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Background: Cervical cancer occurs 80% in developing country including Indonesia and take place in the first rank of incidence rate and third rank in mortality rate in Asian Pacific. Natural history of cervical cancer gives a potential to get accurate screening method. Cervical cancer screening m in Indonesia use VIA and Pap smear method for women in age range 30 to 50 years old. Recently, HPV DNA test has been recommended in international and national policy as primary screening method for cervical cancer. This research aims to  asses cost-effectiveness and economic implications of specific cervical cancer screening modalities., Methods: Cost-effectiveness analysis was conducted from societal perspective. Cost data was collected from four hospitals in Indonesia. Direct medical costs were derived from discussions with an expert panel and hospital billing data, aligning with current practice guidelines. Direct and indirect non-medical costs were estimated from patient interviews. Effectiveness data for the screening methods were extracted from a systematic review of existing literature. Markov model design was used for cost-effectiveness analysis. Budget impact analysis used healthcare perspective method from its billing for cervical cancer patients., Results: Cervical cancer screening costs are calculated using direct medical, non-medical, and indirect expenses. Regarding to cost-effective analysis by incremental cost-effective ratio (ICER), pap smear for every 3 and 5 years is more cost-effective than VIA. HPV DNA also has the potential to be cost-effective. The budget impact analysis investigates scenarios, with a focus on negotiation-based cost reductions for HPV DNA testing. Controlling HPV DNA tariffs at USD 8.76 proves cost-effective., Conclusion: In conclusion, pap smear is the most cost-effective modality, while HPV DNA has the potential to be cost-effective by reducing the unit cost. Despite favorable outcomes, challenges in implementation suggest a phased approach for resource equalization before full deployment.

Introduction: in Senegal, cervical cancer is the leading cause of cancers among women. This study estimated the costs associated with cervical cancer screening and treatment for precancerous lesions from the health system perspective., Methods: we estimated costs for screening, diagnostics, and treatment. We conducted a cross-sectional study in seven regions with primary data collected from 50 health facilities. Data collection included structured questionnaires, with secondary data from the Ministry of Health and other sources. A mixed-methods approach combined ingredients-based costing and financial expenditures to estimate direct medical and non-medical costs. All costs are reported in 2019 USD., Results: average costs were $3.71 for visual inspection with acetic acid, $16.49 for Pap smear, and $46.65 for human papillomavirus deoxyribonucleic acid (HPV DNA) testing. Screening cost drivers were clinical exam supplies and clinical equipment for visual inspection with acetic acid, offsite processing of specimens for Pap smear, and lab equipment costs for HPV DNA procedure. The average cost of diagnosis via colposcopy alone was $25.73, and colposcopy with biopsy/endocervical curettage was $74.96. The average cost of treatment followed by one visit for pre-cancerous lesions was $195.24 for loop electrosurgical excision, $47.35 for cryotherapy, and $32.35 for thermal ablation. Clinical equipment and lab costs were the largest contributors to colposcopy and endocervical curettage/biopsy expenses. Clinical equipment made up the largest portion of cryotherapy, loop electrosurgical excision, and thermoablation costs., Conclusion: this study is the first to estimate the costs of HPV screening and treatment in Senegal, which can be used to inform decision-making on cervical cancer investments., Competing Interests: The authors declare no competing interests., (Copyright: Abdou Diop et al.)

Liquid-based preparation (LBP) cytology is commonly used in most laboratories these days due to its convenience and reliable results for the cervical cancer screening program. The PathTezt™ Liquid-based Pap smear is a second-generation LBP, which uses a filter-based concentration technique in processing the sample., Objective: This study was done to evaluate the cellular fixation, morphology, quality of smear in gynae cytology, and diagnostic interpretation of cervical cytological smears produced by the PathTezt liquid-based processor., Materials and Methods: A total of 400 pap smear samples were taken and processed using the PathTezt 2000 processor. The slides were evaluated in terms of sample adequacy, percentage of the circle covered by epithelial cells, cellular distribution, obscuring factors, and cell fixation., Results: About 95.25% (381) of the samples were satisfactory for the evaluation. In 19 (4.75%) of the samples, epithelial cells covered less than 50% of the circle. A sample with good cellular distribution was seen in 92% of the cases, while 354 (88.5%) samples showed minimal inflammatory background. Almost all the smears (95.75%) had no erythrocytes in the background. All smears showed good quality fixation features toward nuclear, cytoplasm, and microorganisms. The total performance rate was 99%., Conclusion: Although the PathTezt liquid-based processor is still new compared to other first-generation LBP, the smears produced by this method were of high quality and it was cost-effective.

Objective: It has been proposed that cervical cancer screening should be continued in women with previous abnormal results or irregular attendance. We examined the coverage and factors that might influence cervical testing beyond the age range of the organized cervical screening programme in Finland. The national programme invites women in every five years least until the age of 60. After the stopping age, only opportunistic service is available., Methods: Data on cervical testing were collected from the Mass Screening Registry and providers of opportunistic Pap/HPV-testing and were linked with information on socio-economic variables. The study included 373,353 women who had at least one invitation to the national screening programme between ages 50-60 years, and who were aged 65-74 years in the follow-up period 2006-2016. Multivariable binomial regression models were conducted to determine associations., Results: Altogether 33% of the study population had been tested at least once at ages 65-74 years. Previous regular screening attendance (adjRR 1.70; 95% CI 1.67-1.73) and earlier abnormal results (adjRR 2.08; 95% CI 2.04-2.12) were most clearly related to higher testing adherence at older age. Other factors related to higher testing adherence were urban area of residence, domestic mother tongue, high education level, and high socio-economic status., Conclusion: Testing at older age was frequent with normal results, whereas only a small proportion of women with earlier abnormal results or irregular attendance were tested. The upper age limit of the national programme should be raised to 65 years, and the invitations thereafter should be targeted to selected high-risk groups., Competing Interests: Declaration of Competing Interest The authors have no competing interests to declare., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Purpose: The 2010 Affordable Care Act (ACA) provided millions of people with health insurance coverage and facilitated routine cancer screening by requiring insurers to cover preventive services without cost-sharing. Despite greater access to affordable cancer screening, Pap testing has declined over time. The aim of this study is to assess participation in Pap test and HPV vaccination, and adherence to guidelines as outlined by the American Cancer Society (ACS) from the 2010 ACA provision eliminating cost-sharing for preventive services., Methods: Using multi-year responses from the Behavioral Risk Factor Surveillance System, we examined the association between the ACA and participation in and adherence to Pap testing and HPV vaccination behaviors as set by the ACS. The sample included women aged 21-29 who completed the survey between 2008 and 2018 (every other year) and who live in 24 US States (N = 37,893)., Results: Results showed significant decreases in Pap testing rates but increases in the uptake of the HPV vaccine series for all age groups and across all demographics. Post-ACA year significantly predicted increases in HPV + Pap co-testing participation and adherence. Women with health insurance coverage were more likely to engage in both behaviors., Conclusion: Findings raise concerns around declines in the proportion of women receiving and adhering to Pap testing guidelines. A need exists for research to examine the role of increases in HPV vaccination uptake on decreases in Pap testing. Moreover, effective strategies should target increases in cervical cancer screening uptake among women vaccinated against HPV.

Objectives: Low uptake of cancer screening services is a global concern. Our aim was to understand factors that influence the screening decision, including screening and treatment subsidies and a gain-frame message designed to present screening as a win-win., Methods: We analyzed preferences for mammography and Pap smear among women in Singapore by means of discrete choice experiments while randomly exposing half of respondents to a gain-framed public health message promoting the benefits of screening., Results: Results showed that the message did not influence stated uptake, and given the levels shown, respondents were influenced more by treatment attributes, including effectiveness and out-of-pocket cost should they test positive, than by screening attributes, including the offer of a monetary incentive for screening. Respondents also underestimated the survival chances of screen-detected breast and cervical cancers., Conclusions: Combined, these findings suggest that correcting misconceptions about screen-detected cancer prognosis or providing greater financial protection for those who test positive could be more effective and more cost-effective than subsidizing screening directly in increasing screening uptakes., (Copyright © 2020 ISPOR–The Professional Society for Health Economics and Outcomes Research. Published by Elsevier Inc. All rights reserved.)

The establishment of link between high-risk human papillomavirus (HPV) infection and occurrence of cervical cancer has resulted in development of various HPV related control strategies for the prevention of cervical cancer. The objective of the present study was to assess the cost effectiveness of various screening strategies for cervical cancer and human papilloma virus (HPV) vaccination in India. A Markov model based on societal perspective was designed to estimate the lifetime costs and consequences of screening (with either visual inspect with acetic acid (VIA), Papanicolaou test or HPV DNA test at various time intervals) in a hypothetical cohort of 30-65 years age women or vaccination among adolescent girls. Diagnostic accuracy of the screening strategies, efficacy of HPV vaccination and data on transition probabilities was based on the results of the existing meta-analyses. Primary data was collected for assessing per person cost of screening, cost of treating cervical cancer and quality of life. We found that introduction of different screening strategies leads to reduction in lifetime occurrence of cervical cancer cases caused by HPV 16/18 from 20% to 61%, and cervical cancer deaths from 28% to 70%, as compared to no screening. Among various screening strategies, screening with both VIA 5 yearly and VIA 10 yearly came out to be cost effective at 1-time per capita GDP, with VIA every 5 years providing greater health benefits as compared to VIA 10 years. Hence, screening with VIA 5 years at an incremental cost of US$ 829 (INR 54,881) per QALY gained is the recommended strategy for India. Further, with regards to HPV vaccination, it leads to 60% reduction in cancer cases and mortality caused by HPV 16/18 as compared to no vaccination. Moreover, when this vaccinated cohort of adolescent girls is also screened later in their life (with VIA every 10 years and VIA 5 years), it leads to 69%-76% reduction in cancer cases and 71%-81% reduction in cancer deaths. As compared to no vaccination and no screening, both HPV vaccination alone and vaccination plus screening (with VIA every 5 yearly and VIA 10 yearly) appears to be cost effective with ICERs in the range of US$ 86 (INR 5,693) to US$ 476 (INR 31,511) per QALY gained. In the long run, when the cohort of adolescent girls, who were immunized for HPV, reach the age of 30 years, the screening frequency using VIA should be determined based on the coverage of HPV vaccination in that cohort., Competing Interests: The authors have declared that no competing interests exist.

Background: To evaluate and compare the results of three different cervical cancer screening strategies including cytology screening, HR-HPV screening which taking HR-HPV testing as primary test and co-testing which taking both tests at the same time, then provide evidence to explore whether the cervical cancer screening can be conducted in community healthcare centers in Beijing., Methods: 182,119 women aged between 35 and 64, who were screened in the primary healthcare facilities of nine districts in Beijing from January 2014 to March 2015, were enrolled in this study. Cytology screening was performed in participants during January 2014 and December 2014 as a conventional arm. HR-HPV screening strategy and co-testing were randomly allocated to participants on districts level as experimental arm 1 and 2 during January 2015 and March 2015. Cervical Intraepithelial Neoplasia grade 2 or worse (CIN 2+) was defined as endpoint. The screening results and costs to detect a case of three strategies were calculated., Results: The positivity rate, colposcopy referral rate and biopsy referral rate of co-testing were 8.46%, 6.36% and 4.65% respectively, which were all significantly higher than the other two screening strategies. The detection rate of CIN 2+ by co-testing was 5.06‰ and was much more than the other two screening strategies, while the HR-HPV screening had the highest PPV of 14.40%. The HR-HPV screening ignores some lesion which can be found by co-testing. Co-testing refers a woman to colposcopy with a positive screening result at the least cost, but it costs the most to detect a CIN 2+ case., Conclusions: To detect more cases of CIN 2+, co-testing performs better although with the most cost. And the primary healthcare facilities in Beijing have the capability to carry out the cervical cancer screen programs and prompts women with positive screen results to the hospital., (Copyright © 2019 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Objective: To describe cervical cancer screening participation among women in Taiwan under its population-based screening policy and to estimate the economic burden of disease attributable to avoidable disparities in cervical cancer (CC) screening., Methods: We identified a nationally-representative sample of females aged 30 years or above who were eligible for Pap smear testing in Taiwan from 1 January to 31 December 2013. An administrative database with detailed claims of health care utilization under the universal coverage health care system was used. Socioeconomic position of the female subjects was defined using the occupation classification, and two groups were specifically identified: general (O1) and low-income (O5) groups. Differences in screening rate, CC prevalence, and CC-attributable deaths were assessed between the two groups. Economic consequences as a result of screening inequalities were estimated using actual total health care spending (health care expenditure), monetary value per life-year and years of life lost for ill health and screening disparities (health as consumption good), and productivity losses alongside costs of social benefits (health as capital good)., Result: A total of 301,057 enrolled females aged 30 years and older eligible for screening were identified. Overall, 3-year and 1-year screening rates among all subjects were 0.601 and 0.372, respectively. Impact of observed differences in screening translated to US$59,568 of health care spending in one year, 90.4% of which was specific to hospital admissions. When we viewed health as a consumption good and capital good, the impact of screening disparity on health losses through CC would be equivalent to US$78,095 and US$190,868, respectively., Conclusion: Forgone health and economic benefits associated with inequalities in CC screening uptake can be considerable in productive women.

Background: The Rio Grande Valley (RGV) and Laredo regions located along the Texas-Mexico border consist of seven counties with a population of approximately 1.5 million people and a high uninsured rate (33.5%). Cervical cancer mortality in these border counties is approximately 30% higher than the rest of Texas. The RGV and Laredo areas were studied to better understand the state of access to cervical cancer prevention services along the Texas-Mexico border., Methods: Data on the population served and the services provided were analyzed to determine the gap between cervical cancer screenings recommended versus those received. Through interviews, we gathered the perspectives of 16 local stakeholders regarding cervical cancer screening for underserved individuals in the region., Findings: It is estimated that 69,139 uninsured women aged 21-64 years in the RGV/Laredo per year are recommended to undergo cervical cancer screening with Papanicolaou (Pap) and/or human papillomavirus (HPV) testing, but only 8941 (12.9%) Pap tests are being performed by the Federally Qualified Health Center (FQHC) serving uninsured women in these regions. Systemic barriers identified include insufficient provider clinical capacity, the high cost of healthcare, and uncertainty about government funding sources. Patient barriers identified include inadequate knowledge on navigating the local healthcare system, low health literacy, lack of money and childcare, an inability to miss work, limited transportation, and fear of deportation., Conclusion: Decreasing the disparity between cervical cancer screening services provided and those recommended requires addressing the barriers, identified by local experts, which prevent uninsured women from accessing care. These challenges are being addressed through ongoing programs and collaborations.

Objective: Rapid on-site evaluation (ROSE) is a technique beneficial in determining the adequacy of the samples, thereby increasing the diagnostic yield, useful in triage of specimens for ancillary studies and can also help determine a preliminary diagnosis in emergency cases. The different rapid stains for on-site evaluation described in the literature are diff quik, toluidine blue (TB), brilliant cresyl blue (BCB), ultra-fast Pap stains, and rapid hematoxylin and eosin (H&E). This study was undertaken as there is sparse literature regarding the best and the most cost-effective rapid stain., Method: Fine needle aspiration samples from 200 patients with palpable swellings in easily accessible regions were taken. Smears stained by rapid and routine stains were assessed based on four parameters, with provisional diagnosis on the rapid stained smears. A comparative analysis of the advantages and disadvantages of the rapid stains was carried out with appropriate statistical tests with the routinely stained smears as gold standard., Results: There was adequate material in 100% of ROSE smears. rapid pap stained smears showed well preserved cytoplasmic details, nuclear details, and background details. The time taken was least with TB and BCB being 5 s each. The most cost-effective was found to be TB., Conclusions: We conclude that TB is the most cost-effective, quick, least labor-intensive, and reliable rapid stain for ROSE especially in resource-poor settings., (© 2018 Wiley Periodicals, Inc.)

Background: The Affordable Care Act (ACA) required private insurers and Medicare to cover recommended preventive services without any cost sharing to improve utilization of these services. This study is an attempt to identify the impact of removing cost sharing on mammography and pap test utilization rates., Methods: Counterfactual analysis was used to predict what would have been the screening rates in post-ACA if ACA was not there. This was done by estimating a model that examines determinants of dependent variable for the pre-ACA year (pre-ACA year is 2009). The estimated model was then used to predict the dependent variable for the post-ACA year using individual characteristics and other relevant variables unlikely to be affected by ACA (post-ACA year is 2016). Effect of ACA is defined as the difference between the values of dependent variables in post-ACA and the predicted values of dependent variables in the post-ACA year using counterfactual., Results: The counterfactual analysis show that the utilization of mammogram and pap test did not improve following ACA., Conclusion: Removal of cost-sharing under the ACA did not improve mammography or pap test rates. Therefore, financial barrier may not be an important factor in affecting utilization of the screening tests and policy makers should focus on other non-financial barriers in order to improve coverage of the tests.

Objective: About 30% of women who are eligible for cervical cancer (CC) screening remain un-screened or under-screened in Switzerland. HPV testing on self-collected vaginal samples (Self-HPV) has shown to be more sensitive than cytology while also reaching non-attendees. The objective of this study was to explore the cost-effectiveness of offering Self-HPV to non-attendees in Switzerland., Methods: A recursive decision-tree with one-year cycles was used to model the life-long natural HPV history. Markov cohort simulations were used to assess the expected outcomes from the model. The outcomes of three strategies were compared with the absence of screening: Self-HPV and triage with colposcopy (Self-HPV/colpo), Self-HPV and triage with Pap cytology (Self-HPV/PAP), cytological screening and triage with HPV (PAP/HPV). Sensitivity analyses for the key parameters of the model were conducted to check the robustness of findings., Results: Offering a Self-HPV screening to non-attendees could prevent 90% of CC and 94% of CC-related deaths in the study population. The current cytology-based program could reduce by 83% the number of CC cases and by 88% the number of CC-related deaths over the population's lifetime. Compared to the absence of screening, incremental cost-effectiveness ratios (ICER) were estimated to be, per saved Quality Adjusted Life Year (QALY), 12413US$ for the strategy Self-HPV/colpo, 11138US$ for the strategy Self-HPV/Pap and 22488US$ for the strategy PAP/HPV., Conclusions: Offering Self-HPV as a CC screening strategy to non-attendees in Switzerland is a cost-effective solution that is associated with a reduction of CC cases and related deaths. Self-HPV is more cost-effective than the currently used cytology-based screening., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: It often takes considerable time for sufficient evidence to accumulate to support implementation of new methods in routine screening. Where national screening programmes are already effective, switching to a more sensitive screening test may not be a priority. Although risk associated with overly rapid implementation exists, postponement is also associated with a (to date unquantified) missed opportunity to prevent deaths. This risk tends not to be addressed where effective screening methods are already in use. We here estimate the monetary value of a one-year delay in replacing cytology cervical screening with human papillomavirus testing., Methods: Using a previously validated model, we calculated the number of incident and fatal cervical cancers that would be diagnosed by 2030 in England, under the assumption that human papillomavirus testing replaces cytology in 2020 rather than 2019, and the monetary value of the quality-adjusted life years lost in preventable cases., Results: A one-year delay in the implementation of human papillomavirus screening would miss the opportunity to prevent 581 cases of cervical cancer, and lead to a loss of 1595 quality-adjusted life years (3.5% discount rate) with a monetary value of £32 million (at £20,000 per quality-adjusted life year)., Conclusion: This is a measurable loss and should be considered in prioritising decision-making in screening.

Objective: This study compared the screening capacities and cost-effectiveness of the human papillomavirus (HPV) test versus cervicography as an adjunctive test to Papanicolaou (Pap) cytology to detect high-grade cervical neoplasia in Korea, a country with a high prevalence of cervical cancer., Study Design: Of 33,531 Korean women who underwent cervicography as a screening test for cervical cancer between January 2015 and December 2016, we retrospectively analyzed the records of 4117 women who simultaneously or subsequently underwent Pap cytology, an HPV test, cervicography, and colposcopically directed biopsy. At a threshold of cervical intraepithelial neoplasia grade 2 or worse (CIN2+), based on colposcopic biopsy, we compared the diagnostic capacities and cost-effectiveness of these screening tools., Results: The CIN2+ prevalence was 10.8% (446 of 4117 women) and the positive rate of high-risk HPV was 61.0% (2511 of 4117 women). Cervicography as an adjunctive to Pap cytology was a more sensitive test (97.5% vs 93.7%) with a higher odds ratio (15.65 vs 5.86) than the HPV test for detection of CIN2+ (P-value = 0.003). Moreover, the cost of cervicography co-testing was 23% less than that of HPV co-testing, decreasing the cost per patient with CIN2+ lesions from $1474 to $1135., Conclusion: Cervicography and Pap co-testing had superior screening capacity and cost-effectiveness for detection of preinvasive cervical lesions than HPV and Pap co-testing and may be an effective and cost-saving screening strategy in clinical practice in country with a high prevalence of cervical cancer., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Background: The Affordable Care Act (ACA) requires non-grandfathered private insurance plans, starting with plan years on or after September 23rd, 2010, to provide certain preventive care services without any cost sharing in the form of deductibles, copayments or co-insurance. This requirement may affect racial and ethnic disparities in preventive care as it provides the largest copay reduction in preventive care., Objectives: We ask whether the ACA's free preventive care benefits are associated with a reduction in racial and ethnic disparities in the utilization of four preventive services: cholesterol screenings, colonoscopies, mammograms, and Pap smears., Methods: We use a data set of over 6000 individuals from the 2009, 2010, and 2013 Medical Expenditure Panel Surveys (MEPS). We restrict our data set only to individuals who are old enough to be eligible for each preventive service. Our difference-in-differences logistic regression model classifies privately insured Hispanics, African Americans, and Asians as the treatment groups and 2013 as the after-policy year. Our control group consists of non-Hispanic whites on Medicaid as this program already covered preventive care services for free or at a low cost before the ACA., Results: After controlling for income, education, marital status, preferred interview language, self-reported health status, employment, having a usual source of care, age and gender, we find that the ACA is associated with increases in the probability of the median, privately insured Hispanic person to get a colonoscopy by 3.6% and a mammogram by 3.1%, compared to a non-Hispanic white person on Medicaid. Similarly, we find that the median, privately insured African American person's probability of receiving these two preventive services improved by 2.3 and 2.4% compared to a non-Hispanic white person on Medicaid. We do not find any significant improvements for any racial or ethnic group for cholesterol screenings or Pap smears. Furthermore, our results do not indicate any significant changes for Asians compared to non-Hispanic whites in utilizing the four preventive services. These reductions in racial/ethnic disparities are robust to reconfigurations of time periods, previous diagnosis, and residential status., Conclusions: Early effects of the ACA's provision of free preventive care are significant for Hispanics and African Americans. Further research is needed for the later years as more individuals became aware of these benefits.

Objective: To discuss cervical cancer (CC), Human PapillomaVirus (HPV),CC control program and propose alternatives for Chile., Materials and Methods: We analyzed the national program of CC 1966-2015 and the clinical CC guideline 2015-2020;HPV prevalence in women and in cases of CC; HPV infection and serology; the self-vaginal sample; the accuracy and cost-effectiveness of screening with HPV versus Papanicolaou,and triage options among HPV-AR positives., Results: 600 women die of CC each year in Chile, mainly from low resources. Papanicolaou coverage is <70%; Papanicolaou sensitivity is much lowerthan HPV test.Change from Papanicolaou to HPV test is cost-effective. Since 2015, girls under 13 have been vaccinated against HPV., Conclusions: .There are the technical and economic conditions for a substantial improvement of CC in Chile: replacement of the Papanicolaou by HPV; screening every five years, with the option of self-sampling, and triage based on HPV 16/18 or Papanicolaou typing., Competing Interests: Declaration of conflict of interests. The authors declare that they have no conflict of interests.

Background: Current cervical cancer screening guidelines recommend a Pap test every 3 years for women age 21-65 years, or for women 30-65 years who want to lengthen the screening interval, a combination of Pap test and high-risk human papilloma virus testing (co-testing) every 5 years. Little population-based data are available on human papilloma virus test utilization and human papilloma virus infection rates. The objective of this study was to examine the patient-level, cervical cancer screening, and area-level factors associated with human papilloma virus testing and infection among a diverse sample of uninsured and underinsured women enrolled in the New Jersey Cancer Early Education and Detection (NJCEED) Program., Methods: We used data for a sample of 50,510 uninsured/underinsured women, age ≥ 29 years, who screened for cervical cancer through NJCEED between January 1, 2009 and December 31, 2015. Multivariable logistic regression models were used to estimate associations between ever having a human papilloma virus test or a positive test result, and individual- (age, race/ethnicity, birthplace) and area-level covariates (% below federal poverty level, % minority, % uninsured), and number of screening visits., Results: Only 26.6% (13,440) of the sample had at least one human papilloma virus test. Among women who underwent testing, 13.3% (1792) tested positive for human papilloma virus. Most women who were positive for human papilloma virus (99.4%) had their first test as a co-test. Human papilloma virus test utilization and infection were significantly associated with age, race/ethnicity, birthplace (country), and residential area-level poverty. Rates of human papilloma virus testing and infection also differed significantly across counties in the state of New Jersey., Conclusions: These findings suggest that despite access to no-cost cervical cancer screening for eligible women, human papilloma virus test utilization was relatively low among diverse, uninsured and underinsured women in New Jersey, and test utilization and infection were associated with individual-level and area-level factors.

Introduction: Hispanic women in the United States have an elevated risk of cervical cancer, but the existing literature does not reveal why this disparity persists., Methods: We performed a retrospective cohort analysis of 17,828 low-income women aged 21 to 64 years seeking care at Oregon community health centers served by a hosted, linked electronic health record during 2009 through 2013. We assessed the odds of having had Papanicolaou (Pap) tests and receiving human papillomavirus (HPV) vaccine, by race/ethnicity, insurance status, and language., Results: Hispanic women, regardless of pregnancy status or insurance, had greater odds of having had Pap tests than non-Hispanic white women during the study period. English-preferring Hispanic women had higher odds of having had Pap tests than Spanish-preferring Hispanic women (OR, 2.08; 95% confidence interval [CI], 1.63-2.66) but lower odds of having received HPV vaccination (OR, 0.21; 95% CI, 0.12-0.38). Uninsured patients, regardless of race/ethnicity, had lower odds of HPV vaccine initiation than insured patients did. Once a single dose was received, there were no significant racial/ethnic differences in vaccine series completion., Conclusion: In this sample of low-income women seeking care at Oregon community health centers, we found minimal racial/ethnic disparities in the receipt of cervical cancer prevention services. Inequities by insurance status, especially in the receipt of HPV vaccine, persist. Community health center-based care may be a useful model to address racial/ethnic disparities in prevention, but this model would need further population-wide study.

Cervical cancer affects women in their reproductive ages. Screening is an important secondary prevention strategy. The long process of carcinogenic transformation from human papillomavirus (HPV) infection to invasive cancer provides ample opportunities to detect the disease at a stage when treatment is highly effective. Suitable screening tests are cytology, visual inspection after acetic acid application and HPV detection tests. Evidence of effectiveness of the tests to reduce cervical cancer mortality and the cost-effectiveness of screening programs have been demonstrated. Cervical intraepithelial neoplasia grade 2 and grade 3 are the high-grade cervical cancer precursors and need to be treated. Treatment is safe and effective with ablative or excisional techniques. The World Health Organization recommends screening women at least once in a lifetime between 30 and 49 years of age and ensuring effective treatment of the detected abnormalities. Combination of HPV vaccination and population-based screening will be instrumental in eliminating cervical cancer., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Objectives: In June 2011, the SGO recommended that physical exam and symptoms be the primary surveillance methods in patients with endometrial cancer. We sought to evaluate adherence to these guidelines by comparing the use of CT scans, paps and serum CA125 ordered for endometrial cancer surveillance before and after publication of these guidelines., Methods: A retrospective review was performed for all patients undergoing surveillance for endometrial cancer at a single institution between June 2009 and June 2013. We assessed the number of patients without symptoms or abnormal physical exam findings who underwent surveillance CT scans, paps and/or CA125 during the 2years pre- and 2years post-SGO guidelines., Results: 92 patients (n=48 pre-6/2011, n=44 post-6/2011) were identified. Mean patient age was 58years. No significant difference in age, ethnicity, body mass index, or disease grade or stage was noted. There was a significant decline in surveillance CT scans (n=13, 27% vs. n=4, 9%, p=0.03), CA125 (n=14, 29% vs. 5, 11%, p=0.035) and paps (n=34, 71% vs. n=8 vs. 18%, p<0.001). There was no significant difference in disease status at the last follow-up. Institutional cost of surveillance also declined ($14,102.46 2years pre-guidelines, $3,054.99 2years post-guidelines)., Conclusions: In a single urban academic public hospital, after only 2years, clinical adherence to the 2011 SGO endometrial cancer surveillance guidelines resulted in a significant decline in the use of CT scans, CA125 and paps. This reduction does not appear to affect patient outcomes and led to an appreciable decrease in surveillance costs., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Usually HPV related, the cancer is increasingly common in this population.

Objectives: To evaluate the cost-effectiveness of human papillomavirus (HPV) DNA testing (versus Papanicolaou (Pap)-based screening) for cervical cancer screening in Nicaragua., Design: A previously developed Monte Carlo simulation model of the natural history of HPV infection and cervical cancer was calibrated to epidemiological data from Nicaragua. Cost data inputs were derived using a micro-costing approach in Carazo, Chontales and Chinandega departments; test performance data were from a demonstration project in Masaya department., Setting: Nicaragua's public health sector facilities., Participants: Women aged 30-59 years., Interventions: Screening strategies included (1) Pap testing every 3 years, with referral to colposcopy for women with an atypical squamous cells of undetermined significance or worse result ('Pap'); (2) HPV testing every 5 years, with referral to cryotherapy for HPV-positive eligible women (HPV cryotherapy or 'HPV-Cryo'); (3) HPV testing every 5 years, with referral to triage with visual inspection with acetic acid (VIA) for HPV-positive women ('HPV-VIA'); and (4) HPV testing every 5 years, with referral to Pap testing for HPV-positive women ('HPV-Pap')., Outcome Measures: Reduction in lifetime risk of cancer and incremental cost-effectiveness ratios (ICER; 2015 US$ per year of life saved (YLS))., Results: HPV-based screening strategies were more effective than Pap testing. HPV-Cryo was the least costly and most effective strategy, reducing lifetime cancer risk by 29.5% and outperforming HPV-VIA, HPV-Pap and Pap only, which reduced cancer risk by 19.4%, 12.2% and 10.8%, respectively. With an ICER of US$320/YLS, HPV-Cryo every 5 years would be very cost-effective using a threshold based on Nicaragua's per capita gross domestic product of US$2090. Findings were robust across sensitivity analyses on test performance, coverage, compliance and cost parameters., Conclusions: HPV testing is very cost-effective compared with Pap testing in Nicaragua, due to higher test sensitivity and the relatively lower number of visits required. Increasing compliance with recommended follow-up will further improve the health benefits and value for public health dollars., Competing Interests: Competing interests: JJ was the director of the START-UP demonstration projects and received all tests used in the study as a donation from Qiagen; no other relationships or activities that could appear to have influenced the submitted work. JJ was the co-owner and Deputy Manager of Onco Prev International, a Peruvian company, from 2012 through March 2017. Onco Prev International offers cervical cancer screening services and in 2016 also began positioning for distribution of medical devices including colposcopes and the Liger thermocoagulator. Onco Prev International did not commercialize any medical instrument during the time JJ was part of the company., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Objectives: We modelled human papilloma virus (HPV) primary screening scenarios compared with Pap cytology to evaluate clinical effectiveness and projected annual costs in Germany., Study Design: A Markov cohort model was built to compare the budget impact of annual Pap cytology with different 5-yearly HPV screening scenarios: (1) a positive HPV test followed by Pap cytology; (2) a positive HPV test followed by p16/Ki-67 dual-stained cytology; (3) a positive HPV test followed by colposcopy if HPV-16/18-positive or p16/Ki-67 dual-stained cytology if positive for other subtypes; (4) co-testing with HPV and Pap. Screening scenarios were based on a 10-year horizon., Results: All HPV screening scenarios in the model were associated with fewer deaths from missed diagnosis of cervical cancer compared with Pap screening; 10-year totals n=172-344 (1.5-3 per 100,000) versus n=477 (4.1 per 100,000), respectively. Total annual costs were lower with HPV screening than Pap cytology. The projected average annual cost for HPV screening ranged from €117 million to €136 million compared with €177 million for Pap screening, representing annual savings of €41-60 million. The greatest clinical impact was achieved with primary HPV screening (with genotyping) followed by colposcopy for HPV 16/18-positive women or p16/Ki-67 dual-stained cytology for women positive for other HPV subtypes., Conclusion: Screening strategies including primary HPV testing for high-risk subtypes (HPV-16/18) in conjunction with p16/Ki-67 dual-stained cytology can improve the detection of cervical cancer at a lower total annual cost than conventional Pap cytology screening., (Copyright © 2017. Published by Elsevier B.V.)

Context: - See, Test & Treat is a pathologist-driven program to provide cervical and breast cancer screening to underserved and underinsured patient populations. This program is largely funded by the CAP Foundation (College of American Pathologists, Northfield, Illinois) and is a collaborative effort among several medical specialties united to address gaps in the current health care system., Objective: - To provide an outline for administering a See, Test & Treat program, using an academic medical center as a model for providing care and collating the results of 5 years of data on the See, Test & Treat program's findings., Design: - Sources include data from patients seen at Tufts Medical Center (Boston, Massachusetts) who presented to the See, Test & Treat program and institutional data between 2010 and 2014 detailing the outline of how to organize and operationalize a volunteer cancer-screening program., Results: - During the 5-year course of the program, 203 women were provided free cervical and breast cancer screening. Of the 169 patients who obtained Papanicolaou screening, 36 (21.3%) had abnormal Papanicolaou tests. In addition, 16 of 130 patients (12.3%) who underwent mammography had abnormal findings., Conclusions: - In general, women from ethnic populations have barriers that prevent them from participating in cancer screening. However, the CAP Foundation's See, Test & Treat program is designed to reduce those barriers for these women by providing care that addresses cultural, financial, and practical issues. Although screening programs are helpful in identifying those who need further treatment, obtaining further treatment for these patients continues to be a challenge.

Background: Current US cervical cancer screening guidelines do not differentiate recommendations based on a woman's human papillomavirus (HPV) vaccination status. Changes to cervical cancer screening policies in HPV-vaccinated women should be evaluated., Methods: We utilized an individual-based mathematical model of HPV and cervical cancer in US women to project the health benefits, costs, and harms associated with screening strategies in women vaccinated with the bivalent, quadrivalent, or nonavalent vaccine. Strategies varied by the primary screening test, including cytology, HPV, and combined cytology and HPV "cotesting"; age of screening initiation and/or switching to a new test; and interval between routine screens. Cost-effectiveness analysis was conducted from the societal perspective to identify screening strategies that would be considered good value for money according to thresholds of $50 000 to $200 000 per quality-adjusted life-year (QALY) gained., Results: Among women fully vaccinated with the bivalent or quadrivalent vaccine, optimal screening strategies involved either cytology or HPV testing alone every five years starting at age 25 or 30 years, with cost-effectiveness ratios ranging from $34 680 to $138 560 per QALY gained. Screening earlier or more frequently was either not cost-effective or associated with exceedingly high cost-effectiveness ratios. In women vaccinated with the nonavalent vaccine, only primary HPV testing was efficient, involving decreased frequency (ie, every 10 years) starting at either age 35 years ($40 210 per QALY) or age 30 years ($127 010 per QALY); with lower nonavalent vaccine efficacy, 10-year HPV testing starting at earlier ages of 25 or 30 years was optimal. Importantly, current US guidelines for screening were inefficient in HPV-vaccinated women., Conclusions: This model-based analysis suggests screening can be modified to start at later ages, occur at decreased frequency, and involve primary HPV testing in HPV-vaccinated women, providing more health benefit at lower harms and costs than current screening guidelines., (© The Author 2016. Published by Oxford University Press. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Purpose: Best-worst scaling (BWS) is a survey method for assessing individuals' priorities. It identifies the extremes-best and worst items, most and least important factors, biggest and smallest influences-among sets. In this article, we demonstrate an application of BWS in a primary care setting to illustrate its use in identifying patient priorities for services., Methods: We conducted a BWS survey in 2014 in Boston, Massachusetts, to assess the relative importance of 10 previously identified attributes of Papanicolaou (Pap) testing services among women experiencing homelessness. Women were asked to evaluate 11 sets of 5 attributes of Pap services, and identify which attribute among each set would have the biggest and smallest influence on promoting uptake. We show how frequency analysis can be used to analyze results., Results: In all, 165 women participated, a response rate of 72%. We identified the most and least salient influences on encouraging Pap screening based on their frequency of report among our sample, with possible standardized scores ranging from+1.0 (biggest influence) to -1.0 (smallest influence). Most important was the availability of support for issues beyond health (+0.39), while least important was the availability of accommodations for personal hygiene (-0.27)., Conclusions: BWS quantifies patient priorities in a manner that is transparent and accessible. It is easily comprehendible by patients and relatively easy to administer. Our application illustrates its use in a vulnerable population, showing that factors beyond those typically provided in health care settings are highly important to women in seeking Pap screening. This approach can be applied to other health care services where prioritization is helpful to guide decisions., (© 2016 Annals of Family Medicine, Inc.)

Objective: The first aim of this article is to quantify the role of Pap test in cervical cancer prevention, updating the pool of available studies included in a previous meta-analysis. Potential sources of meta-analysis heterogeneity were investigated as second aim. Further evidence of cost-effectiveness has been provided about age and best time interval to perform Pap test screening., Data Sources: The articles' search was conducted using four medical electronic databases: PubMed, Google Scholar, ISI Web, and Scopus. Papers published until the 30th November 2013 were included. The research on Google Scholar was limited to the first 10 pages of web for each study design., Metod of Study Selection: A systematic review/meta-analysis was performed according to PRISMA Statement. New-Castle-Ottawa Scale and Jadad have been adopted for articles quality assessment. From 4143 screened articles, 34 met eligibility criteria and 30 case-control studies were included in meta-analysis. Meta-analysis was carried out using StatsDirect2.8.0. Heterogeneity was investigated with qualitative and quantitative approaches in sensitivity-analysis., Tabulation, Integration and Results: Despite a great heterogeneity (Cochran Q=504.466, df=29, p<0.0001; I²=94.3%; 95%CI=93.1%-95.1%), a significant protective effect of Pap test has been identified (OR=0.33; 95%CI=0.268-0.408, P <0.00011) through the meta-analysis. Sensitivity analysis did not provide significant results (R=0.358 R2=0.128 p<0.469)., Conclusions: The protective role of Pap test against cervical cancer has been confirmed especially among women <40 years. Annual screening still remains the most cost-effective preventive strategy.

Objective: Invasive cervical cancer (ICC) is the fourth most common cancer among women worldwide. Cervical screening programs have reduced the incidence and mortality rates of ICC. We studied the cost-effectiveness of different cervical screening strategies in the Islamic Republic of Iran, a Muslim country with a low incidence rate of ICC., Methods: We constructed an 11-state Markov model, in which the parameters included regression and progression probabilities, test characteristics, costs, and utilities; these were extracted from primary data and the literature. Our strategies included Pap smear screening and human papillomavirus (HPV) DNA testing plus Pap smear triaging with different starting ages and screening intervals. Model outcomes included lifetime costs, life years gained, quality-adjusted life years (QALY), and incremental cost-effectiveness ratios (ICERs). One-way sensitivity analysis was performed to examine the stability of the results., Results: We found that the prevented mortalities for the 11 strategies compared with no screening varied from 26% to 64%. The most cost-effective strategy was HPV screening, starting at age 35 years and repeated every 10 years. The ICER of this strategy was $8,875 per QALY compared with no screening. We found that screening at 5-year intervals was also cost-effective based on GDP per capita in Iran., Conclusion: We recommend organized cervical screening with HPV DNA testing for women in Iran, beginning at age 35 and repeated every 10 or 5 years. The results of this study could be generalized to other countries with low incidence rates of cervical cancer.

Background: Despite implementation of organised screening programme in 2006/2007, cervical cancer (CC) incidence and mortality in Poland are still higher than the average in the European Union. CC and preceding cervical intraepithelial neoplasia (CIN) caused by human papillomaviruses (HPVs) can be prevented by vaccines which are reimbursed in around 20 European countries but not in Poland. CC and CIN can be also detected with the use of HPV tests which are not included in the Polish screening programme. Reimbursement for HPV vaccines and HPV testing requires cost-effectiveness analyses which include country-specific data on the burden and costs of management of cervical neoplasia. Therefore, we investigated the burden of cervical neoplasia and direct costs associated with its detection and management in Poland in 2012 reimbursed by the National Health Fund (NHF) - the only public healthcare insurance institution. We also report administrative costs of the organised screening programme covered by the Ministry of Health., Methods: Data on the burden and reimbursed costs of organised and opportunistic screening as well as management of cervical neoplasia were drawn from the NHF databases. Numbers of women reported with CIN and CC were ascertained., Results: In 2012, there were 765,266 and 1,288,358 reimbursed Pap smears collected within and outside the organised screening programme, respectively. Expenditures on medical and administrative procedures in organised screening reached PLN (Polish Zloty) 41,470,664 and 12,150,398 respectively. The number of women with particular diagnosis and reimbursement for the management of these lesions were as follows: glandular ectropion 208,033 and PLN 37,349,515; CIN1 10,521 and PLN 6,616,375; CIN2 5,812 and PLN 5,071,155; CIN3 6,487 and PLN 7,611,062; unspecified grade CIN 36,575 and PLN 12,352,034; and CC 33,482 and PLN 52,377,006, respectively. In women with ectropion and CIN the total number of local excision/ablative therapeutic procedures on the cervix reached 47,658 and the total number of hysterectomies was 1,321., Conclusion: In 2012, management of approximately 93 thousand women with HPV-related cervical lesions reimbursed in Poland amounted to PLN 84,027,632 which makes it a considerable public health problem. The number of women managed for glandular ectropion is considerable and related costs are high. Total reimbursement for detection, treatment and follow-up of all cervical lesions reaches at least PLN 137 million annually., (Copyright© by the National Institute of Public Health, Prague 2015.)

This paper investigates the effect of expansion to near-universal health insurance coverage in Massachusetts on breast and cervical cancer screening. We use data from 2002 to 2010 to compare changes in receipt of mammograms and Pap tests in Massachusetts relative to other New England states. We also consider the effect specifically among low-income women. We find positive effects of Massachusetts health reform on cancer screening, suggesting a 4 to 5% increase in mammograms and 6 to 7% increase in Pap tests annually. Increases in both breast and cervical cancer screening are larger 3 years after the implementation of reform than in the year immediately following, suggesting that there may be an adjustment or learning period. Low-income women experience greater increases in breast and cervical cancer screening than the overall population; among women with household income less than 250% of the federal poverty level, mammograms increase by approximately 8% and Pap tests by 9%. Overall, Massachusetts health reform appears to have increased breast and cervical cancer screening, particularly among low-income women. Our results suggest that reform was successful in promoting preventive care among targeted populations., (Copyright © 2015 John Wiley & Sons, Ltd.)

Background: Attendance in the cervical cancer screening programme is one of the most important factors to lower the risk of contracting the disease. Attendance rates are often low in areas with low socioeconomic status. Charging a fee for screening might possibly decrease attendance in this population. Screening programme coverage is low in low socio-economic status areas in Gothenburg, Sweden, but has increased slightly after multiple interventions in recent years. For many years, women in the region have paid a fee for screening. We studied the effect of abolishing this fee in a trial emanating from the regular cervical cancer screening programme., Method: Individually randomised controlled trial. All 3 124 women in three low-resource areas in Gothenburg, due for screening during the study period, were randomised to receive an offer of a free test or the standard invitation stating the regular fee of 100 SEK (≈11 €). The study was conducted during the first six months of 2013. Attendance was defined as a registered Pap smear within 90 days from the date the invitation was sent out., Results: Attendance did not differ significantly between women who were charged and those offered free screening (RR 0.93; CI 0.85-1.02). No differences were found within the districts or as an effect of age, attendance after the most recent previous invitation or previous experience of smear taking., Conclusion: Abolishment of a modest screening fee in socially disadvantaged urban districts with low coverage, after previous multiple systematic interventions, does not increase attendance in the short term. Other interventions might be more important for increasing attendance in low socio-economic status areas., Trial Registration: ClinicalTrials.gov NCT02378324.

Objectives To identify socioeconomic and regional inequalities of pap smear coverage in the state of Rio Grande do Sul. Methods An ecological study based on data of the 2011-2012 national health information system to estimate the annual coverage of pap smears for the overall female population of the state and for women without private health insurance. We estimated annual pap smear coverage according to the Municipal Social Vulnerability Index and health macro-regions and regions of the state. Results The percentage of women without private health insurance ranged from 38.1% to 94.2% in the health regions. Pap smear coverage was 17.3% for the overall female population and 23.8% for women without private health insurance. Pap smear coverage was higher in more socially vulnerable municipalities and regions with a higher percentage of women with private health insurance. Conclusions The prevalence of private health insurance should be considered in studies that address the coverage of the Brazilian Unified Health System (SUS).

Objectives: to increase participation of immigrant women at cervical cancer screening programmes., Design: pre-post study to evaluate the efficacy of recall by phone call in immigrant women., Setting and Participants: 6,133 immigrant women in Cesena (Emilia-Romagna Region, Northern Italy) who have never made a Pap test in the last three years., Main Outcome Measures: increment of percentage of immigrant women who participated in cervical cancer screening., Results: the recall by phone call and counselling by linguistic mediators to immigrant women from high-pressure to migrate Country moved their participation percentage to cervical screening programmes from 46% (period 2006-2008) to 56% (period 2011-2013). Linguistic mediators contacted 2,131 of these women and they verified that 1,437 of them have not made a Pap test in the last three years. These women were suggested to do the Pap test and 555 of them (39%) did it; these tests cost about 25 euros each for counselling and telephone recall. Pap tests, colposcopies, and histology results permitted to find out and treat: 2 cervical dysplasia of grade I (mild), 3 of grade II (moderate), and 3 of grade III (severe). These 6 women with moderate or severe dysplasia had an average age of 37 years and have never done a Pap test. The cost to find out these cases of moderate or severe dysplasia was about 2,000 euros each., Conclusion: the recall phone call and counselling by linguistic mediators is effective and low cost to increase the participation of foreign women in screening programmes.

We use the 1997-2008 Medical Expenditure Panel Survey (MEPS) and variation in the timing of state mandates for coverage of colorectal, cervical, and prostate cancer screenings to investigate the behavioral and financial effects of mandates on privately insured adults. We find that state mandates did not result in increased rates of cancer screening. However, coverage of preventive care, whether mandated or not, moves the cost of care from the consumer's out-of-pocket expense to the premium, resulting in a cross-subsidy of users of the service by non-users. While some cross-subsidies are intentional, others may be unintentional. We find that users of cancer screening have higher levels of income and education, while non-users tend to be racial minorities, lack a usual source of care, and live in communities with fewer physicians per capita. These results suggest that coverage of preventive care may transfer resources from more advantaged individuals to less advantaged individuals.

Objective: The main objective of the project was the evaluation of the organizational and financial aspects of midwives in primary health care (PHC), functioning under The Population Program for the Early Detection of Cervical Cancer two years after the implementation of new law regulations, which enable this occupational group to collect cytological material for screening., Material and Methods: Under this project, the data of the Program's Coordinating Centre, affecting midwives' postgraduate education in the field of pap smear tests, was taken into analysis. Furthermore, The National Health Fund (NFZ) reports on contracts entered in the field of the discussed topics, taking into consideration the value of health services performed within the Program in respect of ambulatory care and primary care units., Results: NFZ concluded contracts for the provision of PHC service with 6124 service providers in 2016, including the contracts in the field of providing health services under the cervical cancer prevention program by PHC midwifes, which were entered into by 358 institutions (5.85%). The value of the basic services under the Program, carried out under NFZ contracts in 2014, amounted to approx. PLN 12.3 million, while the value of services performed by PHC midwives represented only 0.38% of this sum., Conclusions: The introduction of legislative changes, allowing PHC midwives to collect cytological material for screening, did not cause, in the period of the observation on a national scale, the expected growth of availability of basic stage services within the cervical cancer prevention program.

Background: South Africa has high rates of HIV and HPV and high incidence and mortality from cervical cancer. However, cervical cancer is largely preventable when early screening and treatment are available. We estimate the costs and cost-effectiveness of conventional cytology (Pap), visual inspection with acetic acid (VIA) and HPV DNA testing for detecting cases of CIN2+ among HIV-infected women currently taking antiretroviral treatment at a public HIV clinic in Johannesburg, South Africa., Methods: Method effectiveness was derived from a validation study completed at the clinic. Costs were estimated from the provider perspective using micro-costing between June 2013-April 2014. Capital costs were annualized using a discount rate of 3%. Two different service volume scenarios were considered. Threshold analysis was used to explore the potential for reducing the cost of HPV DNA testing., Results: VIA was least costly in both scenarios. In the higher volume scenario, the average cost per procedure was US$ 3.67 for VIA, US$ 8.17 for Pap and US$ 54.34 for HPV DNA. Colposcopic biopsies cost on average US$ 67.71 per procedure. VIA was least sensitive but most cost-effective at US$ 17.05 per true CIN2+ case detected. The cost per case detected for Pap testing was US$ 130.63 using a conventional definition for positive results and US$ 187.52 using a more conservative definition. HPV DNA testing was US$ 320.09 per case detected. Colposcopic biopsy costs largely drove the total and per case costs. A 71% reduction in HPV DNA screening costs would make it competitive with the conservative Pap definition., Conclusions: Women need access to services which meet their needs and address the burden of cervical dysplasia and cancer in this region. Although most cost-effective, VIA may require more frequent screening due to low sensitivity, an important consideration for an HIV-positive population with increased risk for disease progression.

Background: Cervical cancer is the second leading cause of cancer cases and deaths among Filipino women because of inadequate access to screening and treatment services. This study aims to evaluate the health and economic benefits of HPV vaccination and its combination with different screening strategies to find the most optimal preventive strategy in the Philippines., Methods: A cost-utility analysis was conducted using an existing semi-Markov model to evaluate different screening (i.e., Pap smear, visual inspection with acetic acid) and vaccination strategies against HPV infection implemented alone or as part of a combination strategy at different coverage scenarios. The model was run using country-specific epidemiologic, cost and clinical parameters from a health system perspective. Sensitivity analysis was performed for vaccine efficacy, duration of protection and costs of vaccination, screening and treatment., Results: Across all coverage scenarios, VIA has been shown to be a dominant and cost-saving screening strategy with incremental cost-effectiveness ratio (ICER) ranging from dominant to Php 61,059 (1443 USD) per QALY gained. VIA can reduce cervical cancer cases and deaths by 25%. Pap smear screening was found to be not cost-effective due to its high cost in the Philippines. Adding HPV vaccination at a cost of 54 USD per vaccinated girl on top of VIA screening was found to be potentially cost-effective using a threshold of 1 GDP per capita (i.e., Php 120,000 or 2835 USD/ QALY) with the most favorable assumption of providing lifelong immunity against high-risk oncogenic HPV types 16/18. The highest incremental QALY gain was achieved with 80% coverage of the combined strategy of VIA at 35 to 45 years old done every five years following vaccination at 11 years of age with an ICER of Php 33,126 (783 USD). This strategy may result in a two-thirds reduction in cervical cancer burden. HPV vaccination is not cost-effective when vaccine protection lasts for less than 20 years., Conclusion: High VIA coverage targeting women aged 35-45 years old at five-year intervals is the most efficient and cost-saving strategy in reducing cervical cancer burden in the Philippines. Adding a vaccination program at high coverage among 11-year-old girls is potentially cost-effective in the Philippines assuming a life-long duration of vaccine efficacy.

Introduction: The sustainability of donor-supported cervical cancer screening for HIV-positive women in underresourced setting is a concern. The authors aimed to determine the willingness of HIV-positive women for out-of-pocket payment for the cancer screening, if necessary., Methods: Questionnaires were administered to 400 HIV-positive women at the Adult HIV clinic, University of Nigeria Teaching Hospital (UNTH), Enugu, Nigeria., Results: In all 11 (2.8%) respondents were aware of Pap smear, but only 1 (9.1%) of them had used it. After cervical cancer screening counseling, 378 (94.5%) respondents were willing to pay for Pap smear, irrespective of the cost. This willingness showed no trend across marital or educational groups. Younger age of respondents was not associated with willingness to pay for Pap smear (odds ratio = 1.24; confidence interval 95%: 0.52, 2.94)., Conclusion: Willingness to pay for Pap smear by HIV-positive women in Enugu, Nigeria, is high. This has implication for the program sustainability., (© The Author(s) 2013.)

Background and Aims: An assessment was performed of the quality of Pap readings in 19 cytology laboratories (CLs) in Mexico from the Cervical Cancer Screening Program., Methods: Nine CLs were affiliated with the Health Ministry (SSA), and ten were affiliated with the Mexican Social Security Institute (IMSS). Two sets of 200 cervical cytology specimens were prepared, one set for each institution. Fourteen percent of the specimens were positive and six were inappropriate for diagnosis (3%). All cervical cytology specimens were processed in the cytopathology laboratory at the General Hospital of Mexico, and histopathology was available for each positive case., Results: Thirty percent of the SSA reading centers had a sensitivity of at least 80%; however, not one of the ten IMSS laboratories evaluated reached this figure. Some reading centers had a sensitivity <65%, meaning that nearly half of the specimens with a cytology consistent with cervical neoplasm were not identified., Discussion: Given these results, it is a priority to effect a paradigm shift combining various screening tests to improve adherence to standards and enhanced cost-effectiveness of the early detection of cervicouterine cancer (CC) in Mexico., (Copyright © 2015 IMSS. Published by Elsevier Inc. All rights reserved.)

Background: To identify the optimal cost effective strategy for the management of women having ASC-US who attended at King Chulalongkorn Memorial Hospital (KMCH)., Design: An Economical Analysis based on a retrospective study., Subject: The women who were referred to the gynecological department due to screening result of ASC-US at King Chulalongkorn Memorial Hospital, a general and tertiary referral center in Bangkok Thailand, from Jan 2008 - Dec 2012., Materials and Methods: A decision tree-based was constructed to evaluate the cost effectiveness of three follow up strategies in the management of ASC-US results: repeat cytology, triage with HPV testing and immediate colposcopy. Each ASC-US woman made the decision of each strategy after receiving all details about this algorithm, advantages and disadvantages of each strategy from a doctor. The model compared the incremental costs per case of high-grade cervical intraepithelial neoplasia (CIN2+) detected as measured by incremental cost-effectiveness ratio (ICER)., Results: From the provider's perspective, immediate colposcopy is the least costly strategy and also the most effective option among the three follow up strategies. Compared with HPV triage, repeat cytology triage is less costly than HPV triage, whereas the latter provides a more effective option at an incremental cost-effectiveness ratio (ICER) of 56,048 Baht per additional case of CIN 2+ detected. From the patient's perspective, the least costly and least effective is repeat cytology triage. Repeat colposcopy has an incremental cost-effectiveness (ICER) of 2,500 Baht per additional case of CIN2+ detected when compared to colposcopy. From the sensitivity analysis, immediate colposcopy triage is no longer cost effective when the cost exceeds 2,250 Baht or the cost of cytology is less than 50 Baht (1USD = 31.58 THB)., Conclusions: In women with ASC-US cytology, colposcopy is more cost-effective than repeat cytology or triage with HPV testing for both provider and patient perspectives.

Background: Despite the increasing number of screening examinations performed for cervical cancer utilizing the Papanicolaou smear test (Pap test), few studies have examined whether this strategy is cost-effective in Korea., Objective: This study was conducted to evaluate the cost-effectiveness of cervical cancer screening strategies incorporating the Pap test based on age at the start and end of screening as well as screening interval., Materials and Methods: We designed four alternative screening strategies based on patient age when screening was started (20 or 30 years) and discontinued (lifetime, 79 years). Each strategy was assessed at screening intervals of 1, 2, 3, or 5 years. A Markov model was developed to determine the cost-effectiveness of the 16 possible cervical cancer screening strategies, and this was evaluated from a societal perspective. The main outcome measures were average lifetime cost, incremental quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratio (ICER)., Results: Compared with various strategies comprising younger starting age, discontinuation age, and longer screening intervals, strategies employing annual screening for cervical cancer starting at a target age of 30 years and above were the most cost-effective, with an ICER of 21,012.98 dollars per QALY gained (with a Korean threshold of 30,000,000 KRW or US$27,272)., Conclusions: We found that annual screening for cervical cancer beginning at a target age of 30 years and above is most cost-effective screening strategy. Considering the potential economic advantages, more intense screening policies for cervical cancer might be favorable among countries with high rates of cervical cancer and relatively low screening costs.

Squamous epithelial cells are susceptible to infection by the human papillomavirus. Infection of squamous epithelium with oncogenic human papillomavirus types is associated with development of dysplasia and potential malignant transformation. Historically, cervical cancer has been the most prevalent human papillomavirus-induced squamous neoplasia. However, because of widespread screening via Pap smear testing, rates of cervical cancer in the United States have decreased dramatically during the past 50 years. Rates of anal cancer, in contrast, have doubled during the past 30 years. The groups at highest risk for development of anal cancer are men who have sex with men, HIV-positive patients, and patients immunosuppressed as a result of solid-organ transplantation. By detecting dysplasia before it develops into invasive cancer, anal Pap smears may be a potentially useful screening tool for anal cancer, particularly in individuals known to be at increased risk. However, at this time, sufficient data supporting the benefit of anal Pap smear screening are lacking. With insufficient evidence, no national health care organizations currently recommend the use of anal Pap smears as a routine screening test, even among high-risk groups., (Copyright © 2014 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.)

Background: Although state Medicaid programs cover cancer screening, Medicaid beneficiaries are less likely to be screened for cancer and are more likely to present with tumors of an advanced stage than are those with other insurance. The current study was performed to determine whether state Medicaid eligibility and reimbursement policies affect the receipt of breast, cervical, and colon cancer screening among Medicaid beneficiaries., Methods: Cross-sectional regression analyses of 2007 Medicaid data from 46 states and the District of Columbia were performed to examine associations between state-specific Medicaid reimbursement/eligibility policies and receipt of cancer screening. The study sample included individuals aged 21 years to 64 years who were enrolled in fee-for-service Medicaid for at least 4 months. Subsamples eligible for each screening test were: Papanicolaou test among 2,136,511 patients, mammography among 792,470 patients, colonoscopy among 769,729 patients, and fecal occult blood test among 753,868 patients. State-specific Medicaid variables included median screening test reimbursement, income/financial asset eligibility requirements, physician copayments, and frequency of eligibility renewal., Results: Increases in screening test reimbursement demonstrated mixed associations (positive and negative) with the likelihood of receiving screening tests among Medicaid beneficiaries. In contrast, increased reimbursements for office visits were found to be positively associated with the odds of receiving all screening tests examined, including colonoscopy (odds ratio [OR], 1.07; 95% confidence interval [95% CI], 1.06-1.08), fecal occult blood test (OR, 1.09; 95% CI, 1.08-1.10), Papanicolaou test (OR, 1.02; 95% CI, 1.02-1.03), and mammography (OR, 1.02; 95% CI, 1.02-1.03). Effects of other state-specific Medicaid policies varied across the screening tests examined., Conclusions: Increased reimbursement for office visits was consistently associated with an increased likelihood of being screened for cancer, and may be an important policy tool for increasing screening among this vulnerable population., (© 2014 American Cancer Society.)

Objective: To compare the costs and number of undetected cases of four cervical cancer screening strategies (CCSS) in Mexico., Materials and Methods: We estimated the costs and outcomes of the following CCSS: a) conventional Papanicolaou smear (Pap) alone; b) high-risk human papilloma virus testing (HR-HPV) as primary screening with Pap as reflex triage; c) HR-HPV as primary screening with HPV-16/18 typing, liquid-based cytology (LBC) and immunostaining for p16/Ki67 testing as reflex triage, and d) co-testing with HR-HPV and LBC with HPV-16/18 typing and immunostaining for p16/Ki67 as reflex triage. The outcome of interest was high-grade cervical lesions or cervical cancer., Results: HR-HPV testing, HPV typing, LBC testing and immunostaining is the best alternative because it is the least expensive option with an acceptable number of missed cases., Conclusions: The opportunity costs of a poor quality CCSS is many false negatives. Combining multiple tests may be a more cost-effective way to screen for cervical cancer in Mexico.

Objective: To estimate the annual cost of the National Cervical Cancer Screening Program (CCSP) of the Mexican Institute of Social Security (IMSS)., Materials and Methods: This cost analysis examined regional coverage rates reported by IMSS. We estimated the number of cytology, colposcopy, biopsy and pathology evaluations, as well as the diagnostic test and treatment costs for cervical intraepithelial neoplasia grade II and III (CIN 2/3) and cervical cancer. Diagnostic test costs were estimated using a micro-costing technique. Sensitivity analyses were performed., Results: The cost to perform 2.7 million cytology tests was nearly 38 million dollars, which represents 26.1% of the total program cost (145.4 million). False negatives account for nearly 43% of the program costs., Conclusion: The low sensitivity of the cytology test generates high rates of false negatives, which results in high institutional costs from the treatment of undetected cervical cancer cases.

Purpose: In France, larger social inequalities are reported for cervical cancer screening, based on individual practice, than for breast cancer screening for which organized screening exists. Our aim was to investigate the association between women's economic situation and breast and cervical cancer screening., Methods: We used data from a large French national health survey conducted in 2010. The economic situation was assessed using the number of adverse economic conditions respondents were facing, based on three variables (low income, lacking food, and perceived financial difficulties). Logistic regressions were adjusted for socioeconomic and sociodemographic characteristics, healthcare use and insurance, and health behaviors., Results: Mammography was less frequent among women experiencing two or more adverse economic conditions, whereas Pap smear was less frequent among women experiencing at least one adverse economic condition. For both screenings, higher rates were observed among women who lived in the Paris region. Sociodemographic indicators and health behaviors were associated with Pap smear, whereas healthcare use and insurance characteristics were associated with mammography., Conclusions: The women's economic situation is an important determinant of breast and cervical cancer screening in France in 2010. Alleviating economic barriers to female cancers screening should be a priority in future programs implementation.

We evaluated the overall coverage, frequency and costs of Pap testing by screening modality and health care provider in Finland. Information about Pap testing in the Finnish female population of 2.7 million was obtained from nationwide population-based registry data. Among women aged 25-69 years, 87% had had a Pap test taken within or outside the organised programme at least once during the last 5 years and half of those screened in the organised programme had also had at least one Pap test taken outside the programme. Of the annual average of 530,000 Pap tests taken, 84% were taken for screening purposes and 16% as follow-up. Forty percent of the 446,000 annual screening tests were taken in the organised programme, 55% as opportunistic tests in public primary or student health care or by private providers and 5% in public secondary health care. One-fifth of all opportunistic screening Pap tests were taken from women aged <25. The voluminous opportunistic Pap testing in public primary health care was concentrated in young women aged 25-29 whereas the bulk of opportunistic testing in private health occurred in age groups eligible for organised screening. The total cost of all screening Pap tests was €22.4 million, of which 71% incurred in opportunistic screening. Of the 84,000 annual follow-up Pap tests and their €8.3 million total costs, ∼60% incurred in organised screening or in secondary health care., (© 2013 UICC.)

Objective: Assessing the impact of subsidized healthcare insurance on access to cervical cytology in Medellin, Colombia., Materials and Methods: Propensity score matching (PSM) was used with 2008 Life Quality Survey in Colombia figures to obtain a control group comparable to a treatment group. This involved using stratification estimates, the k-nearest-neighbor algorithm and kernel density for calculating impact size, Results: Access to cytology for 19 to 49 year-old women having subsidized healthcare insurance were 2.2 % to 2.9 % lower compared to women who did not have any healthcare insurance. Estimates were not statistically significant for women over 50 years-old., Discussion: Women lacking healthcare insurance having increased access to cytology could be explained by charities or social programs aiding the population lacking healthcare insurance.