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ObjectiveTo compare the cost and effects of three sampling strategies for human papillomavirus (HPV) primary screening.DesignCost-consequence analysis using a decision tree in Excel.SettingEngland.ParticipantsA cohort of 10,000 women age 25 to 65 eligible for the NHS Cervical Screening Programme (NHSCSP) (Box 1).MethodsThe model was informed by the NHSCSP HPV primary screening pathway and adapted for self-sampling. It used a 3-year recall cycle with routine screening in year 1 and recall screening in years 2/3. Parameters were obtained from published studies, manufacturers, NHSCSP reports, and input from experts.InterventionsThree sampling strategies were: 1) routine clinician-collected cervical sample, 2) self-collected first-void (FV) urine; 3) self-collected vaginal swab. The hypothetical self-sampling strategies involved women being mailed a sampling kit at home.Main outcome measuresPrimary outcomes: overall costs (for all screening steps to colposcopy), number of complete screens, and cost per complete screen. Secondary outcomes: number of women screened, number of women lost to follow-up, cost per colposcopy, and total screening costs for a plausible range of uptake scenarios.ResultsIn the base case, the average cost per complete screen was £56.81 for clinician-collected cervical sampling, £38.57 for FV urine self-sampling, and £40.37 for vaginal self-sampling. In deterministic sensitivity analysis (DSA), the variables most affecting the average cost per screen were the cost of sample collection for clinician-collected sampling and the cost of laboratory HPV testing for the self-sampling strategies. Scaled to consider routine screening in England, if uptake in non-attenders increased by 15% and 50% of current screeners converted to self-sampling, the NHSCSP would save £19.2 million (FV urine) or £16.5 million (vaginal) per year.ConclusionSelf-sampling could provide a less costly alternative to clinician-collected sampling for routine HPV primary screening and offers opportunities to expand the reach of cervical screening to under-screened women.Strengths and limitations of the studyThis is the first study to assess the cost of screening for cervical cancer using self-collected first-void urine or vaginal swab compared to the current strategy of clinician-collected cervical sampling within the context of England’s NHS Cervical Screening Programme (NHSCSP).The cost per screen was used to calculate the total cost of the NHSSCP in England, allowing a comparison of different uptake scenarios if self-sampling was offered to non-attenders only or to all eligible women.Limited published data were available to inform the cost of self-sampling devices and HPV laboratory testing of self-collected samples.One pathway for self-sampling was examined. However, there are alternative pathways which could be explored, some of which are dependent on new technologies, such as DNA methylation testing, being validated and costed. |
