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Nghiem VT , Davies KR , Beck JR , Follen M , Cantor SB
Overtreatment and cost-effectiveness of the see-and-treat strategy for managing cervical precancer
Cancer Epidemiol Biomarkers Prev. 2016 Feb 29;25(5) :807-14
PMID: 26929242 PMCID: PMC4873397 URL: http://www.ncbi.nlm.nih.gov/pubmed/26929242
AbstractBACKGROUND: 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 evaluate the overtreatment and cost-effectiveness of the see-and-treat strategy compared with usual care. METHODS: 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 (QALYs). We estimated incremental cost-effectiveness ratios (ICERs) 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. RESULTS: In the base-case, the see-and-treat strategy yielded an ICER of $70,774/QALY compared to 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. CONCLUSION: 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. IMPACT: The see-and-treat strategy was reasonable for particular settings, i.e. those with low treatment adherence.
NotesNghiem, Van T Davies, Kalatu R Beck, J Robert Follen, Michele Cantor, Scott B Cancer Epidemiol Biomarkers Prev. 2016 Feb 29. pii: cebp.1044.2015.