Visual inspection with acetic acid is more cost-effective than Pap smears for cervical cancer screening in Honduras

Background/significance:

Cervical cancer is the leading cancer killer of women in developing countries because effective screening technologies are not universally applied. In the setting of scarce resources, determining the most cost-effective screening program is important.

Objective/Purpose:

To compare the cost-effectiveness of Pap smears to that of visual inspection with acetic acid (VIA) for cervical cancer screening in Honduras.

Methods:

Cost effectiveness and decision analysis were performed. The primary outcome variable was 10-year cancer prevalence. Three hypothetical populations of 35-year-old women were compared: never-screened women, women screened with VIA, and women screened with Pap smears. Primary data from our cervical cancer screening program in Honduras was used to determine screening characteristics of Pap smear and VIA, loss-to-follow-up, prevalence of precancerous lesions, and cost of screening and treatment. Published data was used to model the natural history of cervical dysplasia with and without treatment. Data was analyzed using Tree-age.

Results:

Although false positives are rare, the current Pap smear system in Honduras fails to detect up to 90% of dysplasia. VIA detects more dysplasia, but the false-positive rate exceeds 40%. Cost-effectiveness analysis revealed that, for a hypothetical cohort of 1000 Honduran women age 35, screening with Pap smears would cost USD$4253 with no appreciable decrease in cancer rates. VIA would cost USD$10,250 and reduce cancer cases by 43% (from 5.07 to 2.85 per 1000), thus costing USD$4723 per avoided cancer case.

Discussion/conclusions:

VIA dramatically outperforms Pap smears in Honduras, and represents a cost-effective alternative for cervical cancer screening in this setting.