC treatment costs over the lifetimes of cohorts eligible for vaccination in Ethiopia. We estimated the household OOP ...
BMC Medicine, 2011
Background: The World Health Organization (WHO) recommends that the cost effectiveness of introducing human papillomavirus (HPV) vaccination is considered before such a strategy is implemented. However, developing countries often lack the technical capacity to perform and interpret results of economic appraisals of vaccines. To provide information about the feasibility of using such models in a developing country setting, we evaluated models of HPV vaccination in terms of their capacity, requirements, limitations and comparability. Methods: A literature review identified six HPV vaccination models suitable for low-income and middle-income country use and representative of the literature in terms of provenance and model structure. Each model was adapted by its developers using standardised data sets representative of two hypothetical developing countries (a low-income country with no screening and a middle-income country with limited screening). Model predictions before and after vaccination of adolescent girls were compared in terms of HPV prevalence and cervical cancer incidence, as was the incremental cost-effectiveness ratio of vaccination under different scenarios. Results: None of the models perfectly reproduced the standardised data set provided to the model developers. However, they agreed that large decreases in type 16/18 HPV prevalence and cervical cancer incidence are likely to occur following vaccination. Apart from the Thai model (in which vaccine and non-vaccine HPV types were combined), vaccine-type HPV prevalence dropped by 75% to 100%, and vaccine-type cervical cancer incidence dropped by 80% to 100% across the models (averaging over age groups). The most influential factors affecting cost effectiveness were the discount rate, duration of vaccine protection, vaccine price and HPV prevalence. Demographic change, access to treatment and data resolution were found to be key issues to consider for models in developing countries.
BMC medicine, 2011
Background The World Health Organization (WHO) recommends that the cost effectiveness of introducing human papillomavirus (HPV) vaccination is considered before such a strategy is implemented. However, developing countries often lack the technical capacity to perform and interpret results of economic appraisals of vaccines. To provide information about the feasibility of using such models in a developing country setting, we evaluated models of HPV vaccination in terms of their capacity, requirements, limitations and comparability. ...
International Journal of Women's Health
Background: In countries with limited resources, a targeted HPV vaccination strategy by focusing in selected regions is preferable to be implemented than a nationwide vaccination strategy. Objective: This study aimed to review articles on economic evaluations of HPV vaccination in countries over the world that applied targeted vaccination strategies. Methods: Approximately 1769 articles were obtained from two databases (1242 and 527 articles from PubMed and ProQuest, respectively). The inclusion criteria in this systematic review were studies about full economic evaluations of HPV vaccination in targeted area or sub-national level and written in English. Full-text screening was applied to evaluate the eligibility. Final articles obtained were referred to the Consolidated Health Economic Evaluation Reporting Standard (CHEERS) checklist. Finally, we included only 4 articles that met all inclusion and exclusion criteria. Results: Included studies in this review focused in different targeted regions, such as Punjab State in India, Vientiane in Lao PDR, Southern Vietnam in Vietnam, and Brazilian Amazon in Brazil. From 24 criteria in the CHEERS checklist, all included studies could meet 21 criteria (87.5%). All included studies in this review applied modeling approaches, which can estimate the number of cases and treatment costs averted. Applying various settings, the results of this study showed that HPV vaccination could potentially reduce the number of cervical cancer cases by 20-72%. Taking cervical cancer screening into account, this study showed that targeted HPV vaccination was cost-effective or even cost-saving. Conclusion: Implementation of HPV vaccination in sub-national level as the initial step before nationwide vaccination is more favorable to be implemented in countries with limited budget.
Cervical cancer in low and middle income countries: Addressing barriers to radiotherapy delivery
Gynecologic Oncology Reports, 2017
The global cervical cancer burden falls disproportionately upon women in low and middle-income countries. Insufficient infrastructure, lack of access to preventive HPV vaccines, screening, and treatment, as well as limited trained personnel and training opportunities, continue to impede efforts to reduce incidence and mortality in these nations. These hurdles have been substantial challenges to radiation delivery in particular, preventing treatment for a disease in which radiation is a cornerstone of curative therapy. In this review, we discuss the breadth of these barriers, while illustrating the need for adaptive approaches by proposing the use of brachytherapy alone in the absence of available external beam radiotherapy. Such modifications to current guidelines are essential to maximize radiation treatment for cervical cancer in limited resource settings.
The Lancet, 2020
Background The WHO Director-General has issued a call for action to eliminate cervical cancer as a public health problem. To help inform global efforts, we modelled potential human papillomavirus (HPV) vaccination and cervical screening scenarios in low-income and lower-middle-income countries (LMICs) to examine the feasibility and timing of elimination at different thresholds, and to estimate the number of cervical cancer cases averted on the path to elimination. Methods The WHO Cervical Cancer Elimination Modelling Consortium (CCEMC), which consists of three independent transmission-dynamic models identified by WHO according to predefined criteria, projected reductions in cervical cancer incidence over time in 78 LMICs for three standardised base-case scenarios: girls-only vaccination; girls-only vaccination and once-lifetime screening; and girls-only vaccination and twice-lifetime screening. Girls were vaccinated at age 9 years (with a catch-up to age 14 years), assuming 90% coverage and 100% lifetime protection against HPV types 16, 18, 31, 33, 45, 52, and 58. Cervical screening involved HPV testing once or twice per lifetime at ages 35 years and 45 years, with uptake increasing from 45% (2023) to 90% (2045 onwards). The elimination thresholds examined were an average age-standardised cervical cancer incidence of four or fewer cases per 100 000 women-years and ten or fewer cases per 100 000 women-years, and an 85% or greater reduction in incidence. Sensitivity analyses were done, varying vaccination and screening strategies and assumptions. We summarised results using the median (range) of model predictions. Findings Girls-only HPV vaccination was predicted to reduce the median age-standardised cervical cancer incidence in LMICs from 19•8 (range 19•4-19•8) to 2•1 (2•0-2•6) cases per 100 000 women-years over the next century (89•4% [86•2-90•1] reduction), and to avert 61•0 million (60•5-63•0) cases during this period. Adding twice-lifetime screening reduced the incidence to 0•7 (0•6-1•6) cases per 100 000 women-years (96•7% [91•3-96•7] reduction) and averted an extra 12•1 million (9•5-13•7) cases. Girls-only vaccination was predicted to result in elimination in 60% (58-65) of LMICs based on the threshold of four or fewer cases per 100 000 women-years, in 99% (89-100) of LMICs based on the threshold of ten or fewer cases per 100 000 women-years, and in 87% (37-99) of LMICs based on the 85% or greater reduction threshold. When adding twice-lifetime screening, 100% (71-100) of LMICs reached elimination for all three thresholds. In regions in which all countries can achieve cervical cancer elimination with girls-only vaccination, elimination could occur between 2059 and 2102, depending on the threshold and region. Introducing twice-lifetime screening accelerated elimination by 11-31 years. Long-term vaccine protection was required for elimination. Interpretation Predictions were consistent across our three models and suggest that high HPV vaccination coverage of girls can lead to cervical cancer elimination in most LMICs by the end of the century. Screening with high uptake will expedite reductions and will be necessary to eliminate cervical cancer in countries with the highest burden.
Model-Based Impact and Cost-Effectiveness of Cervical Cancer Prevention in Sub-Saharan Africa
Vaccine, 2013
Using population and epidemiologic data for 48 countries in sub-Saharan Africa, we used a model-based approach to estimate cervical cancer cases and deaths averted, disability-adjusted life years (DALYs) averted and incremental cost-effectiveness ratios (I$ (international dollar) per DALY averted) for human papillomavirus (HPV) vaccination of pre-adolescent girls. Additional epidemiologic data from Uganda and South Africa informed estimates of cancer risk reduction and cost-effectiveness ratios associated with pre-adolescent female vaccination followed by screening of women over age 30. Assuming 70% vaccination coverage, over 670,000 cervical cancer cases would be prevented among women in five consecutive birth cohorts vaccinated as young adolescents; over 90% of cases averted were projected to occur in countries eligible for GAVI Alliance support. There were large variations in health benefits across countries attributable to differential cancer rates, population size, and population age structure. More than half of DALYs averted in sub-Saharan Africa were in Nigeria, Tanzania, Uganda, the Democratic Republic of the Congo, Ethiopia, and Mozambique. When the cost per vaccinated girl was I$5
Health and economic impact of HPV 16/18 vaccination and cervical cancer screening in Eastern Africa
International Journal of Cancer, 2011
Eastern Africa has the world's highest cervical cancer incidence and mortality rates. We used epidemiologic data from Kenya, Mozambique, Tanzania, Uganda, and Zimbabwe to develop models of HPV-related infection and disease. For each country, we assessed HPV vaccination of girls before age 12 followed by screening with HPV DNA testing once, twice, or three times per lifetime (at ages 35, 40, 45). For women over age 30 we assessed only screening (with HPV DNA testing up to three times per lifetime or VIA at age 35). Assuming no waning immunity, mean reduction in lifetime cancer risk associated with vaccination ranged from 36-45%, and vaccination followed by screening once per lifetime at age 35 with HPV DNA testing ranged from 43-51%. For both younger and older women, the most effective screening strategy was HPV DNA testing three times per lifetime. Provided the cost per vaccinated girl was less than I$10 (I$2 per dose), vaccination had an incremental cost-effectiveness ratio (I$ [international dollars]/year of life saved [YLS]) less than the country-specific per capita GDP, a commonly cited heuristic for "very costeffective" interventions. If the cost per vaccinated girl was between I$10 (I$2 per dose) and I$25 (I$5 per dose), vaccination followed by HPV DNA testing would save the most lives and would be considered good value for public health dollars. These results should be used to catalyze design and evaluation of HPV vaccine delivery and screening programs, and contribute to a dialogue on financing HPV vaccination in poor countries.