Jie-Bin Lew

The burden of cervical cancer in China: Synthesis of the evidence

The burden of cervical cancer in China has not been characterized in detail. We reviewed cervical cancer data from national mortality surveys and registries, and conducted a meta‐analysis to estimate the prevalence of high‐grade lesions (HSIL) and high‐risk human papillomavirus (HR‐HPV) infections in rural Shanxi Province. We found that a national survey in the 1970s estimated age‐standardized cervical cancer mortality rates as ∼15 and ∼83/100,000 women nationally and in Xiangyuan, Shanxi; but the latest survey (2004–2005) found much lower rates of ∼3 and ∼7/100,000, respectively. IARC registries record age‐standardized cervical cancer incidence in China as <5/100,000 (1998–2002); but the five registry sites cover <2% of the population, and the gross domestic product per capita at each of the registry sites is higher than Chinas average (by a factor ranging from 1.3 to 3.9). The pooled estimate of the prevalence of HSIL and HR‐HPV in women aged 30–54 years in Shanxi was 3.7%(95%CI:2.7–4.8%) and 17.2%(95%CI:13.1–21.3%), respectively. Based on a feasible range informed by the incidence data for China and other unscreened populations, the predicted indicative annual number of new cervical cancer cases nationally, in the absence of any intervention, ranges from ∼27,000 to 130,000 (2010) to 42,000 to 187,000 (2050). In conclusion, recent data suggest comparatively low rates of cervical cancer incidence in China, which may be partly explained by the location of registry sites in higher socioeconomic status areas. However, the evidence is consistent with considerable heterogeneity within China, with a higher disease burden in some rural areas such as Shanxi. Therefore, the lower reported rates of cervical cancer in China should be interpreted cautiously.

The predicted impact of HPV vaccination on male infections and male HPV-related cancers in Australia.

Australia implemented a National HPV Vaccination Program in 2007, with routine vaccination of 12-13 year old females and catch-up in females aged 13-26 years to 2009. The aim of this study was to estimate the impact of the current female-only national vaccination program on males, and then to estimate the incremental benefits to males from being included in the program. We used preliminary data to estimate vaccination coverage in females. We then fitted a dynamic model of sexual behaviour and HPV transmission in Australia to local data on female pre-vaccination age-specific HPV prevalence, predicted the corresponding pre-vaccination prevalence in males due to heterosexual transmission, and modelled the short and long term impact of female-only versus female-and-male vaccination programs. The estimated 3-dose female coverage rates were 78% (range 70-80%) for ongoing coverage in 12-13 year old girls; and from 74% (range 70-80%) in 14 year olds, to 25% (range 15-35%) for women aged 26 years old in 2007. The median estimate for age-standardised pre-vaccination HPV 16 prevalence in females and males aged 15-59 years was 3.2% (95% range: 2.4-4.1%) and 3.1% (95% range: 2.2-4.2%), respectively. The current program in females is predicted to result in a 68% reduction in male HPV 16 infections by 2050, leading to an estimated long term reduction of 14% in rates of cancers of the head, neck and anogenital area. The estimated proportion of the maximum possible vaccine-conferred benefit to males from a female-and-male program which will be achieved by female-only vaccination is 73% (range in probabilistic sensitivity analysis: 53-78%). In conclusion, up to three-quarters of the maximum possible vaccination-conferred benefit to males due to reduced heterosexual transmission will be achieved by the existing female-only program.

The predicted impact of vaccination on human papillomavirus infections in Australia

Vaccines based on human papillomavirus (HPV) 16 and 18 virus‐like particles have the potential to prevent ∼70% of cervical cancers. In Australia, public vaccination against HPV commenced in April 2007, and includes routine vaccination of females aged 12–13 years, and a 2‐year school and GP‐based catch‐up in females aged 12–26 years. The objectives of this study were to estimate initial vaccination coverage rates, to describe current patterns of sexual behavior in young females, and to predict the impact of vaccination on HPV16 infections. We reviewed early coverage data, estimating that coverage in 2007/2008 will reach 86% (feasible range 67–90%) for 12‐ to 13‐year‐old girls, with lower rates attained in older females. A review of survey data found that the median age of first intercourse in Australian females is 16 years, with ∼90% of women sexually active at 22 years. Using these data, we performed an analysis of HPV transmission to predict the impact of vaccination on HPV infection rates. The public program is predicted to result in a reduction in the age‐standardized incidence of HPV16 infections of 56% by 2010 (feasible range 48–61%), and 92% by 2050 (feasible range 76–95%). Elective vaccination of older women and vaccination of males may provide some incremental gains, but the benefits to women of vaccinating males will be less if coverage of females remains high. In conclusion, the current vaccination program is expected to result in a substantial and rapid reduction in the incidence of HPV16 in Australia.

Prevention of cervical cancer in rural China: evaluation of HPV vaccination and primary HPV screening strategies.

Comprehensive evaluation of the cost-effectiveness of HPV vaccination in China has not previously been performed. The objective of this study was to evaluate vaccination as an alternative or addition to primary HPV screening with careHPV (Qiagen, Gaithersburg, USA), and to assess the threshold total cost per vaccinated girl (CVG) at which strategies involving vaccination would become viable compared to screening-only strategies in rural China. We used data from field studies in Shanxi Province to support modelling of HPV vaccination and screening, including local information on sexual behaviour, HPV prevalence, test accuracy, treatment protocols and costs. We evaluated several strategies involving screening once or twice per lifetime or at regular 5-yearly intervals, with or without vaccination of young females at age 15 years, assuming 70% coverage for both screening and vaccination. We also predicted cross-sectional cancer incidence each year to the year 2050 for a range of strategies. We found that strategies involving vaccination would be cost-effective at CVGs of US

Evaluation of primary HPV-DNA testing in relation to visual inspection methods for cervical cancer screening in rural China: an epidemiologic and cost-effectiveness modelling study

50-54 or less, but at CVGs >

Cervical cancer screening in Australia: modelled evaluation of the impact of changing the recommended interval from two to three years.

54, screening-only strategies would be more cost-effective. If vaccination of young cohorts is combined with two rounds of careHPV screening for women aged 30-59 years in 2012 and 2027, a predicted indicative 33% reduction in cervical cancer incidence by 2030 would be sustained until 2050, with incidence rates decreasing thereafter. In conclusion, taking into account estimated vaccine delivery costs (for 3 doses), a per-dose HPV vaccine cost of approximately <

Will cervical screening remain cost-effective in women offered the next generation nonavalent HPV vaccine? Results for four developed countries.

9-14 would be required for strategies involving vaccination to be cost-effective. Overall, combined screening and vaccination approaches are required to maximise outcomes in rural China.

Cost effectiveness of human papillomavirus test of cure after treatment for cervical intraepithelial neoplasia in England: economic analysis from NHS Sentinel Sites Study

BackgroundA new lower-cost rapid-throughput human papillomavirus (HPV) test (careHPV, Qiagen, Gaithersburg, USA) has been shown to have high sensitivity for the detection of high grade cervical intraepithelial neoplasia.MethodsWe assessed the outcomes and cost-effectiveness of careHPV screening in rural China, compared to visual inspection with acetic acid, when used alone (VIA) or in combination with Lugols iodine (VIA/VILI). Using data on sexual behaviour, test accuracy, diagnostic practices and costs from studies performed in rural China, we estimated the cost-effectiveness ratio (CER) and associated lifetime outcomes for once-lifetime and twice-lifetime screening strategies, and for routine screening at 5-yearly, 10-yearly and IARC-recommended intervals. The optimal age range for once-lifetime screening was also assessed.ResultsFor all strategies, the relative ordering of test technologies in reducing cervical cancer incidence and mortality was VIA (least effective); VIA/VILI; careHPV@1.0 pg/ml and careHPV@0.5 pg/ml (most effective). For once-lifetime strategies, maximum effectiveness was achieved if screening occurred between 35-50 years. Assuming a participation rate of ~70%, once-lifetime screening at age 35 years would reduce cancer mortality by 8% (for VIA) to 12% (for careHPV@0.5) over the long term, with a CER of US

Estimation of the costs of cervical cancer screening, diagnosis and treatment in rural Shanxi Province, China: a micro-costing study

557 (for VIA) to

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

959 (for careHPV@1.0) per life year saved (LYS) compared to no intervention; referenced to a 2008 GDP per capita in Shanxi Province of