1. ¹Unit of Infections and Cancer (UNIC), Cancer Epidemiology Research Programme, Catalan Institute of Oncology (ICO), Av. Gran Via, s/n km. 2.7, 08907 L'Hospitalet de Llobregat, Barcelona, Spain
2. ²Department of Health Policy and Management, Program in Health Decision Science, Harvard School of Public Health, 718 Huntington Avenue, 2nd Floor; Boston, MA 02115, USA
3. ³Department of Paediatrics, Obstetrics, Gynaecology and Preventive Medicine, Program in Public Health and the Methodology of Biomedical Research, Universitat Autónoma de Barcelona (UAB), Bellaterra 08193 (Cerdanyola del Vallès), Spain
4. ⁴IDIBELL, CIBERESP, Barcelona, Spain
5. ⁵Infections and Cancer Epidemiology Group, Epidemiology and Biology Cluster, International Agency for Research on Cancer (IARC), 150 Cours Albert Thomas, Lyon CEDEX 08 69372, France

Correspondence: Professor SJ Goldie, E-mail: sue_goldie@harvard.edu

Revised 9 May 2008; Accepted 12 May 2008; Published online 8 July 2008.

Abstract

Cervical cancer is a leading cause of cancer death among women in low-income countries, with 25% of cases worldwide occurring in India. We estimated the potential health and economic impact of different cervical cancer prevention strategies. After empirically calibrating a cervical cancer model to country-specific epidemiologic data, we projected cancer incidence, life expectancy, and lifetime costs (I$2005), and calculated incremental cost-effectiveness ratios (I$/YLS) for the following strategies: pre-adolescent vaccination of girls before age 12, screening of women over age 30, and combined vaccination and screening. Screening differed by test (cytology, visual inspection, HPV DNA testing), number of clinical visits (1, 2 or 3), frequency (1 , 2 , 3 per lifetime), and age range (35–45). Vaccine efficacy, coverage, and costs were varied in sensitivity analyses. Assuming 70% coverage, mean reduction in lifetime cancer risk was 44% (range, 28–57%) with HPV 16,18 vaccination alone, and 21–33% with screening three times per lifetime. Combining vaccination and screening three times per lifetime provided a mean reduction of 56% (vaccination plus 3-visit conventional cytology) to 63% (vaccination plus 2-visit HPV DNA testing). At a cost per vaccinated girl of I$10 (per dose cost of $2), pre-adolescent vaccination followed by screening three times per lifetime using either VIA or HPV DNA testing, would be considered cost-effective using the country's per capita gross domestic product (I$3452) as a threshold. In India, if high coverage of pre-adolescent girls with a low-cost HPV vaccine that provides long-term protection is achievable, vaccination followed by screening three times per lifetime is expected to reduce cancer deaths by half, and be cost-effective.