Cost-effectiveness estimates: the need for complete reporting – Authors' reply
Authors: Jie-Bin Lew, Kate T Simms, Megan A Smith, Marion Saville, Ian Hammond, Karen Canfell
Journal: The Lancet Public Health (2017)

We thank James O'Mahony for his comments on our study.1Lew J-B Simms KT Smith MA et al.Primary HPV testing versus cytology-based cervical screening in women in Australia vaccinated for HPV and unvaccinated: effectiveness and economic assessment for the National Cervical Screening Program.Lancet Public Health. 2017; 2: e96-107Summary Full Text Full Text PDF Scopus (107) Google Scholar The strategies considered in our evaluation were pre-specified according to a Decision Analytic Protocol, which was developed by the Protocol Advisory Sub-Committee for Australia's Medical Services Advisory Committee (MSAC). The protocol included strategies that were more likely to be acceptable to women and providers, and therefore of greatest interest in Australian policy context. A 5-yearly interval for human papillomavirus (HPV)-based screening options was specified for the main analysis. We also did supplementary analysis at a 6-yearly interval, and considered variations in screening age range, screening test technology (eg, conventional cytology, manual liquid-based cytology, image-read liquid-based cytology, or HPV testing), triage options, exit testing options, and invitation strategies. On the basis of the comprehensive modelled analysis done in 2014 and an extensive review of the literature, MSAC's recommendations stated “MSAC supported HPV testing as the primary cervical screening test every 5 years”.2Medical Services Advisory CommitteeMSAC outcomes: application no. 1276—renewal of the National Cervical Screening Program. Australian Government Department of Health, Canberra2014http://www.msac.gov.au/internet/msac/publishing.nsf/Content/D924E2F768B13C4BCA25801000123B9E/Φle/1276%20-%20Final%20MSAC%20PSD%20-%20NCSP%20Renewal.pdfGoogle Scholar Therefore, the subsequent evaluation done in 2015–16 considered screening at 5-yearly intervals only. Theoretical analysis of many, incrementally longer, screening intervals could also have been done (screening intervals as long as 10 years for HPV screening have been implemented in the Netherlands in women older than 40 years3Wentzensen N Arbyn M Berkhof J et al.Eurogin 2016 roadmap: how HPV knowledge is changing screening practice.Int J Cancer. 2017; 140: 2192-2200Crossref PubMed Scopus (81) Google Scholar). However, because the choice of strategies that are included in an economic evaluation can influence the calculated incremental cost-effectiveness ratios (ICERs) for other included strategies, it is important that a policy-facing evaluation involves a careful a priori specification of the main strategies of interest for a particular country. We did not explicitly report on ICERs in the evaluation findings because these are usually referenced to the effects and costs of current practice. The decision maker thus usually obtains an estimate of the additional cost per life-year saved (or per quality-adjusted life-year saved), compared with current practice, after investing in a new intervention. In this case, however, the ICER calculation could not be referenced to current practice because the evaluation had the highly favourable outcome that all strategies for HPV screening—including both 5-yearly and 6-yearly HPV screening options—were cost saving and life-year saving compared with current practice for cytology-based screening. Given this win-win situation, other outcomes were considered to be more informative for decision making in Australia, such as health outcomes (eg, cervical cancer cases and deaths) and resource utilisation (eg, colposcopies, test volumes, and treatment numbers). After fully considering all of these outcomes, MSAC supported HPV testing as the primary cervical screening test every 5 years.2Medical Services Advisory CommitteeMSAC outcomes: application no. 1276—renewal of the National Cervical Screening Program. Australian Government Department of Health, Canberra2014http://www.msac.gov.au/internet/msac/publishing.nsf/Content/D924E2F768B13C4BCA25801000123B9E/Φle/1276%20-%20Final%20MSAC%20PSD%20-%20NCSP%20Renewal.pdfGoogle Scholar We do acknowledge that for other countries, more detail on our initial comparison between 5-yearly and 6-yearly screening and the ICERs for alternate strategies might be useful. We present the detailed findings in the appendix. However, we urge caution in interpretation of these findings because, in relation to Australia, they do not reflect the final evaluation of 5-yearly HPV screening that we did to incorporate clinical management guidelines, and, in relation to other countries, they reflect the Australian situation for burden of disease, screening and vaccination uptake, management pathways, health-care costs, and health economic conventions. We have previously found that country-specific differences can heavily influence evaluation findings.4Simms KT Smith MA Lew JB et al.Will cervical screening remain cost-effective in women offered the next generation nonavalent HPV vaccine? Results for four developed countries.Int J Cancer. 2016; 139: 2771-2780Crossref PubMed Scopus (51) Google Scholar Therefore, we recommend that other countries considering primary HPV screening also invest in doing similar country-specific and comprehensive modelled evaluations of health and economic outcomes in the context of HPV vaccination. J-BL and KTS are co-first authors. J-BL, KTS, MAS, MS, and KC have received grant support from the Victorian Cytology Service, all outside the submitted work. IH declares no competing interests. Download .pdf (1.31 MB) Help with pdf files Supplementary appendix Primary HPV testing versus cytology-based cervical screening in women in Australia vaccinated for HPV and unvaccinated: effectiveness and economic assessment for the National Cervical Screening ProgramPrimary HPV screening every 5 years with partial genotyping is predicted to be substantially more effective and potentially cost-saving compared with the current cytology-based screening programme undertaken every 2 years. These findings underpin the decision to transition to primary HPV screening with partial genotyping in the Australian National Cervical Screening Program, which will occur in May, 2017. Full-Text PDF Open AccessCost-effectiveness estimates: the need for complete reportingI read with interest Jie-Bin Lew and colleagues' study published in The Lancet Public Health.1 This study is an accomplished simulation analysis of the costs and effects of cervical screening for which Lew and colleagues should be commended for. I do, however, want to call attention to specific observations regarding the completeness of reporting within the study. Full-Text PDF Open Access