Carga de enfermedad relacionada con el Virus del Papiloma

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Volume II
Health and Economic Outcomes of Human Papillomavirus (HPV) Vaccination in
Selected Countries in Latin America:
A PRELIMINARY ECONOMIC ANALYSIS
2008
A collaborative project of
The Sabin Vaccine Institute (Sabin), Washington, DC, USA
Harvard School of Public Health, Boston, MA, USA
Institut Catalá d’Oncología, Barcelona, Spain
Pan American Health Organization (PAHO) Washington, DC, USA
Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA
Prepared by
Dagna Constenla, Sue Goldie, Nelson Alvis, Meredith O’Shea, Steven Sweet, Marite
Valenzuela, Gabriel Cavada, Fernando de la Hoz, Emilia Koumans, Maria N Labbo, Cait
Koss, Hector Posso
Disclaimer
The findings and conclusions in this report are those of the authors and do not
necessarily represent the views of the U.S. Centers for Disease Control and Prevention
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TABLE OF CONTENTS
VOLUME II
EXECUTIVE SUMMARY
CHAPTER 1
INTRODUCTION
1.1 BACKGROUND
1.2 STUDY AIMS
CHAPTER 2
METHODS
2.1 ECONOMIC LITERATURE REVIEW
2.2 COST-EFFECTIVENESS ANALYSIS
2.2.1 ANALYTIC OVERVIEW
2.2.2 OVERVIEW OF MODELS
2.2.3 PERSPECTIVE AND SCOPE OF THE ANALYSIS
2.2.4 MODEL INPUTS
2.2.5 SENSITIVITY ANALYSIS
CHAPTER 3
RESULTS
3.1 DESCRIPTION OF ECONOMIC PAPERS REVIEWED
3.2 COST ANALYSIS
3.2.1 COSTS OF TREATING PRECANCEROUS LESIONS AND CERVICAL CANCER
3.2.2 DIRECT NONMEDICAL COSTS ASSOCIATED WITH PRECANCEROUS LESIONS AND
CERVICAL CANCER
3.2.3 OVERALL CANCER TREATMENT COSTS
3.2.4 ECONOMIC EVALUATION
3.2.5 HEALTH OUTCOMES FOR ADOLESCENT HPV 16 AND 18 VACCINATION
3.2.6 COST-EFFECTIVENESS OF VACCINATION
3.2.7 FINANCIAL IMPLICATIONS OF HPV 16 AND 18 VACCINATION
CHAPTER 4
DISCUSSION
4.1 MAIN FINDINGS
4.2 REGIONAL CONTEXT
4.3 LIMITATION OF THE LITERATURE REVIEW
4.4 LIMITATIONS OF THE EPIDEMIOLOGICAL DATA
4.5 LIMITATIONS OF THE ECONOMIC STUDY
REFERENCES
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APPENDIXES
Appendix A. Model comparison validation: Impact of HPV 16 and 18 vaccination on
mean reduction in lifetime risk of cervical cancer_____________________________ 178
Appendix B. Epidemiological parameters (Appendix Tables 1 and 2) ____________ 180
Appendix C. List of physicians interviewed _________________________________ 181
Appendix D. Sample expert interview survey ________________________________ 184
Appendix E. Summary of screening strategies across studied countries1 _________ 195
Appendix F. Summary of treatment of precancerous lesions across studied countries1
___________________________________________________________________ 199
Appendix G. Diagnostic and staging procedures and treatment modalities of invasive
cervical cancer by stage across studied countries1 ___________________________ 208
Appendix H. Unit costs associated with the detection and treatment of precancerous
lesions and treatment of cervical cancer by stage and country __________________ 225
Appendix I. Costs of transportation and lost work time associated with precervical cancer
and invasive cervical cancer by stage and country ___________________________ 273
Appendix J. Vaccination cost per vaccinated girl and components of cost, expressed in
different currencies by country ___________________________________________ 276
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TABLES AND FIGURES
Table 1. Treatment costs associated with precancerous lesions and cervical cancer
(International dollars, 2005) _____________________________________________ 150
Table 2. Direct nonmedical costs of precancerous lesions and cervical cancer
(International dollars, 2005) _____________________________________________ 151
Table 3.
2005)
Cancer treatment cost estimates and model inputs (International dollars,
152
Table 4.
Adolescent HPV 16 and 18 vaccination: health outcomes _____________ 153
Figure 1. Impact of HPV 16 and 18 vaccination on deaths averted for multiple birth
cohorts for six Latin American countries (Argentina, Brazil, Chile, Colombia, Mexico, and
Peru) ______________________________________________________________ 154
Table 5. Adolescent HPV 16 and 18 vaccination: CEA with assumption of lower-bound
cancer costs and vaccine cost of I$25 (~I$5 per dose)* _______________________ 155
Table 6. Adolescent HPV 16 and 18 vaccination: CEA with assumption of upper-bound
cancer costs and vaccine cost of I$25 (~I$5 per dose)* _______________________ 155
cancer costs and vaccine cost of I$50 (~I$12 per dose)* ______________________ 155
Table 10. Adolescent HPV 16 and 18 vaccination: CEA with assumption of upperbound cancer costs and vaccine cost of I$75 (~I$20 per dose)* _________________ 157
Table 11. Affordability and budget implications of HPV 16 and 18 vaccination based on
varying costs per vaccinated girl for 70% coverage of five birth cohorts ___________ 158
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ABBREVIATIONS
CDC
Centers for Disease Control and Prevention
CEA
Cost-Effectiveness Analysis
CIN
Cervical intraepithelial neoplasia
CI5C
Cancer Incidence in Five Continents
DALY
Disability-Adjusted Life Year
GDP
Growth Domestic Product
GLOBOCAN
Global Burden of Cancer
IRAC
International Agency for Research on Cancer
HPV
Human Papillomavirus
HPV DNA
Human Papillomavirus Deoxyribonucleic Acid (Screening Test)
ICER
Incremental Cost-Effectiveness Ratio
I$
International Dollar
LAC
Latin America and the Caribbean
LEEP
Loop Electrosurgical Excision Procedure
MeSH
Medical Subject Headings
PAHO
Pan American Health Organization
PPP
Purchasing Power Parity
QALY
Quality-Adjusted Life-Year
SVI
Sabin Vaccine Institute
VIA
Visual Inspection using Acetic Acid (Screening
Method)
VILI
Visual Inspection using Lugol’s Iodine (Screening
Method)
WHO
World Health Organization
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YLD
Years Lived with Disability
YLL
Years of Life Lost
YLS
Years of Life Saved
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EXECUTIVE SUMMARY
Background and Aim
Human Papillomavirus (HPV) is a virus associated with cervical cancer and other malignancies.
Although high-risk HPV types 16 and 18 are two of the most common cancer-causing HPV types,
responsible for more than 70% of invasive cervical cancer, variation exists both in the age-related
prevalence of HPV and in the proportions of HPV 16 and 18 associated with cancer. Recently,
vaccines against HPV types 16 and 18 have created opportunities for primary prevention in areas
where organized secondary prevention with screening has been difficult.
The aim of this document is to provide estimates of the health and economic outcomes of HPV
vaccination in selected countries in Latin America. The findings will be used to inform national
health authorities about the burden of HPV and the economic value of implementing an HPV
vaccination program in selected countries of the region.
This document is the second of a two-part report; the first part is a meta-analysis of the burden of
HPV in Latin America and the Caribbean; this second part is a cost-effectiveness study of HPV
vaccination. This document complements the meta-analysis (described elsewhere) and provides
specific economic information for six selected countries in Latin America. Although some of the
epidemiologic estimates from the two documents may differ because of differences in methods,
the reports should be viewed as complementary in aiding understanding of HPV infection and its
financial and human cost in Latin American and Caribbean countries.
Methods
We synthesized available data to estimate the cost-effectiveness of vaccination for HPV 16 and
HPV 18 in six selected countries in Latin America (Argentina, Brazil, Chile, Colombia, Mexico,
and Peru). We conducted a comprehensive literature review of epidemiologic data in countries of
the region to gain information about age-specific rates of cervical cancer incidence and mortality
and about distribution of HPV 16 and HPV 18 associated with cervical cancer.
We researched national treatment guidelines to establish treatment practices for precancerous
lesions and cervical cancer in each country. To further determine cervical cancer treatment by
stage and cost of care, we conducted surveys in several countries of the region in person and by
telephone or e-mail. These surveys contained specific questions about screening for
precancerous lesions and about diagnosis and treatment of cervical cancer. In addition, surveys
were conducted from which we derived assumptions about the costs required to vaccinate
preadolescent girls against HPV.
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To conduct the cost-effectiveness projections, we used an Excel-based model developed as a
companion model to a previously validated microsimulation model of HPV infection and cervical
cancer. The Excel-based model relies on simplified assumptions to explore the costs and benefits
of vaccination and is less data intensive than a comprehensive microsimulation model; as such, it
is an appropriate tool if its use is restricted to generating broad qualitative insights into the
potential benefits of vaccination against HPV 16 and HPV 18 for preadolescent girls in the six
selected countries. This model cannot compare screening costs and benefits with those of
vaccination.
To provide contextual insights into the benefits and cost-effectiveness of vaccination compared
with screening and of vaccination combined with screening, we also show results from previously
published models developed by Goldie et al. for selected countries for which adequate
epidemiologic data were available to conduct empirical calibration. These previously published
models evaluate the cost-effectiveness of prevention strategies that include both vaccination and
screening.
Model outcomes include the following measures: reduction in lifetime risk for cervical cancer,
number of averted cervical cancer cases and deaths from cervical cancer, number of years of life
saved (YLS), number of averted disability-adjusted life years (DALYs), and lifetime costs.
Although not age-weighted, DALYs reflect the disability weight and duration estimates for cervical
cancer as provided in the Global Burden of Disease study conducted by the World Health
Organization (WHO) [119].
This report describes the performance of vaccination strategies by using incremental costeffectiveness ratios, which are defined as the additional cost of a specific strategy, divided by its
additional benefit (life expectancy gain per woman). Each cost-effectiveness ratio is compared
with that of the next most costly strategy. Results are presented in International dollars (I$, 2005)
for broad comparison across countries, and financial costs are also expressed in local currency
and U.S. dollars for use by local and regional decision makers. We followed recommendations
from several published sources for economic evaluations and adopted a modified societal
perspective and discounted future costs and life years by 3% annually.
To enable country-specific payors to differentiate cost-effectiveness results (i.e., information on
value for money from a long-term perspective) and affordability (i.e., information on financial costs
and budget limitations over a short time), we provide crude estimates of the financial costs of
vaccination.
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Findings
HPV is a relatively common infection affecting an estimated 20 million people in the United States
and causing annually nearly half a million cases of cervical cancer worldwide. Cervical caner is
caused by certain types of HPV, mainly types 16 and 18. According to the World Health
Organization, cervical cancer accounts for more than 2.5 million years of life lost (YLL) each year.
Based on available data for six countries, the total direct medical cost per case for screening
ranged from I$10 to I$81 per woman and from I$534 to I$1,402 per woman for treatment of
precancerous lesions. Highest screening costs occurred in Argentina, and highest treatment
costs occurred in Brazil. These costs were mainly attributed to the cost of specialist consultation
(in the case of screening) and hospital stay (in the case of treating precancerous lesions). The
cost of cervical cancer treatment was much higher than precancerous lesion treatment and
ranged from I$3,745 (Peru) to I$14,438 (Argentina) per woman, with highest costs for more
advanced stages of cervical cancer. The majority of this treatment cost was attributed to the costs
of hospital stay and palliative care.
Using an Excel-based model to evaluate the clinical benefits of vaccination in the six selected
countries of the region and assuming 70% vaccination coverage by 12 years of age, lifelong
immunity, and 100% efficacy against HPV types 16 and 18, we found that HPV vaccination
reduced cancer incidence by approximately 40% in Mexico and Chile, and by more than 50% in
Argentina. With vaccination, almost 45,000 cancer deaths and 74,000 cervical cancer cases
could be averted over the lifetime of a single birth cohort, compared to outcomes with no
intervention. Most averted cases and deaths would appear in Brazil, where cervical cancer is
more common than in other countries of the region. When 10 birth cohorts are considered,
assuming 70% coverage, we would expect to prevent nearly half a million deaths over the lifetime
of the vaccinated girls in the region.
If cancer costs were reduced and cost per vaccinated girl were I$100, the Excel model’s
assessment of the cost-effectiveness ratio for preadolescent vaccination, compared with no
intervention (no screening or vaccination), shows that the cost per saved life-year from a societal
perspective would range from I$670 (Chile) to I$1,500 (Mexico). At lower costs of I$75 per
vaccinated girl (I$20 per dose), I$50 per vaccinated girl (I$12 per dose), and I$25 per vaccinated
girl (I$5 per dose), the cost per saved year of life would range from I$420 (Chile) to I$1,040
(Mexico), I$180 (Chile) to I$580 (Mexico), and I$10 (Brazil) to I$160 (Peru), respectively. At I$25
per vaccinated girl (I$5 per dose), vaccination was cost saving in Chile and Argentina. Because
these results were generated for vaccination only, the incremental ratios appear more attractive
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than they would if the baseline for comparison was screening. For example, previously published
independent models that include screening as well as vaccination show that as the cost per
vaccinated girl approximates I$100, vaccination plus screening (at ages 35, 40, and 45) is more
effective than vaccination alone, although the incremental cost-effectiveness ratio increases (i.e.,
becomes less attractive) with higher vaccine costs. For example, in Mexico, a combined
vaccination and screening strategy at I$75, I$100, and I$360 per vaccinated girl (using 2-visit
HPV DNA testing) results in costs of I$1,530, I$1,780, and I$7,070 per YLS, respectively,
compared with cost-effectiveness ratios of the next best strategy.
According to published data, at the vaccine price of I$360 per girl (the approximate current 2008
U.S. vaccine price) screening, with or without vaccination, used as the main cervical cancer
prevention option in countries able to provide screening, was generally more cost-effective than
vaccination alone. As the cost per vaccinated girl declines, however, preadolescent vaccination
followed by screening three times per lifetime may be the most effective option in countries able
to provide both. In the poorest countries in this region, vaccination alone, if available for a
markedly reduced price and if widespread coverage of young girls is achievable, may be the most
feasible option to reduce cervical cancer.
Although vaccination appears to be cost-effective according to the criterion of the incremental
cost-effectiveness ratio being less than the per capita Gross Domestic Product (GDP) of a
specific country, vaccination may not be affordable. Even an intervention that provides good
value for invested resources may have prohibitive financial requirements that cannot be met by
the health care systems of countries studied. For those six countries, the financial costs would be
$270 million (present value discounted 3% annually) to vaccinate five birth cohorts at 70%
coverage with a cost per vaccinated girl of I$25. At a cost of I$50 per vaccinated girl, the financial
costs of vaccinating just five birth cohorts at 70% coverage would be nearly $600 million; at a cost
of I$360 per vaccinated girl, the cost would be more than $4 billion. These estimates of costs for
broad coverage show the important difference between cost-effectiveness and affordability.
Limitations of this analysis include gaps in our understanding of the natural history of HPV,
uncertainties about the epidemiology and temporal trends of cervical cancer in many countries,
lack of high-quality data on screening, costs associated with HPV-related diseases, and access to
and costs of cervical cancer treatment for many countries. Data are lacking on the cost of
initiating, enhancing, and maintaining a new adolescent vaccination program and on the longterm efficacy of the vaccine (i.e., whether it will provide life-long immunity). For countries with
ongoing screening, the cost-effectiveness of vaccination strategies, either alone or combined with
screening, is heavily dependent on assumptions about the quality, coverage, effectiveness, and
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costs of screening. Collecting these data will be critical for facilitating evidence-based vaccine
decisions.
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CHAPTER 1 INTRODUCTION
1.1
Background
According to the Centers for Disease Control and Prevention (CDC), approximately 20 million
people are currently infected with Human Papillomavirus (HPV) [105]. HPV is a virus that causes
genital warts and has been associated with cervical cancer and other malignancies. Cervical
cancer is the second most frequent malignant neoplasia affecting women worldwide, accounting
for approximately 10% of overall cancer incidence among women [106]. Cervical cancer is also
the primary cause of cancer-related deaths among women. In 2000, 470,606 cases and 233,372
deaths associated with cervical cancer were reported [2,107–109]. The majority (80%) of this
burden arises in less developed countries, where cervical cancer is the leading malignancy in
women [107,108,110]. Recent estimates from the World Health Organization (WHO) suggest that
in the Latin American and Caribbean region, cervical cancer accounts for 2.5 million years of life
lost (YLL) [2], 72,000 cases, and 38,000 deaths. The estimated age-adjusted incidence rates for
cervical cancer are 32.6 per 100,000 women in the Caribbean, 30.6 per 100,000 women in
Central America, and 28.6 per 100,000 women in South America [2].
Cervical cancer is fully preventable when early detection and screening programs are available.
However, despite these programs’ effectiveness and low cost, they have proven to be relatively
unsuccessful in Latin America and the Caribbean (LAC). This lack of success is due in part to the
apparent absence of well-organized screening programs, which are difficult to implement in lowresource settings [111]. Another reason these programs are unsuccessful is because women with
abnormal cytology results are not always tracked [111]. In Mexico, fewer than 13 percent of
potentially preventable cases have been averted despite having a screening program in place for
more than 20 years. Costa Rica is another country where screening programs have met with
limited success. Only a small number of prevented cases have been reported since national
screening programs were established forty years ago.
The potential benefits of HPV vaccination are considerable. Currently, two vaccines are available
that are designed to protect against the two most aggressive types of HPV. The first vaccine,
Gardasil® (quadrivalent) (Merck & Co., Inc., Whitehouse Station, New Jersey, USA), was
approved by the U.S. Food and Drug Administration in 2006. The second vaccine, Cervarix®
(bivalent) (GlaxoSmithKline [GSK] Biologicals, Inc., Rixensart, Belgium), was approved in
Australia by the Therapeutic Goods Administration of Australia in 2007. Persons most likely to
benefit from these vaccines are young girls and preadolescents (starting at age 9) who have not
yet become sexually active.
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However, even if women are vaccinated with these recently approved vaccines, they will still
need a regular Papanicolaou (Pap) smear and, depending on their age, an HPV DNA test
because HPV vaccines do not reduce the risk for cervical cancer completely. Approximately 15
types of the HPV virus can cause cervical cancer. Gardasil® and Cervarix® are designed to
protect against two HPV types that are responsible for 70% of all cervical cancers [112].
Gardasil® also protects against HPV types 6 and 11, which cause genital warts. Researchers in a
2006 study published in the online edition of Lancet found that Cervarix® also prevented
infection with HPV strains 31 and 45, which, together with strains 16 and 18, cause more than
80% of cervical cancer cases [9]. Recently GSK announced that it would begin a trial to
determine whether Cervarix® provides better protection against cervical cancer than Gardasil®
[113].
1.2
Study aims
The aims of this report are to briefly review the economic evidence for cervical cancer screening
and HPV vaccination, to provide an estimate of the cost of cervical cancer screening and
treatment in six selected countries of the LAC region (Argentina, Brazil, Chile, Colombia, Mexico,
and Peru), and to estimate the health and economic outcomes of HPV vaccination. This study is
the second part of a two-part report available to policy makers for evaluating the feasibility of
implementing an HPV vaccination program in these countries. The first part of the report focuses
on a meta-analysis of the burden of HPV in Latin America and the Caribbean. Available data, not
necessarily derived only from the meta-analysis, were used to develop projections of the costeffectiveness of HPV vaccination; hence, differences may be observed in number of cases and
deaths in the two parts of the report.
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CHAPTER 2 METHODS
This section begins with a description of the economic literature review, including the search
strategy. The literature review description is followed by a brief discussion of the methods and
model framework, perspective and scope of the analysis, model inputs, and sensitivity analyses.
2.1
Economic literature review
We conducted an economic literature review simultaneously with the systematic review of
epidemiologic studies described in the first part of this report. References with relevant economic
data were included to provide a critical overview of the economic issues related to HPV and to
assess the implications for prevention strategies (e.g., screening and vaccination). We identified
relevant studies, including general economics papers, studies on the burden or cost of illness,
economic evaluations, and official reports from countries in the region. Most of these papers were
published in English or Spanish from 2003 through 2007. Much of the published literature and
some of the completed study reports in the public domain were obtained from the PubMedMEDLINE, Bireme-MEDLINE, Bireme-LILACS, SciELO, and the COCHRANE library databases.
Manual bibliographic searches revealed additional articles.
Articles that were not true economic evaluations (e.g., reviews of applied studies, commentaries,
or editorials without original data) were excluded, as were some articles that substantially
replicated results from other articles. Due to the limited range of published studies originating in
LAC, studies from North America and Europe were included. We also considered studies
containing only abstracts as well as work in the process of being published.
The medical subject heading (MeSH) terms used to survey the literature on the cost of HPV
included “costs”, “cost analysis”, “cost of illness”, “cost-benefit analysis”. MeSH terms used to
survey the literature on the economics of vaccines included “costs”, “cost analysis”, “cost of
illness”, “hospital costs”, “cost control”, “cost-effectiveness analysis”, “cost-benefit analysis”, “cost
savings”, “delivery of health care”, “drug costs”, “economic value of life”, “healthcare costs”, “HPV
and vaccination”.
Based on predefined inclusion and exclusion criteria, we abstracted full-text peer-reviewed
studies for the final economic analysis. We reviewed the selected studies for country of
evaluation, publication year, vaccine strategies assessed, study design, method of evaluation,
cost measures, perspective, and period of analysis used. We report results are as they were
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presented in the literature. That is, no adjustments of expenditures or savings to present value
were made.
2.2
2.2.1
Cost-effectiveness analysis
Analytic overview
We synthesized the available data to estimate the incremental cost-effectiveness ratios (ICERs)
of HPV vaccination for six countries in Latin America (Argentina, Brazil, Chile, Colombia, Mexico,
and Peru). These countries were selected because of their available epidemiologic and economic
data and their willingness and ability to participate. Each country’s economic, social, and political
climates were also considered, although these factors did not necessarily affect inclusion.
The models we used integrated health burden estimates and economic burden estimates
generated by this study to develop country-level estimates of the value for money represented by
the investment in and use of the existing HPV vaccines (Gardasil® and Cervarix®). These
vaccines are the only ones that may help guard against diseases caused by HPV types 16 and
18, which together cause 70% of cervical cancer cases [3]. Both are given as three injections
over six months. Gardasil® is recommended for use in girls and young women 9–26 years of
age, and Cervarix® is recommended for use in girls and young women 10-25 years of age.
We conducted a comprehensive literature review of epidemiologic data in countries in the region
to gather information about age-specific cervical cancer incidence rates and the distribution of
HPV 16 and HPV 18 in cervical cancer cases [11].
We describe the performance of vaccination strategies by using incremental cost-effectiveness
ratios, defined as the additional cost of a specific strategy, divided by its additional benefit (per life
expectancy gain per woman), compared with the next most costly strategy. Results are presented
in international dollars (2005) for purposes of broad comparison across countries, and financial
costs are also expressed in local currency and U.S. dollars to assist local and regional decision
makers. All future costs and health benefits were discounted at an annual rate of 3% [114].
To provide information that enables country-specific payors to differentiate cost-effectiveness
results (i.e., information on value for money from a long-term perspective) and affordability (i.e.,
information on financial costs and budget limitations over a short time horizon), we provide crude
estimates of the financial costs of vaccination.
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As an approximate benchmark and for comparison purposes only, we used the per capita Gross
Domestic Product (GDP) as a threshold and assumed that vaccination strategies costing less
than a country’s per capita GDP might be cost-effective.
2.2.2
Overview of models
To conduct the cost-effectiveness projections, we used an Excel-based model developed as a
companion model to a previously validated microsimulation model of HPV infection and cervical
cancer [115]. The Excel-based model relies on simplified assumptions identified as reasonable by
comparing results of this model’s projected benefits and cost-effectiveness to those generated by
the more complex microsimulation model. An exercise to demonstrate the validity of comparing
simplified assumptions appears in Appendix A and has been published [11]. The Excel-based
model may be used to explore the costs and benefits of vaccination and is less data intensive
than the comprehensive microsimulation model; as such, the Excel-based model is an
appropriate tool provided its use is restricted to generating broad qualitative insights into the
potential benefits of vaccinating preadolescent girls against HPV 16 and HPV 18. The Excelbased model follows cohorts from birth to death (100 years). The microsimulation model is
described elsewhere [115].
Model outcomes include reductions in the lifetime risk for cervical cancer, the number of averted
deaths from cervical cancer, and lifetime costs. Outcomes also include increases in number of
averted cases of cervical cancer, years of life saved (YLS), and disability-adjusted life years
(DALYs) averted. DALYs reflect the disability weight and duration estimates for cervical cancer as
provided in WHO’s Global Burden of Disease study [121], although the DALYs are not age
weighted.
After integrating the epidemiologic data, we assumed the following: (1) the overall mean duration
of time between development of invasive cancer and death is 6 years but may vary from 2 to 10
years; (2) distribution of cervical cancer by stage in an unscreened population is 30% local, 40%
regional, and 30% distant, although stage distribution varied in sensitivity analyses; (3) ratio of
mortality to incidence varies by country, with the poorest countries (e.g., Haiti) having mortality to
incidence ratios of 80% (range, 60%–90%) and other countries having ratios of about 60%
(range, 40%–80%); and (4) cancer incidence has not appreciably changed with low levels of
effective cervical cytology screening. Because our goal is to identify the avertable burden and
potential cost-effectiveness of vaccination against HPV 16 and 18 and because the model did not
include screening, we do not examine strategies that include both vaccination and screening. For
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practical reasons, we assumed that scaling up cervical cytology to a high coverage level and a
high-quality screening program are not realistic options.
We also assumed the following about the performance of the HPV 16 + 18 vaccine: (1) the
vaccine effectively prevents HPV 16 and 18 in girls without previous infection and provides longlasting protection against HPV 16 and 18; (2) the vaccine, even at high coverage rates, does not
alter the risk of cervical cancer associated with HPV types other than 16 and 18; and (3)
successful coverage is defined as completion of a three-dose course by a girl. We assumed 70%
population coverage, although we varied coverage from 0% to 90%.
Results are presented for a strategy for 2007 of 70% vaccination of a single birth cohort of
preadolescent girls (i.e., 12 years old), using a 100% effective vaccine at a cost ranging from I$25
to I$360 per vaccinated girl.
To provide insights into the benefits and cost-effectiveness of vaccination relative to screening
and of vaccination combined with screening, we summarized selected results from previously
published models developed by Goldie et al. for a few countries with adequate epidemiologic data
to conduct empirical calibration. These previously published models evaluated the costeffectiveness of strategies that included both vaccination and screening [11].
2.2.3
Perspective and scope of the analysis
We performed the analysis from a modified societal perspective, which considered all direct
medical and nonmedical costs borne by governments and families (costs for cancer treatment
included women’s time and transportation costs). We also considered the health care system in
the base case analysis and included costs borne by medical facilities, providers of health care,
and other facilities and providers of vaccine-related services.
2.2.4
Model inputs
Health outcomes
The primary outcome measures considered for both models were the total health-care and nonhealth-care costs of cervical cancer and the disease burden and societal costs averted by
vaccination. Number of cases of cervical cancer, number of deaths from cervical cancer, YLSs,
disability-adjusted life years (DALYs) averted, and lifetime costs (in 2005 international dollars)
were also calculated.
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ICERs compare the difference in cost with and without HPV vaccination over the difference in
health outcome with and without HPV vaccination. For the cost-effectiveness analyses, medical
costs averted by vaccination were subtracted from costs invested in vaccination and then divided
by the health outcome. An example of the relationship between cost and health outcome is
described by the following ICER:
ICER = Vaccine related costs – averted disease costs
DALYs averted by vaccination
Epidemiologic data
For our companion Excel-based model, which is intended to provide broad qualitative insight into
the potential benefits of HPV 16 + 18 vaccination, we used cervical cancer incidence rates and
prevalence of HPV 16 and 18 among women with cervical cancer. Cervical cancer incidence
rates were drawn from GLOBOCAN 2002 (the WHO database containing estimates of incidence
and mortality for the year 2002) [119] or from cancer registry data available in Cancer Incidence
in Five Continents (CI5C) [110]. CI5C incidence data cover entire national populations or samples
of these populations from selected regions.
We applied data hierarchically according to quality, with the best data considered to be those
from CI5C followed by data from GLOBOCAN 2002 (see Appendix B for rates). We used a meta1
analysis to estimate the proportion of HPV 16 and HPV 18 in cervical cancer cases [116]. For
those countries with specific information in the meta-analysis, we used the provided estimate or
the pool of estimates for the country if more than one citation was included. For those countries
without specific information, we devised a regional pool. Smith et al. include both single- and
multiple-type HPV infections [116]; women with multiple HPV types are counted more than once,
so the overall prevalence of HPV types totals more than 100%. Specifically, women with both
HPV 16 and 18 are counted twice; therefore, the HPV 16 and 18 distribution is inflated. To avoid
that overestimate, we used a hierarchical classification in which multiple types are assigned
according to the most common type, and women are counted only once. For example, a woman
with both HPV types 16 and 18 is classified as HPV 16. This classification implies that the
prevalence of HPV 16 remains the same, but the prevalence of HPV 18 decreases, thus altering
the HPV16/18 distribution. The prevalence of HPV 18 was corrected for cervical cancer cases
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with multiple types 16 and 18 when this information was reported (provided by the International
Agency for Research on Cancer). The final prevalence of HPV 18 that we report is the prevalence
presented in the Smith et al. meta-analysis less the prevalence of women with both types. For
those studies with multiple types but no specific information, we used a 3.3% correction (i.e.,
overall average of prevalences from articles with available information on multiple types 16 and
18). Because cancer prevalence is thought to be underestimated in some of these data sources,
we conducted sensitivity analyses to explore the implications of underreporting and
underestimation.
The model relies on detailed population data by age for each country. Demographic estimates for
age-group–specific population size and age-group–specific life expectancy were drawn from
United Nations World Population Prospects 2004 data [117] and from 2004 WHO life tables [118].
We assumed that the average age at initiation of sexual activity and the levels of other risk factors
remained constant over the time horizon.
DALYs
In addition to estimating numbers of cases and deaths, we expressed the disease burden in
DALYs, which provide a standardized measure of disease burden that allows for cross-disease
comparisons of burden [119]. DALY estimate includes two components: YLL due to premature
mortality and years lived with disability (YLD). Calculations of YLL were based on country-specific
mean life expectancies for girls 9 and 12 years of age (Excel model) [118]. For the calculation of
YLD, we considered morbidity only from disease severe enough to require medical care. We
calculated YLD by using default disability weights from WHO’s Global Burden of Disease study
[119] and WHO’s guidelines for cost-effectiveness studies [120]. The calculated DALYs reflect the
disability weight and duration estimates for cervical cancer as provided in the Global Burden of
Disease [121]. This calculation is not age weighted and uses an annual discount rate of 3%.
Use of health services for early detection of precancerous lesions and treatment
of cervical cancer
National guidelines for the detection of precervical cancer and treatment of cervical cancer were
available for each of the six selected countries. Most of these guidelines were published by
government-sponsored institutions that focused on early detection and treatment of cervical
1
Estimates of the proportion of HPV 16 and HPV 18 in cervical cancer derived from the Sabin Vaccine Institute metaanalysis were not available at the time of the analysis.
137
2
cancer in each country. We used these guidelines to derive resource-use profiles for each
country. We used the resource-use profiles to learn about treatment practices in each country
and to help identify the level of input of each resource in the treatment of precancerous lesions
and cervical cancer. National guidelines generally included what, in theory, is provided to and for
patients who are at risk for precancerous lesions or who are diagnosed with cervical cancer.
The information in these guidelines was not always complete. To augment this information, we
contacted HPV researchers in nine countries and asked them to respond to a survey. We visited
some of these researchers in Argentina, Brazil, Chile, and Colombia and corresponded with
others by telephone or e-mail. We surveyed health care providers to determine HPV treatment by
stage and cost of care. In addition, we reviewed conference abstracts, and, with the help of the
Pan American Health Organization (PAHO), we contacted national Ministries of Health in nine
countries in the region to identify additional information about cervical cancer treatment.
The survey sent to health researchers contained specific questions about screening for
precancerous lesions and about the diagnosis and treatment of cervical cancer. Most of the
experts interviewed were obstetricians, oncologists, or primary care physicians working in the
public sector, but we also interviewed physicians working in the private sector. Fourteen
physicians responded to the surveys. Appendix C provides a list of all physicians interviewed.
Surveys were originally developed in English and were translated into Spanish and Portuguese to
facilitate physicians’ responses. Appendix D contains an example of the Spanish version of the
survey. The surveys contained two sets of questions: the first set addressed practices used in the
early detection of precancerous lesions; the second set addressed diagnosis and treatment
practices (acute and long-term care) for invasive cervical cancer by stage (i.e., stages IA1, IA2,
IB1, IB2, IIA, IIB, IIIA-IIIB, IVA, and IVB).
Although we were unable to include a comparative screening strategy for the Excel-based model,
we made a substantial effort to identify screening information (e.g., coverage, protocols,
guidelines, and costs) for the following reasons: (1) to provide qualitative comparisons to
vaccination outcomes, (2) to conduct future cost-effectiveness analyses using more complex
models that can accommodate simulation of primary and secondary prevention, and (3) to
2
Resource use profiles included diagnosis for precervical cancer, treatment for precervical cancer, diagnosis and staging
for invasive cervical cancer, treatment of invasive cervical cancer by stage, follow-up treatment by stage, and palliative
care by stage.
138
provide useful information to countries for comparison of financial costs associated with screening
with financial costs required for vaccination. We reviewed studies including both screening and
vaccination. We also summarize selected results from previously published models developed by
Goldie et al. for some countries having adequate epidemiologic data for conducting empirical
calibration. These previously published models evaluated the cost-effectiveness of strategies that
included both vaccination and screening [11].
The information we gathered from the surveys regarding screening strategies was consistent with
the information provided in the national guidelines. For example, in Argentina, women undergo
cervical cytology (with Pap smears) during their first screening visit and return for results in a
second visit. If results are negative, women are screened once every three years. If results are
positive, women are screened every six months for three years. In Brazil, women undergo initial
screening in the first visit; those with positive results undergo colposcopy/biopsy in a second visit,
which is followed by treatment of abnormalities at a tertiary clinical site in a third visit. In Chile,
cervical cytology is performed in the majority of women every six months to rule out falsenegative results.Women with negative screens are screened every three years. In Colombia,
women undergo a Pap smear every three years. Screen-negative women undergo a second Pap
smear a year later to confirm a negative result. If the second Pap smear is negative, a Pap smear
is scheduled every three years after the second negative test. However, if the second Pap smear
is positive, women undergo a Pap smear three times a year. Women in Mexico are offered a
screening protocol similar to Argentina’s. In Peru, women undergo a screening test (90%, Pap
smear; 5%, HPV DNA testing; 3%, visual inspection using acetic acid [VIA]; and 2%, visual
inspection using Lugol’s iodine [VILI]). Those women with positive results undergo a screening
test every six months. The test is repeated again and, if results are negative, a test is scheduled
once every three years thereafter. Appendix E summarizes the screening recommendations and
current practices of studied countries.
Treatment of precancerous lesions depends on the lesions’ size and type and may include
cryosurgery, loop electrosurgical excision procedure (LEEP), cold knife conization, or simple
hysterectomy. According to information from the surveys, precancerous lesions are generally
treated on an outpatient basis. The classification system of cervical intraepithelial neoplasia (CIN)
is used in the studied countries to provide information about the precancerous condition of the
cervix. After initial screening, screen-positive women generally undergo a gynecological exam,
colposcopy, and directed biopsy to determine whether they are suitable for follow-up or same-day
treatment such as cryosurgery or LEEP. Biopsy-confirmed CIN 1 lesions are generally followed
by colposcopy and cytology every six months until the lesion regresses to normal or until
evidence of progression appears. Only a small proportion of women in these countries with CIN 1
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lesions require treatment. In contrast, all biopsy-confirmed CIN 2 and 3 lesions in the studied
countries require treatment because of the potential of these lesions to progress to invasive
cervical cancer.
Women undergoing treatment for CIN 2 and 3 lesions are generally treated as outpatients;
however, certain procedures such as cold knife conization require general or regional anesthesia,
and women undergoing these procedures may need to be admitted to a hospital. Treatment of
complications resulting from procedures such as cold knife conization is also reported in these
countries. Women treated for precancerous lesions in the studied countries generally return for a
follow-up visit two to six weeks after treatment for a gynecological examination and discussion of
results of histopathology (in cases involving LEEP and cold knife conization) and at six and
twelve months for a screening test and coloscopy and directed biopsy (in cases of persistent
lesions). Appendix F summarizes the treatment of precancerous lesions in studied countries.
Staging is required for women who have a histologic diagnosis of cervical cancer. For the studied
countries, the International Federation of Gynecology and Obstetrics staging system is
recommended for staging invasive cervical cancer. This classification system is based on tumor
size and on the extent of spread of disease in the pelvis and distant organs. Like precancerous
lesions, treatment of invasive cervical cancer depends on lesion size and type. The most
common tests and procedures performed for staging and treatment of invasive cervical cancer in
the studied countries included vaginal and rectal examination, abdominal ultrasound, cystoscopy,
proctoscopy, cone biopsy, chest x-ray, computerized tomography scan of abdomen and pelvis,
magnetic resonance imaging of pelvis, and blood tests. Appendix G describes methods used for
cervical cancer staging in the studied countries.
Once the extent of the cancer’s growth is assessed, several treatment modalities can be
performed, including surgery, radiotherapy, and chemotherapy. For the studied countries, the
most commonly reported surgical procedures include simple abdominal hysterectomy for
treatment of stage IA1 and radical hysterectomy or pelvic lymphadenectomy or both for treatment
of stages IA2 to IIA. Length of stay in the hospital for a surgical procedure varies by country but
averages seven to ten days. Surgical procedures are generally performed in a tertiary-level
hospital and require about two to three hours. Most of these procedures were performed to effect
a cure, but most countries (Brazil, Chile, Colombia, Mexico, and Peru) reported palliative surgery
to relieve symptoms, particularly at advanced stages of cervical cancer.
Radiotherapy (teletherapy, brachytherapy) was commonly reported for treatment of stages IB1
through IVB. However, in countries like Brazil, Chile, and Colombia, use of radiotherapy was
140
reported for treatment as early as stages IA1 and IA2. For treatment of stages IA1 through IIA,
radiotherapy was sometimes used concurrently with surgery. For bulkier tumors and for women
with extensive lymph node involvement, radiotherapy was used as the sole treatment.
Teletherapy was generally used in addition to brachytherapy. Radiotherapy sessions were
generally given five days a week for about five weeks in a tertiary-level hospital. Women
receiving radiotherapy were either admitted to a hospital or were treated as outpatients. For
women admitted to a hospital for radiotherapy, the length of stay varied between two and three
days, depending on the dose rate. For all studied countries, palliative therapy was commonly
reported to relieve symptoms.
A third treatment modality for invasive cervical cancer is chemotherapy. The most commonly
used drug in the studied countries was cisplatin. Chemotherapy was generally given for the
treatment of bulkier tumors; however, in Brazil, Chile, and Colombia, chemotherapy was reported
as being used in early stages of cervical cancer, specifically stage IA2 (Brazil) and stage IB2
(Chile and Colombia). Cisplatin is generally given concurrently with surgery or radiation or both.
Five to six cycles of chemotherapy were generally administered to
women who undergo
chemotehrapy.
Women treated with surgery or radiotherapy generally return for follow-up visits every three
months for the first two years. Several tests are performed during these follow-up visits, including
vaginal and rectal examination and Pap smears. Appendix G provides a summary of the
treatment modalities of invasive cervical cancer by stage and country.
Costs associated with precancerous lesions and cervical cancer treatment
Low estimates for treatment costs were determined by using methods of indirect estimation
previously used by others in the absence of primary data [115,122]. We compared these
estimates to the data we collected in our study sites: Argentina, Brazil, Chile, Colombia, Mexico,
and Peru. The costs for cervical cancer treatment represent an average treatment cost per case
and are assumed to be realized at around median survival time after cancer onset. Every
detected cancer case is assumed to incur cancer treatment costs. The base case value was
estimated by using data collected separately. Because we accepted the favorable assumption
that women with detected cancer have access to care in the latter estimation procedure, we refer
to the treatment cost of all detected cases as the upper treatment cost estimate, and we vary it
widely in sensitivity analyses. Methods of collecting cost data and of conducting surveys to
assess clinical practice assumptions are documented below.
141
Costs are presented in 2005 international dollars, a currency that provides a means of translating
and comparing costs among countries, taking into account differences in purchasing power.
Costs are also presented in local currency and in U.S. dollars for local and regional decision
makers. For the latter, we needed to distinguish tradable from nontradable goods. Vaccine,
wastage, and freight are considered tradable goods. Whether expressed in local currency units or
in U.S. dollars, they are converted by using exchange rates of the U.S. dollar to local currency
units. Administration and vaccine support are considered local nontradable goods. To express
nontradable goods in local currency units, we converted them from international dollars by using
purchasing power parity (PPP) exchange rates. When expressing administration and vaccine
support in U.S. dollars, the local currency units are converted by using U.S. dollar exchange
rates.
Health care costs
Cost-generating events were estimated based on two main sources: country-specific
management guidelines and expert surveys. The unit cost for detection of precancerous lesions
and treatment of invasive cervical cancer was based on estimates provided by the finance
departments of local hospitals and national administrative data in each studied country. Unit cost
estimates associated with the detection and treatment of precancerous lesions and the treatment
of cervical cancer by stage and by country are summarized in Appendix H.
The cost per stay as an inpatient was calculated by multiplying the per diem rate by length of stay
and adding the cost of diagnostics and medications. The per diem rate includes the
accommodation and administration costs (i.e., costs of the bed, building, utilities, maintenance,
administration, and equipment), food, and personnel. Mean hospital lengths of stay were derived
from combined physician surveys and varied by stage: 1.17 and 2.67 days for precancerous
lesions CIN1 and CIN2, respectively; 2.50 days for stage IA1; 3.30 days for stages IA2 and IB1;
5.17 days for stage IB2; 4.17 days for stage IIA; 3.67 days for stage IIB; 2.00 days for stages
IIIA–IIIB; 1.83 days for stage IVA; and 2.83 days for stage IVB.
The cost per outpatient visit was based on the cost of visiting a general practitioner, a nurse, or a
specialist (obstetrician or oncologist). According to physicians surveyed, 50% of women with
precancerous lesions have an average of one to two outpatient visits with a general practitioner,
66% are seen by the nurse once or twice, and 78% are seen once or twice by the obstetrician or
oncologist. An estimated 79% of women with invasive cervical cancer are seen in the outpatient
setting. The majority (99%) of this outpatient care is for staging of cervical cancer, 56% is for
treatment, and 100% is for follow-up and palliative care. An average of 2.67, 4.26, 4.50, 12.67,
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6.50, 7, 17.67, 20.17, 21.17, and 22.00 outpatient visits were reported for cervical cancer
screening, stage CIN1, stage CIN2, stage IA1, stage IA2, stage IB1, stage IB2, stage IIA, stage
IIB, and stages IIIA–IV, respectively. The majority of these outpatient visits were for palliative care
treatment. Unit cost estimates for outpatient visits were based on the average provided by the
finance departments of public institutions and administrative sources.
The total screening and diagnostic cost per woman was calculated by first multiplying the number
of each test used by the frequency of its use, multiplying that number by each test’s unit cost, and
then summing the total cost for all tests administered to each woman. Unit cost estimates for
screening and diagnostic tests were based on the average given by the finance departments of
public institutions and administrative sources described previously.
Costs associated with surgery were based on data from finance departments of hospitals and
national administrative data. The total average cost of surgery was calculated by multiplying the
cost per surgery performed by the proportion of cervical cancer patients who had the surgery and
the frequency with which the surgery was performed; this total was then summed to calculate the
total cost for all the surgeries performed per woman. The costs associated with radiotherapy and
chemotherapy were calculated in a similar manner.
Costs associated with medications were based on national formularies and prices quoted by the
finance departments of hospitals and local pharmacies. The total medication cost per patient was
calculated by multiplying the cost per dose of each medication used by the number of doses
administered and then summing the total cost for all the medications administered to a single
patient.
Societal costs
In addition to health care costs, transportation costs to health care facilities were also included in
the cost calculations. For the base case analysis, these costs were based on assumptions made
about the number of trips to and from the doctor’s office and/or the hospital and the cost of each
trip. The number of trips to and from the doctor’s office and/or hospital was based on the number
of outpatient visits and hospital admissions reported by physicians in the studied countries. The
cost of each trip was derived directly from the National Association of Transport Services of each
country [123,124].
Indirect costs associated with lost time from paid work were also calculated for women. For the
base case analysis, these costs were calculated by using 1) the number of days off work (one
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outpatient consultation or one day in the hospital was assumed to be the same as one day off
work); 2) an average 2005 minimum monthly salary in Argentina, Brazil, Chile, Colombia, Mexico
and Peru of I$765.6 [125,126], I$337.5 [127], I$1,856.8 [128], I$308 (Personal communication,
Nelson Alvis, September 2007), I$1,636.8 [126], and I$728.19 [126], respectively; and 3) an
assumption of 22 days of work per month. Appendix I summarizes the average direct nonmedical
and indirect costs of precancerous lesions and cervical cancer by stage and country.
Vaccination costs
Vaccination costs include several components: (1) the cost (or price) of three doses; (2) costs
associated with vaccine wastage, freight into the country, supplies and administration; (3)
programmatic costs (i.e., vaccine support costs) associated with immunization support, such as
training, social mobilization, transportation within the country, monitoring and surveillance, cold
chain equipment and maintenance, waste management, and injection safety. Because the price
for the HPV vaccine for different countries is not established and the associated vaccination
programmatic and support costs are uncertain, we varied a hypothetical cost per vaccinated girl
from I$10 to I$360.
Similar to other studies, we assumed for each composite cost a distribution of component costs.
For example, at I$25 per vaccinated girl, we assumed three doses of vaccine at I$5 each,
wastage of I$2.25, freight and supplies of I$1.31, administration of I$1.50, immunization support
costs of I$2.94, and incremental costs of a new adolescent program of I$2. For comparison, we
also conducted an analysis that assumes that the price of the vaccine is similar to the U.S. price.
Appendix J shows an example conversion of a cost of I$25 per vaccinated girl into countryspecific currencies.
Vaccine efficacy and coverage
Clinical trials of HPV vaccine have been conducted in Latin America, North America, Europe, and
Asia; hence, we used estimates of the effectiveness of the bivalent HPV vaccine conducted in
North America (Canada and the United States) and Brazil because these trials were considered
to be most applicable to the population being considered. Vaccine efficacy estimates against HPV
16 and 18 were assumed to be 100%[129,130]. Vaccination coverage was assumed to be 70%,
and dose completion rates were assumed to be 100%.
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2.2.5
Sensitivity analysis
The models described above require country-specific data concerning the epidemiology of the
disease, the economic costs associated with different outcomes, and vaccine efficacy. Although
some of these data are available, the quality and representativeness are severely limited in some
instances. These data limitations create uncertainties regarding final estimates of economic
burden and cost-effectiveness, but these preliminary results will hopefully begin a dialogue about
the relative cost-effectiveness of vaccination. We conducted sensitivity analyses around many of
the most notable uncertainties to identify those assumptions and parameters that are most
influential for results.
RESULTS
Results are presented in three sections. Section 3.1 summarizes the economic papers reviewed.
Section 3.2 presents the results of the cost analyses by country. Section 3.3 presents the results
of the cost-effectiveness analyses by country.
2.3
Description of economic papers reviewed
A recent chapter [11] provides an in-depth view of the economics of HPV 16 and 18 vaccination
in LAC countries. We will focus our attention here on citing some of the more salient points of
recent publications that address modeling the impact of HPV vaccines and cervical cancer
screening strategies in developed and developing countries. This information serves as an
introduction to the recent publication.
Various modeling studies have explored the potential benefits of cervical cancer screening and/or
HPV vaccination of preadolescent girls at the population level [115,131–137]. Most of these
studies are based on state-transition disease models that focus on cervical cancer screening
options in high-income countries. Issues addressed in these studies include (a) choice of
screening interval, (b) age for starting and stopping screening, (c) enhancements to conventional
cytology, and (d) integration of HPV DNA testing into cytology-based screening programs as a
primary screening test or as a triage for equivocal cytology results for women older than 30 years
of age [132].
Despite differences in model structures and assumptions, these studies indicate several general
conclusions, which have been highlighted by Goldie and colleagues in a 2006 paper [133]. One
conclusion is that the cost-effectiveness of screening in the general population becomes less
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favorable when screening is performed more frequently than every 2–3 years. According to
Goldie et al., this decrease in feasibility of screening is due to the almost linear increase in
screening costs when screening tests are performed frequently; simultaneously, incremental
gains in benefits rapidly diminish with increased cost [133].
In addition, screening at a very young age is not considered beneficial and could even be harmful
when unnecessary procedures such as colposcopy are performed among younger populations. A
policy of starting screening at 20–25 years of age and stopping at around 60–65 years of age is
considered by most experts to be acceptable as benefits of screening decline rapidly after age 65
due to the natural history of the disease [138]. Experts note, however, that screening older
women who have not previously been screened may be cost-effective because of the high risk of
disease in older, unscreened populations [133].
Another notable trend is the small incremental benefit of using screening tests that have higher
sensitivity than conventional Pap smears (e.g., primary screening with HPV DNA testing among
older women). According to experts, using screening tests with higher sensitivity results in little
incremental benefit and is generally associated with high ICERs due to increased costs of
frequent screening tests [139]. However, similar strategies with more sensitive screening tests
appear to be cost-effective in the context of screening every 3–5 years [134,140–142].
Experts note that small changes in the specificity of screening tests can have an important impact
on the cost-effectiveness of screening in settings where frequent screening and aggressive
follow-up strategies are performed [143]. With frequent screening, the impact on costs is much
greater, an important consideration because, compared to the Pap smear, HPV DNA testing has,
on average, 20%–30% greater sensitivity and 5%–10% lower specificity for detecting high-grade
cancer lesions when combined testing of all women is performed. Specificity of screening has a
greater impact in settings with high coverage rates. Moreover, combining cytology and HPV DNA
testing in a screening program could help lengthen testing intervals from 1–3 years to 3–5 years.
The combination of these two tests reaches sensitivity and negative predictive values that
approach 100% [133].
Few modeling studies on screening in developing countries have been identified [132,144–150].
Many of these studies, including the earlier one by Sherlaw-Johnson and colleagues [146],
showed that screening efforts should focus on using a combination of cytology and HPV DNA
testing on women 30–59 years of age at least once during their lifetimes to reduce lifetime risk of
cervical cancer by up to 30%. Goldie and colleagues conducted a comprehensive assessment of
novel cervical cancer screening strategies in five countries and concluded that lifetime cancer risk
146
can potentially be reduced by about 25% when one-visit VIA or two-visit HPV DNA testing
targeted women 35–40 years of age [132]. When screening strategies were increased to 2–3
times during a lifetime, the risk reduction was nearly doubled. In all five developing countries, a
one-visit screening strategy was as cost-effective as hepatitis B immunization, second-line
treatment for tuberculosis, and malaria prevention with bed nets [132].
Early modeling studies explored the impact of an HPV vaccine using conservative efficacy levels
that mirrored those of HIV and genital herpes vaccines [151]. Based on the assumption of limited
vaccine protection, Hughes and colleagues projected a moderate HPV vaccine impact. These
researchers identified concerns about increased progression of high-risk types other than HPV 16
and 18 and about reduced cross-immunity. These concerns were shared by Goldie and
colleagues in their study using a cohort model calibrated to data from Costa Rica [136]. These
researchers assumed a vaccine efficacy of 98%, which yielded a 51% reduction in lifetime risk of
invasive cancer [136]. In another study, Goldie and colleagues found that vaccination against
HPV types 16 and 18 resulted in a small incremental increase in the number of cervical cancer
cases attributable to types other than HPV 16 and 18 [135]. They also found that the costeffectiveness of a combined primary and secondary prevention program depended on various
factors, including the age at which vaccination occurred, age at which screening was initiated,
and screening frequency. These findings were consistent with those reported by Kulasingam and
Myers [137].
Models also explored the added benefits and impact of costs of HPV vaccination on cervical
cancer incidence in males and older women [151-154]. Preliminary findings of these studies
suggest that direct protection of males against certain HPV-related conditions may be achieved.
In their study in which no type-specific immunity was assumed, Taira and colleagues found little
benefit in vaccinating boys [152]. However, the impact of vaccinating girls alone was high. Similar
results were found in another study in which long-lasting type-specific immunity was assumed
[153].
Indirect protection of women may result from reduced HPV transmission. Modeling studies have
shown that little additional reduction in cervical cancer can be gained by vaccinating males when
high HPV vaccination coverage of females is achieved because HPV vaccination directly protects
women from cervical cancer [131,153,154]. At lower coverage of women, vaccinating boys may
contribute to controlling infection, but more gains may be derived by vaccinating girls instead of
boys. Studies also find that direct protection of a woman may be reduced as age at vaccination
increases because older women may have already been exposed to HPV infection [131,153,154].
147
Despite differences in methodology, the state-transition modeling studies yield remarkably similar
results. The study conducted by Barnabas and colleagues, for example, found that a 90%
coverage rate of preadolescent girls results in a 91% reduction in HPV type-specific cervical
cancer incidence [153]. Other studies reported similar findings [135,136,151]. Scientists agree
that state-transition models using cohort or Monte Carlo simulation can be adequate tools for
projecting the vaccine impact on cervical cancer.
Models of transmission dynamics are being used increasingly to estimate the potential benefits of
HPV vaccination [152,153,154]. These models are based on assumptions that a person’s
acquisition of infection depends on that person’s sexual behavior and on the distribution of the
infection within the population [131].
In the context of middle-income countries like Brazil, findings of modeling studies based on
transmission dynamics suggest that adding HPV vaccination to routine screening strategies (e.g.,
1–3 times per lifetime) would be cost-effective provided vaccine price is low [115]. With an
assumed coverage rate of 100%, the projected reduction in cancer incidence with vaccination
alone was estimated to be 61%; with vaccination and screening three times in a lifetime, reduced
incidence was approximately 75%. Moreover, the ICERs associated with non-dominated
strategies are most influenced by vaccination costs. As the cost of the vaccine increased, the
ICERs associated with vaccination plus screening increased as well [115].
Models of HPV transmission dynamics find that the impact of the HPV 16 and 18 vaccine on both
prevalence of infection and infection-related disease is greatest in the absence of screening.
When screening is compared with vaccination, the impact of screening on cancer incidence
reduction is much lower than the impact of vaccination. These models have also shown that the
age at vaccination is important for outcomes. According to these models, the strategy that has the
best long-term outcome is vaccinating girls before exposure to potential HPV infection. However,
scientists agree that many factors need to be considered when adapting a vaccination strategy,
including the age at which sexual behavior is common and the extent to which the vaccine is
replacing naturally derived protection.
The findings of these complex models need to be validated with long-term field implementation
studies. A few issues should be considered, such as cost of the vaccine, which is currently over
$100 per dose, and administration costs, which are expected to be higher than for routine
vaccination schedules. Also, because most countries do not have an HPV vaccine program,
barriers to the introduction of HPV vaccine exist, which include but are not limited to adapting or
148
building an adolescent vaccination program and targeting preadolescent girls only instead of both
girls and boys.
The literature points to various factors that affect the applicability of cost-effectiveness studies of
cervical cancer prevention and screening. These factors include age-specific cancer incidence;
all-cause life expectancy; temporal trends of major epidemics; age structure of populations;
availability, effectiveness, and costs of cancer treatment; and health system costs of the
prevention or screening intervention.
2.4
Cost analysis
The results presented here provide insight into the costs associated with precancerous lesions
and cervical cancer by stage and by country. These costs are considered to be the best available
estimates for the countries studied.
2.4.1
Costs of treating precancerous lesions and cervical cancer
Estimates of total costs per case associated with precancerous lesions and cervical cancer are
provided in Table 1. These costs (in 2005 international dollars) are presented by stage and
country and are calculated by using national treatment guidelines and physician surveys, which
were described previously.
The total direct medical cost per case for screening and treatment of precancerous lesions
ranged from I$10 to US$81 per woman and from I$534 to I$1,402 per woman, respectively, with
highest costs incurred in Argentina (screening) and Brazil (treatment of precancerous lesions). In
all countries, most of the cost was attributed to the cost of specialist consultation (for screening)
and hospital stay (for treatment of precancerous lesions). For cervical cancer treatment, the total
cost per case was between I$3,745 and I$14,438 per woman; highest costs were incurred in
Argentina due to higher palliative care costs.
Disease progression considerably affected the cost of treatment. As expected, treatment costs
associated with invasive cervical cancer were found to be the most resource intensive. Treatment
costs increased as cervical cancer progressed and curative treatment was no longer an option.
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Table 1. Treatment costs associated with precancerous lesions and cervical cancer
(International dollars, 2005)
Cost per event
Argentina
Brazil
Chile
Colombia
Mexico
Peru
a
Event
Screening
81
10
33
37
52
15
CIN 1
534
864
553
974
648
595
CIN 2
1,094
1,402
969
1,252
1,159
729
IA1
5,157
5,169
5,267
4,823
4,900
3,745
IA2
10,031
8,447
5,738
6,540
7,988
7,407
IB1
13,350
8,633
7,301
6,648
7,954
7,918
IB2
13,424
9,026
7,655
6,984
7,981
7,884
IIA
13,577
8,145
8,486
7,232
8,073
8,086
IIB
13,616
8,350
8,836
7,380
8,559
8,148
IIIA–IIIB
14,039
8,739
9,422
7,734
8,895
8,486
IVA
14,061
8,851
10,078
8,028
9,149
8,550
IVB
14,438
9,042
10,534
8,455
9,528
8,660
a
CIN, Cervical intraepithelial neoplasia; IA1–IVB, stages of invasive cervical cancer
For economic evaluations, the most important consideration is that the relative costs of the
different items are consistent within each country’s column. For example, one would expect that
the treatment cost of more advanced stages of cervical cancer would be more costly than the
treatment cost of early stage cervical cancer and that the latter would be more costly than the
cost of treating precancerous lesions. This relationship was apparent in all countries and is a
direct result of including palliative treatment costs.
Comparison of costs among countries was of less interest here than country-specific costs.
However, because the costs are applied to a set of resource-use data derived from various
centers in six countries, consistency of definition of items being costed was necessary. Overall,
levels of health care expenditure and absolute price levels for health care resources varied
among the six Latin American countries. Generally, one would expect the unit costs for all items
to show the same relationship between two countries; for example, unit costs in Mexico would be
expected to be higher than those in Peru. This study shows that such a relationship among
countries exists except for certain procedures and follow-up treatment. In these cases, the
differences could arise from genuine differences in the relative costs for these items, from
differences in financial responsibilities between health and nonhealth agencies, or from different
definitions of the item or service being used. When such differences appeared, they were
checked to ensure that they were genuine relative cost differences rather than inconsistencies in
the cost measurement.
150
2.4.2
Direct nonmedical costs associated with precancerous lesions and cervical
cancer
Table 2 provides estimates of direct nonmedical costs for patients undergoing screening and for
patients with precancerous lesions and cervical cancer. The average cost to transport a woman
undergoing screening for cervical cancer ranged from I$2 to I$7. The average cost to transport a
woman with precancerous lesions ranged from I$12 to I$33. For women with a confirmed
diagnosis of cervical cancer, the average transportation cost ranged from I$15 to I$112; the
highest transportation costs were incurred in Chile.
The nonmedical costs associated with lost wages for women with cervical cancer (I$3,460) were
much higher than those for women with precancerous lesions (I$61). This difference occurs
because more women with cervical cancer lost time from work than women with precancerous
lesions (85% versus 35%).
Table 2. Direct nonmedical costs of precancerous lesions and cervical cancer (International
dollars, 2005)
Argentina
Brazil
Chile
Colombia
Transp
Time
Transp
Time
Transp
Time
Transp
Time
costs
loss
costs
loss
costs
loss
costs
loss
Screening
7
70
6
31
5
169
5
28
CIN 1
24
244
13
61
19
591
13
70
CIN 2
20
209
13
61
33
1,013
19
102
IA1
27
278
51
245
69
2,110
55
294
IA2
34
348
48
230
69
2,110
57
308
IB1
34
348
48
230
60
1,857
36
196
IB2
47
487
102
491
88
2,701
91
490
IIA
44
452
99
476
112
3,460
75
406
IIB
51
522
90
430
93
2,870
81
434
IIIA–IIIB
91
940
90
430
82
2,532
81
434
IVA
91
940
86
414
93
2,870
81
434
IVB
95
974
90
430
93
2,870
83
448
a
CIN, Cervical intraepithelial neoplasia; IA1–IVB, stages of invasive cervical cancer
Eventa
2.4.3
Mexico
Transp
Time
costs
loss
2
74
12
446
16
595
22
818
19
707
15
558
19
707
61
2,232
61
2,232
61
2,232
61
2,232
61
2,232
Peru
Transp
Time
costs
loss
5
66
21
265
19
240
36
463
39
496
39
496
75
960
75
960
77
993
80
1,026
80
1,026
80
1,026
Overall cancer treatment costs
Table 3 provides cancer cost estimates for stages I–IV. The first set of cost estimates (lower
bound) was estimated by using methods that indirectly estimate cancer treatment costs based on
extrapolating from primary data in one country to another [115,122]. These estimates include both
direct medical and direct nonmedical costs such as cost of transportation. The second set of cost
estimates (upper bound) was based on country-specific physician surveys described earlier. This
set of costs includes only direct medical costs.
151
The derived cancer cost estimates are much lower than in-country estimates because palliative
care costs are included in the latter estimates. Of importance is that for the lower bound
estimates, the costs for treating stages II–IV are consistently lower than for stage I. In contrast,
the upper bound estimates have a reversed effect; treating more advanced stages of disease is
always more costly than treating the early stages of the illness because palliative (long-term)
care, which is the focus in the later stages of the illness, is accounted for in the upper-bound
estimates but not in the lower-bound estimates. Another important consideration is that Argentina
incurs the highest cancer treatment costs in both the lower-bound and upper-bound estimates
due to the higher costs of treatment.
Table 3.
Cancer treatment cost estimates and model inputs (International dollars, 2005)
Country
Derived estimates
(Lower Bound)
In-country data collection
(Upper Bound)
Stage I
Stages II–IV
Stage I
Stages II–IV
Argentina
5,107.37
4,301.72
9,894.72
14,516.96
Brazil
3,834.30
3,229.46
7,416.14
8,755.72
Chile
4,388.56
3,696.30
6,095.07
9,442.39
Colombia
3,444.84
2,901.44
6,003.79
7,787.16
Mexico
4,368.55
3,679.44
7,313.91
9,295.52
Peru
2,749.07
2,315.42
6,425.95
8,507.53
2.4.4
Economic evaluation
In this section, we make projections of the health and economic outcomes of HPV vaccination
compared with outcomes for no vaccination.
2.4.5
Health outcomes for adolescent HPV 16 and 18 vaccination
Table 4 provides estimates of the health outcomes for adolescent HPV 16 and HPV 18
vaccination. Results shown are for a single birth cohort assumed to have 70% coverage by 12
years of age. The lifetime reduction in cancer ranges from 39% to 54%; the lowest reduction in
cancer rates occurs in Chile, and the highest reduction occurs in Argentina. Vaccinating 70% of
the 12-year-old girls would prevent between 2,767 (Chile) and 35,363 (Brazil) cervical cancer
cases over a cohort’s lifetime and between 1,660 (Chile) and 21,218 deaths (Brazil).
152
Table 4.
Adolescent HPV 16 and 18 vaccination: health outcomes
Country
Cancer
Incidence
Lifetime
Reduction in
Cancer, %
Cases of
cancer
averted
Cancer
deaths
averted
% of
cases/deaths
across the
region
Years of life
saved
(YLS)
Argentina
23.2
53.86
5,796
3,478
6%
86,921
Brazil
23.4
48.17
35,363
21,218
35%
474,912
Chile
25.8
39.41
2,767
1,660
3%
48,461
Colombia
36.4
40.30
9,512
5,707
10%
140,264
Mexico
29.5
39.60
15,213
9,128
16%
215,813
Peru
48.2
47.46
5,218
3,131
5%
69,046
73,869
44,322
75%
97,984
58,791
100%
Total for 6
countries
Total for 33
countries
Figure 1 presents the impact of adolescent HPV 16 and 18 vaccination on the number of deaths
averted for multiple birth cohorts, with an assumption of an average coverage of 70% in the six
studied countries. For example, in a 10-year vaccination program in which we vaccinate 70% of
12-year-old girls for 10 consecutive calendar years in these six countries, we would expect to
prevent nearly half a million deaths. When we assumed a 30%–50% underestimation of cancer
burden in the registries used for our cancer incidence estimates, the averted burden increased by
the same degree of magnitude. Further, when we also accounted for both future population
growth and explored the implication of temporal trends resulting in increased rates of cancer, a
10-year program would easily avert more than one million deaths over the lifetime of the
vaccinated girls.
600,000
Cancer Deaths Averted
500,000
400,000
300,000
200,000
100,000
0
10 birth cohorts
5 birth cohorts
3 birth cohorts
1 birth cohort
153
Figure 1. Impact of HPV 16 and 18 vaccination on deaths averted for multiple birth cohorts
for six Latin American countries (Argentina, Brazil, Chile, Colombia, Mexico, and Peru)
Cost-effectiveness of vaccination
Table 5 summarizes the incremental costs and ICERs of adolescent HPV 16 and HPV 18
vaccination. The cost per YLS from a societal perspective would range from I$10 (Brazil) to I$160
(Peru), and vaccination would be cost saving in Argentina and Chile compared with costs of
outcomes with no vaccination. This analysis assumes that all women with detected invasive
cervical cancer are treated; the costs are derived indirectly (as previously described) and are
therefore considered lower-bound estimates. The incremental costs include a strategy of
vaccination of 70% for a single birth cohort of preadolescent girls (i.e., 12-year-olds) in 2007 with
a 100% effective vaccine at a cost per vaccinated girl of I$25 (~I$5 per dose) and are compared
with costs of outcomes with no vaccination.
154
Table 5. Adolescent HPV 16 and 18 vaccination: CEA with assumption of lowerbound cancer costs and vaccine cost of I$25 (~I$5 per dose)*
Country
Cancer
Incidence
Incremental
Costs (I$)
ICER
(I$/YLS)
ICER
(I$/DALY)
Argentina
23.2
-593,233
Saving (-40)
Saving (-30)
Brazil
23.4
648,421
10
10
Chile
25.8
-629,952
Saving (-70)
Saving (-70)
Colombia
36.4
1,101,643
40
40
Mexico
29.5
4,865,009
120
110
Peru
48.2
2,117,122
160
160
* CEA, cost-effectiveness analysis; cancer incidence source: Globocan 2002 [109]; ICER, Incremental costeffectiveness ratio; I$, International dollars; YLS, years of life saved; DALY, disability-adjusted life years.
Table 6 summarizes the incremental costs and ICERs of HPV vaccination when upper-bound
cancer costs (in-country estimates) are assumed. Adolescent HPV 16 and 18 vaccination is cost
saving in all countries if upper-bound costs are assumed. This analysis uses the same
assumptions as the previous analysis except that costs are based on protocols collected as part
of a cost survey instead of being derived indirectly.
Table 6. Adolescent HPV 16 and 18 vaccination: CEA with assumption of upperbound cancer costs and vaccine cost of I$25 (~I$5 per dose)*
Cancer
Incremental Costs
ICER
ICER
Country
Incidence
(I$)
(I$/YLS)
(I$/DALY)
Argentina
23.2
-12,834,602
Saving (-770)
Saving (-740)
Brazil
23.4
-41,301,364
Saving (-450)
Saving (-440)
Chile
25.8
-4,031,630
Saving (-430)
Saving (-420)
Colombia
36.4
-8,476,018
Saving (-330)
Saving (-320)
Mexico
29.5
-12,712,279
Saving (-310)
Saving (-300)
Peru
48.2
-4,659,049
Saving (-360)
Saving (-340)
* CEA, cost-effectiveness analysis; cancer incidence source: Globocan 2002 [109]; ICER, Incremental costeffectiveness ratio; I$, International dollars; YLS, years of life saved; DALY, disability-adjusted life years.
Table 7 summarizes the incremental costs and ICERs of HPV vaccination if lower-bound cancer
costs are assumed and using a cost per vaccinated girl of I$50 (~I$12 per dose), compared with
the cost of outcomes with no vaccination. The vaccination program is no longer cost saving when
the cost per vaccinated girl is higher than I$50, but it may still be considered cost-effective in all
countries.
cancer costs and vaccine cost of I$50 (~I$12 per dose)*
155
Cancer
Incidence
Incremental
Costs(I$)
ICER
(I$/YLS)
ICER
(I$/DALY)
Argentina
23.2
5,290,582
320
310
Brazil
23.4
30,244,666
330
320
Chile
25.8
1,668,953
180
170
Colombia
36.4
9,212,000
360
340
Mexico
29.5
23,917,014
580
560
Peru
48.2
7,281,810
560
530
Country
* CEA, cost-effectiveness analysis; cancer incidence source: Globocan 2002 [109]; ICER, Incremental cost-effectiveness
ratio; I$, International dollars; YLS, years of life saved; DALY, disability-adjusted life years.
Table 8 summarizes the incremental costs and ICERs of HPV vaccination with the assumption of
upper-bound cancer costs and a cost per vaccinated girl of I$50 (~I$12 per dose), compared with
the costs of outcomes with no vaccination. The vaccination program is cost saving in all countries
except Mexico and Peru, where vaccination costs I$150 per YLS and I$40 per YLS, respectively.
Of great importance in reviewing these results is that the estimates for vaccination are compared
with costs of outcomes resulting from doing nothing, i.e., neither screening nor vaccinating. In
countries such as Mexico and Peru, where some level of screening occurs, the most appropriate
analysis will compare the ICER of each strategy (vaccination alone, screening alone, and
combined vaccination and screening) with the ICER of the next best strategy. Even so, these
ratios provide a contextual basis for the potential cost-effectiveness of HPV 16 and 18 vaccination
relative to other vaccines that have been adopted or are under consideration in this region of the
world.
Table 8.
Adolescent HPV 16 and 18 vaccination: CEA with assumption of upper-bound
Cancer
Incremental Costs
ICER
ICER
Country
Incidence
(I$)
(I$/YLS)
(I$/DALY)
Argentina
23.2
-6,950,787
Saving (-420)
Saving (-400)
Brazil
23.4
-11,705,119
Saving (-130)
Saving (-120)
Chile
25.8
-1,732,725
Saving (-190)
Saving (-180)
Colombia
36.4
-365,661
Saving (-10)
Saving (-10)
Mexico
29.5
6,339,726
150
150
Peru
48.2
505,639
40
40
Table 9 summarizes the incremental costs and ICERs with the assumption of lower-bound cancer
costs and a cost per vaccinated girl of I$75 (~I$20 per dose), compared with costs of outcomes
with no vaccination. The cost per YLS from a societal perspective would range from I$420 (Chile)
to I$1,040 (Mexico).
156
Cancer
Incremental Costs
ICER
ICER
Country
Incidence
(I$)
(I$/YLS)
(I$/DALY)
Argentina
23.2
11,174,397
670
640
Brazil
23.4
59,840,911
660
630
Chile
25.8
3,967,858
420
410
Colombia
36.4
17,322,358
670
650
Mexico
29.5
42,969,019
1,040
1,000
Peru
48.2
12,446,497
950
910
Table 10 summarizes the incremental costs and ICERs with the assumption of upper-bound
cancer costs and vaccine cost of I$75 (~I$20 per dose) per vaccinated girl, compared to costs
resulting from no vaccination. The cost per YLS from a societal perspective would range from
I$60 (Chile) to I$610 (Mexico) and would be cost saving in Argentina.
Cancer
Incremental
ICER
ICER
Country
Incidence
Costs (I$)
(I$/YLS)
(I$/DALY)
Argentina
23.2
-1,066,972
Saving (-60)
Saving (-60)
Brazil
23.4
17,891,126
200
190
Chile
25.8
566,180
60
60
Colombia
36.4
7,744,697
300
290
Mexico
29.5
25,391,731
610
590
Peru
48.2
5,670,326
430
420
Because these results were generated for vaccination only, the incremental ratios appear more
attractive than they would be if the baseline for comparison is screening. For example, according
to previously published independent models that include screening as well as vaccination [11], as
the cost per vaccinated girl approximates I$100, vaccination plus screening (at ages 35, 40, and
45) is preferable to vaccination alone, although the incremental cost-effectiveness ratio increases
(i.e., becomes less attractive) with higher vaccine costs. For example, in Mexico, a combined
vaccination and screening strategy that costs I$75, I$100, and I$360 per vaccinated girl and that
uses 2-visit HPV DNA testing costs I$1,530, I$1,780, and I$7,070 per YLS, respectively,
compared with cost outcomes of the next best strategy.
157
A previous analysis in Brazil [115], using the empirically-calibrated models mentioned above,
showed that when the vaccine cost rose above I$75 per vaccinated girl, vaccination alone was no
longer preferred; instead, vaccination plus screening three times in a woman’s lifetime (at ages
35, 40 and 45 years) was preferable. In Brazil, this combined vaccination and screening strategy,
costing I$75, I$100, and I$450 per vaccinated girl and using 2-visit HPV DNA testing, costs
I$1,100, I$1,700, and I$9,600 per YLS, respectively, compared with costs of screening alone.
2.4.6
Financial implications of HPV 16 and 18 vaccination
Cost-effectiveness analysis, which is about value for money and opportunity costs of not investing
the dollars elsewhere, is not the same as affordability (which is about impact on the current
budget) and financial costs over a short time horizon.
Table 11 shows the financial costs for the six studied countries. According to a threshold of each
country’s GDP per capita, vaccination would be cost-effective in all countries evaluated if the cost
per vaccinated girl is less than I$75 (implied cost per dose of I$20). However, the financial costs
of vaccinating five birth cohorts at 70% coverage would be $270 million (2008 value discounted
3% annually) at I$25 per vaccinated girl, almost $600 million at I$50 per vaccinated girl, and more
than $4 billion at I$360 per vaccinated girl; thus, whether HPV vaccination is affordable as well as
cost-effective in these countries is uncertain.
Table 11. Affordability and budget implications of HPV 16 and 18 vaccination based
on varying costs per vaccinated girl for 70% coverage of five birth cohorts
Cost per vaccinated girl
I$25
I$50
I$360
Argentina
$22,802,814
$50,239,204
$389,371,186
Brazil
$120,678,403
$262,951,492
$2,022,107,977
Chile
$7,746,554
$18,174,568
$146,857,377
Colombia
$28,258,592
$66,316,739
$535,955,252
Mexico
$67,664,604
$155,995,259
$1,246,481,871
Peru
$19,783,465
$43,893,204
$341,846,289
All 6 countries
$266,934,432
$597,570,466
$4,682,619,952
158
CHAPTER 3 DISCUSSION
3.1
Main findings
HPV infection is a common sexually transmitted disease; an estimated 20 million people are
currently infected. Most HPV-related cancer deaths are due to cervical cancer. Of the half million
cervical cancer cases reported annually worldwide, LAC countries account for 72,000 cases and
38,000 deaths. Cervical cancer results in significant illness as well as economic burden in the
studied countries.
In Latin America, scientists have contributed to the goal of preventing cervical cancer through
multidisciplinary research and cooperative projects with pharmaceutical and biotechnology
companies. Examples of these projects are major molecular epidemiologic studies conducted in
Mexico, Costa Rica, Panama, and Colombia and HPV prevalence and screening studies
conducted in Costa Rica, Brazil, Mexico, and Colombia. In addition, several countries in the
region have well-established cancer registries that provide essential cancer information. The
region has also had a strong presence in the case-control studies of the International Agency for
Research on Cancer (IRAC) and has recruited a large number of female participants in
vaccination trials. In recent years, models have been developed to explore the transmission
dynamics of HPV and the cost-effectiveness of vaccination and screening strategies in middleincome countries like Brazil. The current collaboration, led by the Albert B. Sabin Vaccine Institute
and assisted by many organizations, including the Harvard School of Public Health, the Institut
Catalá d’Oncología, PAHO, and CDC, is further testimony of the scientific community’s continuing
commitment to improving awareness of HPV in the region.
Findings of the economic literature have consistently shown that vaccination with current bivalent
and quadrivalent HPV vaccines can have a substantial impact in settings lacking effective
screening programs. If the cost of vaccination per girl is under I$75, vaccination has the potential
to be cost-effective when the per capita GPD criterion is used as an approximate indicator of
monetary resource constraints. HPV vaccination may, in some cases, be cost saving. In countries
with established ongoing screening programs, vaccination may be cost-effective if screening
programs are modified. Modelling studies show that vaccinating boys in addition to girls may not
be as cost-effective as vaccinating girls alone. Scientists agree that further collection of empirical
data needs to be carried out to parameterize and validate these models.
159
The vast majority of studies of screening in high-income countries or in countries with existing
screening programs have focused their attention on identifying optimal screening intervals and
appropriate ages for starting and stopping screening and on enhancing conventional cytology
programs. In low-income countries with infrequent or no screening, studies have focused on
finding alternative noncytologic tests and strategies that enhance the link between treatment and
screening and on targeting older women (35–45 years) for screening one, two, or three times
during their lifetimes. Findings from these studies are consistent.
Based on the available data, the total direct medical cost per case for screening and treatment of
precancerous lesions ranged from I$10 (Brazil) to I$81 (Argentina) per woman and from I$534
(Argentina) to I$1,402 (Brazil) per woman, respectively. Higher treatment costs were incurred in
Brazil due to higher treatment costs of precancerous lesions. The cost of cervical cancer
treatment was much higher than for precancerous lesions and ranged from I$3,745 (Peru) to
I$14,438 (Argentina) per woman; higher costs were incurred in the more advanced stages of
cervical cancer.
HPV vaccines have been shown to be effective in preventing infection and disease related to
HPV genotypes 16 and 18 in healthy women. Assuming 70% vaccination coverage by 12 years of
age and 100% efficacy against types 16 and 18 in six selected countries of the region (Argentina,
Brazil, Chile, Colombia, Mexico, and Peru), we found that almost 45,000 cancer deaths and
74,000 cervical cancer cases would be averted over the lifetime of a single birth cohort. Most of
the cases and deaths averted were in Brazil, where cervical cancer is more common than in other
countries of the region. When 10 birth cohorts with 70% coverage are considered, we would
expect to prevent nearly half a million deaths over the lifetime of the vaccinated girls. These
results emphasize the importance of HPV vaccination as a cost-effective intervention for
preventing women’s death.
If the vaccine cost approaches the price of I$100 per dose and if vaccination coverage for a
single birth cohort of preadolescent girls (i.e., 12-year-olds) in the six countries studied was 70%,
then vaccination is no longer preferable to screening if we assume lower-bound costs for cancer
treatment. At lower costs of I$75 per vaccinated girl (I$20 per dose), the cost per YLS would
range from I$420 (Chile) to I$1,040 (Mexico). At costs of I$50 per vaccinated girl (I$12 per dose),
the cost per YLS would range from I$180 (Chile) to I$580 (Mexico), respectively.
Based on published data, screening, with or without vaccination, as the main cervical cancer
prevention option in countries able to provide screening, was generally more cost-effective than
vaccination alone if the vaccine cost was I$360 per girl. As the cost per vaccinated girl declines,
160
however, preadolescent vaccination, followed by screening three times per lifetime, may be the
most cost-effective option in countries able to provide both. In the poorest countries in this region,
vaccination alone, if available for a markedly reduced price and if widespread coverage is
achievable in young girls, may be the most feasible option to reduce cancer.
Cost-effectiveness analysis, which is about value for money and opportunity costs of not investing
the dollars elsewhere, is not the same as affordability (which is about impact on the current
budget) and financial costs over a short time horizon. When compared to WHO benchmarks for
cost-effectiveness, HPV vaccination meets the criteria, provided the cost per vaccinated girl is
less than I$75 (implied cost per dose of I$20). However, the financial requirements for vaccinating
five birth cohorts at 70% coverage would be $267 million at I$25 per vaccinated girl, almost $600
million at I$50 per vaccinated girl, and over $4 billion at I$360 per vaccinated girl, making HPV
vaccination expensive.
Clearly, given national financial constraints, decision makers faced with many cost-effective
interventions will need to consider affordability as well as programmatic capacity and
sustainability. Although averted treatment costs can partially offset costs of vaccination, in some
health systems, distributions of costs and savings may not be equitable; hence, the impact of
averted treatment costs on affordability of interventions may be less than presented in this
analysis.
3.2
Regional context
This analysis supports the conclusion that cervical cancer poses a sizable burden in the six
countries studied and results annually in 72,000 cases and 38,000 deaths in the LAC region.
Establishing the burden of disease is a first step to accelerating vaccine introduction. Several
large-scale programs are contributing to improved awareness of HPV and cervical cancer and are
setting the stage for more widespread use of the HPV vaccine in the region. In 2007, an
International Symposium on Clinical and Scientific Aspects of HPV was held in Medellin,
Colombia, where important information concerning the latest progress on prevention and control
strategies for cervical cancer was presented. Several studies around the world are currently being
conducted to learn more about the burden of cervical cancer and the economics of various
treatment and vaccination strategies. The findings of this study and those of the meta-analysis
(Volume I), which report on the economics of HPV vaccination and the burden of HPV infection,
respectively, were presented in Mexico City in May 2008.
161
Our epidemiologic estimates (projected cases and deaths) differed from the meta-analysis
estimates (discussed separately) in several respects. Our scope was narrower in that we focused
on only six countries rather than the region as a whole. In addition, we used estimates from the
Globocan 2002 and CI5C databases rather than estimates derived from the meta-analysis, which
included wide variations in study methodology.
3.3
Limitation of the literature review
Due to our limited timeframe, we did not review in detail all economic studies on cervical cancer
screening and vaccination, nor did we explicitly assess study quality. We included the most
recently published review papers on screening and vaccination rather than investigating each
paper separately. Additionally, we incorporated information from key disease experts who have
local knowledge of the HPV disease burden that may not be published in the literature.
3.4
Limitations of the epidemiological data
Cancer registries and GLOBOCAN 2002 provide data by calendar year and age group. In this
economic analysis, we modeled a member of a birth cohort forward through her entire life, not for
a calendar year. Cancer data are analyzed to provide age-specific rates for five-year age groups,
and these rates are applied in the model to the appropriate age groups and superimposed on the
population age structure data to calculate number of cases and deaths. Observed differences in
estimates result from changes in methods and should not be interpreted as a time-trend effect.
The degree of detail and quality of cancer data may vary considerably as they are derived from
many countries through the registration of vital events. In addition, cancer data may not always
be the most recent data, as these data are collected and compiled after the events to which they
relate. While the cancer incidence data used in the analysis were considered the most recent
estimates at the time of analysis, more recent estimates may be available directly from local
sources. Caution must be exercised when comparing these estimates with previously published
estimates, as sources of data are continuously improving in quality and extent.
The age-standardized rate (world standard) is calculated by using the five age groups 0–14, 15–
44, 45–54, 55–64, and 65+. The result may slightly differ from that computed by using the same
data categorized according to traditional five-year age groups.
162
Our understanding of the natural history of HPV infection has many gaps. For instance, we do not
know whether HPV infections become latent and undetectable in the basal epithelial layer and
whether infections are acquired or reactivated later in life.
Also, uncertainties exist about the epidemiology and temporal trends of cervical cancer in many
countries. Estimates from extensively populated areas and information about HPV type
distributions in individual countries still need to be researched. The role of HPV in cervical cancer
also is uncertain, and risk factors for progression to invasive cancer are unknown. Also unknown
is the role of upstream cofactors that may contribute to HPV infection and downstream cofactors
that may result from HPV infection.
HPV epidemiology also has uncertainties. For example, we do not know the geographical
differences in risk factors among HPV types, nor do we know the distribution of HPV types in
precancerous lesions for planning new HPV assays. The meta-analysis (Volume 1) discusses risk
factors and HPV epidemiology and may help clarify some of these uncertainties.
3.5
Limitations of the economic study
Screening and treatment strategies inputs
Although the field of HPV diagnostics is progressing at a considerable rate and has provided
valuable information about the usefulness of typing, high-quality data on screening is still lacking.
Also, strategies to achieve high coverage and eliminate disparities still need to be developed.
In addition, gaps in knowledge exist concerning screening algorithms among HPV-vaccinated
women and the effectiveness of VIA in combination with screen-and-treat and other methods.
Surveys were conducted in each country to provide information about screening and treatment
strategies.
Vaccination inputs
We used vaccine efficacy data from the bivalent HPV vaccine trials conducted in North America
(Canada and the United States) and in Brazil, as these trials were considered to be most
applicable to the population under consideration. Because these trials were not conducted in
other countries of the region, the vaccine efficacy data may not be generalizable to the Latin
American countries studied.
163
We assumed that 70% of preadolescents were fully vaccinated, so we did not adjust for potential
protection provided by incomplete vaccination (e.g., receiving only one or two doses of HPV
vaccine). Such protective effects may increase vaccine cost-effectiveness.
Our vaccination coverage estimate was based on coverage of 70% overall. We assumed that all
groups within a country would have equal likelihood of vaccination and would be vaccinated at
the recommended time. If high-risk populations are missed or vaccination is delayed, the
effectiveness may be reduced.
Some questions remain concerning long-term efficacy, protection indicators, strategies, optimal
vaccination age, and ways to go about vaccinating the Latin American populations that need it
most to achieve broad protection.
We did not estimate the benefits of cross protection or examine the uncertainty of waning
immunity, as these issues were beyond the scope of the study.
Due to methodological difficulties and time constraints, we did not consider the potential indirect
protective effect of herd immunity on people who are not vaccinated. Herd immunity could offset
gaps in delivery of full-course, on-time vaccination as well as prevent disease in nontargeted
populations and improve the cost-effectiveness of HPV vaccination.
Finally, we evaluated the effect of a vaccine that protects against HPV types 16 and 18 and
focused only on cervical cancer outcomes (mortality and cases). We did not include outcomes of
HPV types 6 and 11, as they were beyond the scope of the analysis. These outcomes are
reported in published U.S. analyses. [131,152,153]
Population inputs
We did not consider other groups aside from preadolescent girls in the analysis. Other target
groups (e.g., boys and younger girls) should be considered in future analyses once the
epidemiology of HPV, the natural history and transmission of HPV infection, and the mechanism
and duration of protection by HPV vaccines are better understood.
Cost inputs
Our estimates of resource use, medical treatment costs, and indirect costs were developed using
physician and caregiver interviews and data from selected facilities in each of six countries.
164
These estimates are based on public system costs only and could be improved with patient-level
data and larger samples.
We did not consider costs borne by families for treatment of cervical cancer in less formal settings
(i.e., treatment at home or by traditional healers).
Several questions remain regarding costs associated with HPV-related diseases as well as
access to and costs of cervical cancer treatment for many countries.
Because the price of HPV vaccine for different countries is still not established and the associated
vaccination programmatic and support costs are also uncertain, we made assumptions about
vaccination costs by expressing a composite value, the cost per vaccinated girl, and varied it from
I$10 to I$360. Future studies should focus on the cost of adolescent vaccination programs,
particularly the cost of the vaccine itself, as this cost is likely to be a major determinant of the cost
and affordability of any vaccine program.
Data are unavailable on the cost of initiating, scaling up, and maintaining a new adolescent
vaccination program; the cost of reaching adolescents; and the programs needed to achieve high
coverage. Our economic analysis is based on an assumption of the cost of an adolescent
vaccination program because no standard cost exists. Administration costs for HPV vaccination
are expected to be higher than for traditional vaccines because few countries have routine
vaccination programs for preadolescents.
Model limitations
The Excel-based model used in this analysis was simple and helped to generate estimates of
avertable burden and cost-effectiveness (and affordability) estimates of HPV vaccination.
Ongoing research uses more complex models that assess vaccination and screening (including
screening algorithms that consider various screening tests, ages at which to begin screening,
age-specific screening strategies, and screening frequency). Vaccine research also incorporates
multiple HPV types beyond HPV 16 and 18, which are targeted by the current vaccines, and
thereby address the possibility of type replacement in the context of vaccination. The research
also reflects uncertainty of outcomes in a more sophisticated manner by simulating individual
women, tracking each woman’s health history, and allowing her history of screening, vaccination,
health, and behavior to affect her future risk. Also, HPV vaccine research includes dynamic
transmission considerations necessary to address questions of male vaccination and herd
immunity, as well as issues surrounding the duration of protection of the vaccine (i.e., the extent
165
to which the vaccine provides lifelong protection and the impact of a waning vaccine/booster dose
on cost-effectiveness results).
166
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in
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177
Appendix A. Model comparison validation: Impact of HPV 16 and 18 vaccination on mean reduction in lifetime risk of cervical cancer
Shown is the mean reduction (thick grey line) in lifetime risk of cervical cancer with HPV 16 and 18 vaccination of 70% of a 12-year-old birth
cohort generated by using empirically calibrated models for Argentina, Brazil, Chile, Colombia, Peru, and Mexico. The range (orange
rectangles) represents the minimum and maximum reductions across the good-fitting parameter sets for each country-specific model. The stars
indicate the average reduction predicted with the Excel-based companion model.
178
Source: Goldie SJ, Diaz M, Constenla D, Alvis N, Andrus JK, Kim SY. Mathematical models of cervical cancer prevention in Latin America and
the Caribbean. Vaccine. 2008;26(S11):L59–72.
179
Appendix B. Epidemiological parameters (Appendix Tables 1 and 2)
Table 1. Cervical cancer incidence rates by data source and age group for studied countries
Data
10–
15–
20–
25–
30–
35–
Country
0–4 5–9
40–44 45–49 50–54 55–59 60–64 65–69 70–74 75–79 80
Sources
14
19
24
29
34
39
Argentina
CI5C
0.00 0.00 0.00 0.66
3.23
9.27 32.29 46.53 51.24
59.02
49.00
33.07
49.75
31.16
48.96
41.94
41
Brazil
CI5C
0.00 0.00 0.07 0.36
2.49
9.57 24.22 40.57 64.50
89.04
94.40 105.74 104.91 111.22 104.19 104.19 104
Chile
CI5C
0.00 0.00 0.08 0.61
3.93 17.92 53.46 77.75 106.00 123.64 117.02 119.34 116.17 103.72 78.66
56.94
75
Colombia
CI5C
0.00 0.00 0.00 0.08
2.19 12.10 28.79 53.98 75.33 101.40 115.47 126.86 146.03 144.55 142.40 135.63 135
Globocan
Mexico
0.00 0.00 0.00 14.00 14.00 14.00 14.00 14.00 14.00
80.36
80.36
84.71
84.71 112.07 112.07 112.07 112
2002
Peru
CI5C
0.00 0.00 0.12 0.33
1.50
6.28 15.94 35.55 49.29
73.76
90.96 110.90 99.32 111.53 112.62 119.09 111
Sources: Globocan 2002. International Agency for Research on Cancer (IRAC). Parkin DM, et al., Editors. Cancer Incidence in Five Continents Vol. VIII, No. 155. Lyon, France: IARC Scientific
Publications; 2002..
Table 2. Estimates of prevalence of HPV 16/18 in cervical cancer by country and source
Country/Region
% HPV 16/18
Estimate from Smith 2007
meta-analysis [101]
Argentina
Brazil
Chile
Colombia
Mexico
Peru
76.9
68.8
56.3
57.6
56.6
67.8
Argentina pool
Brazil pool
Chile
Colombia pool
Mexico pool
Peru
180
Appendix C. List of physicians interviewed
Argentina
Jorge A. Gomez, Ph.D.
Epidemiologic Advisor for Vaccines (HPV)
Latin America & Caribbean
GlaxoSmithKline Biologicals
Carlos Casares 3690,
(B1644BCD), Buenos Aires
Argentina
Tel: 54-11- 4725-8995
E-mail: [email protected]
Dr. Silvio Tatti
Sociedad Argentina de Colposcopía
Universidad de Buenos Aires
Argentina
Brazil
Dr. Nelson Vespa Junior
Instituto Brasileiro de Controle do Câncer /
IBCC
Sao Paulo, Brazil
Dr. Francisco Galdo Coelho
IBCC
Sao Paulo, Brazil
Tel: +55 11 9908-3220
Dr. Ronaldo Rangel Costa
IBCC
Sao Paulo, Brazil
Chile
Sra. Marta Prieto
Coordinadora
Programa de Cáncer Cervicouterino
Ministerio de Salud
Santiago, Chile
Dr. Hugo Salinas Portillo
Red Hospital Clínico
Universidad de Chile
Chile
Colombia
Martha Patricia Velandia Gonzalez
Encargada del Programa Ampliado de
Inmunización
Bogotá
Colombia
E-mail:
[email protected]
Dr. Orlando Borre
Liga contra el Cancer
Cartgena de Indias
Colombia
Dra. Celia Castillo
Directora Profamilia
Cartagena de Indias
Colombia
Dra. Elizaberth Lopez
Decana de la Facultad de Medicina
Universidad de Cartagena
Colombia
E-mail: [email protected] y
[email protected]
Dr. Luis Alzamora
Liga contra el Cancer/
Departamento de Ginecologia y
Obstetricia de la
Clínica Maternidad Rafael Calvo (Hospital
Universitario)
181
Cartgena de Indias
Colombia
Colombia
Dr. David Romero
Obstetricia de la
Clínica Materidad Rafael Calvo (Hospital
Universitario)
Cartgena de Indias
Colombia
Dr. Julio Faciolince
Obstetricia de la
Universitario)
Cartgena de Indias
Colombia
Honduras
Hilda Lourdes Aguilar Cantarero
Programa Nacional para el Control del
Cáncer
Secretaría de Salud, segundo piso
Apartado Postal 3102
Tegucigalpa, M.D.C.
Honduras
Dr. Sergio Girado
Obstetricia de la
Universitario)
Cartgena de Indias
Colombia
Dominican Republic
Dra. Elizabeth Gomez, Epidemiologa
Directora
Direccion General de Epidemiologia
Secretaria de Estado de Salud Publica
Republica Dominicana
Tel: 809-686-9140
Fax 809-689-8395
E-mail [email protected] ;
[email protected]
Jamaica
Professor Horace Fletcher
University of the West Indies
Dept. Obstetrics/Gynaecology
Mona
Kingston, Jamaica
Dr. Nestor Martinez
Obstetricia de la
Universitario)
Cartgena de Indias
Guyana
Dr. Janice Woolford
EPI Manager/MCH Director
Ministry of Health
Brickdam
Georgetown,
Guyana
Mexico
Dr. Eduardo Lazcano Ponce
Director del Centro de Investigación en
Salud Poblacional
Instituto Nacional de Salud Pública de
México
Tel. 01 777 3293003
Fax 01 777 3111148
Email: [email protected]
182
Dra. Vesta Richardson
Director General del Centro Nacional
para la Salud de la Infancia y la
Adolescencia (CENSIA)
Ciudad de México
Mexico
Alejandro Garcia Carranca
Instituto Nacional de Cancerología
Av San Fernando 22,
Col Toriello Guerra del Tialpan,
México DF CP 14080
E-mail:
[email protected]
183
Appendix D. Sample expert interview survey
ENCUESTA SOBRE LA DETECCIÓN TEMPRANA Y TRATAMIENTO DEL
CÁNCER CERVICOUTERINO
INFORMACIÓN GENERAL
1. Nombre del entrevistado ___________________________
2. Tipo de especialidad del entrevistado______________________________
3. País ___________________________
4. Fecha de finalización de la encuesta: |___|___| día |___|___| mes |___|___| año
DETECCIÓN TEMPRANA DEL CÁNCER CERVICOUTERINO
En primer lugar, tenemos algunas preguntas sobre la detección temprana del cáncer
cervicouterino. Sírvase responder de acuerdo con su experiencia y conocimientos
especializados.
5. ¿Existe en su país un programa para la prevención (screening) y el control del
cáncer cervicouterino con metas y objetivos definidos?
SÍ / NO (Sírvase marcar uno)
En caso afirmativo, sírvase responder a las preguntas a partir de la número 6. Si no
hay un programa para la prevención (screening) y el control del cáncer
cervicouterino en su país, sírvase pasar a la pregunta 34.
6. ¿En qué nivel está estructurado este programa en relación con su administración
y la prestación de servicios? (Sírvase indicar)
 Nivel primario de atención
 Nivel secundario de atención
 Nivel terciario de atención
 Otro, sírvase indicar: __________________________
7. ¿Quién está a cargo de la coordinación de este programa de prevención
(screening) del cáncer cervicouterino? (Sírvase indicar)
 Médicos
 Enfermeras
 Otro, sírvase indicar: __________________________
8. Aproximadamente, ¿cuál es la cobertura actual de este programa de prevención
(screening) (porcentaje de mujeres evaluadas en la población beneficiaria)?
(Sírvase indicar)
 < 10%
 10-25%
 26-50%
 51-75%
 76-85%
 > = 86%
9. De las mujeres que son detectadas con el cáncer cuellouterino,
¿aproximadamente cuál es el porcentaje de mujeres que reciben diagnóstico y
tratamiento de seguimiento? (Sírvase indicar)
 < 10%
 10-25%
 26-50%
 51-75%
 76-85%
 > = 86%
10. ¿Está funcionando algún sistema de vigilancia de las mujeres detectadas que
requieren seguimiento?
184
11. ¿Tienen que pagar de su bolsillo las mujeres por las medidas de prevención
(citología - prueba de Papanicolaou, análisis del VPH, ADN) que son
realizadas ? (Sírvase indicar)
 Sí
 No
12. ¿Cuánto pagan por estos exámenes de detección del cáncer cuello uterino?
(Sírvase indicar)
 Pago total
 Pago parcial
 No se paga
13. ¿Tienen que pagar de su bolsillo las mujeres por el diagnóstico (colposcopía y
biopsia)? (Sírvase indicar)
 Sí
 No
14. ¿Cuánto pagan por el diagnóstico (colposcopía y biopsia)? (Sírvase indicar)
 Pago total
 Pago parcial
 No se paga
15. ¿Tienen las mujeres que pagar de su bolsillo por el tratamiento de lesiones pre
cancerosas? (Sírvase indicar)
 Sí
 No
16. ¿Cuánto pagan por el tratamiento de lesiones pre cancerosas? (Sírvase indicar)
 Pago total
 Pago parcial
 No se paga
17. ¿Tienen las mujeres que pagar de su bolsillo por el tratamiento del cáncer
cervicouterino? (Sírvase indicar)
 Sí
 No
18. ¿Cuánto pagan por el tratamiento del cáncer cervicouterino? (Sírvase indicar)
 Pago total
 Pago parcial
 No se paga
Si respondió afirmativamente a cualquiera de las preguntas 11, 13, 15 y 17, sírvase
pasar a la pregunta 19 y continúe con la encuesta. De lo contrario, sírvase pasar a
la pregunta 23.
19. Aproximadamente, ¿cuánto cuesta en promedio por paciente los exámenes
realizados para la detección temprana del cáncer cuello uterino? Sírvase incluir
los costos de los exámenes de laboratorio (citología - prueba de Papanicolaou,
análisis del VPH, ADN) que se realizan para la detección temprana del cáncer
cuello uterino.
|__|__|__|__|__|__| por paciente (expresar en moneda nacional) (coloque 0
si no lo sabe)
20. Aproximadamente, ¿cuánto cuesta en promedio por paciente el diagnóstico
(colposcopía y biopsia)?
|__|__|__|__|__|__| (expresar en moneda nacional) (coloque 0 si no lo
sabe)
21. Aproximadamente, ¿cuánto cuesta en promedio por paciente el tratamiento de
lesiones pre cancerosas?
185
sabe)
22. Aproximadamente, ¿cuánto cuesta en promedio por paciente el tratamiento de
cáncer cervicouterino?
sabe)
23. ¿A qué edad se suele comenzar a detectar (screen) a las pacientes en relación
con el cáncer cervicouterino? (Sírvase indicar)
 < = 9 años
 10 a 12 años
 13 a 15 años
 16 a 19 años
 +20 años
 Otro grupo de edad, sírvase indicar:________________________
24. ¿Con qué frecuencia se realiza la detección de cáncer cervicouterino por lo
general? (sírvase indicar)
 Anualmente
 Año de por medio
 Cada dos años
 Cada tres años
 Nunca
25. ¿Qué exámenes se realizan para detectar el cáncer cuellouterino por lo
general? (sírvase indicar)
 Citología (prueba de Papanicolaou)
 Análisis del VPH, ADN
 Otro análisis, sírvase indicar: _____________________________________
26. ¿Cuántas de estas pruebas se realizan por año por lo general? (sírvase indicar
el tipo de pruebas y además mencione el número de pruebas por año por
paciente)
 Citología (prueba de Papanicolaou): ________________ por año
 Análisis del VPH, ADN :___________________ por año
 Otro, sírvase indicar: ______________________, _________________ por
año
27. ¿Dónde suelen realizarse estas pruebas por lo general? (sírvase indicar)
 Consultorio para pacientes ambulatorios
 Consultorio de detección para el cáncer cuello uterino
 Consultorio de planificación familiar
 Consultorio médico
 Otro, sírvase indicar:
________________________________________________
28. ¿Cómo se realizan estas pruebas por lo general? (sírvase indicar)
 Como parte de los servicios preventivos sistemáticos de salud
 Como parte de los servicios de salud materno infantil
 Como una campaña especial para la prevención del cáncer cervicouterino
 Otro, sírvase indicar:
_________________________________________________
29. ¿Quién realizará por lo general estas pruebas? (Sírvase indicar)
 Técnicos de laboratorio
 Ginecólogos
 Médicos de cabecera y comunitarios
 Enfermeros
 Otro, sírvase indicar: ___________________________________________
186
30. ¿Dónde se analizan e interpretan estas pruebas por lo general? (Sírvase
indicar)
 Laboratorio de patología
 Consultorio médico
 Hospital
 Centros oncológicos
 Otro, sírvase indicar: _____________________________________________
31. ¿Cuál es el tiempo promedio que transcurre entre el momento en que se realiza
las pruebas de detección y el momento en que se entregan los resultados a la
mujer? (Sírvase indicar)
 < 1 semana
 1 a 2 semanas
 2 a 3 semanas
 > 3 semanas
32. ¿Cómo se notifica a la mujer el resultado de estas pruebas? (Sírvase indicar)
 En persona en el consultorio médico
 Por teléfono
 Por correo
33. ¿Qué ocurre si una mujer tiene una evaluación anormal? (Sírvase indicar)
 Se le pide que regrese a realizarse más pruebas en el lapso de seis meses
 Se repite la prueba en la próxima consulta médica
 Regresa para una colposcopía o una biopsia de inmediato
TRATAMIENTO EN LA ETAPA PREVIA AL CÁNCER
A continuación se mencionan algunas preguntas sobre la manera en que usted
tratará por lo general a los pacientes en el estadio previo al cáncer (CIN 1 o CIN
2/3). Sírvase responder de acuerdo con su experiencia y conocimientos
especializados.
34. ¿Cuál es el porcentaje de pacientes con CIN 1 que por lo general será
sometido a los siguientes procedimientos e intervenciones? (Sírvase escribir la
respuesta en la segunda columna del cuadro en la página siguiente).
35. ¿Cuál es el porcentaje de pacientes con CIN por lo general tratados en los
servicios ambulatorios? (Sírvase escribir la respuesta en la tercera columna del
cuadro a continuación. Indique el número de consultas ambulatorias).
36. ¿Cuál es el porcentaje de pacientes con CIN por lo general tratados en el
hospital? (Sírvase escribir la respuesta en la cuarta columna del cuadro a
continuación. Indique el número de días en el hospital).
37. ¿Cuál es la tasa general de complicaciones menores y mayores que resultan de
estos procedimientos o intervenciones? (Sírvase escribir la respuesta en la
quinta y sexta columnas del cuadro a continuación). La complicación menor se
define como algo que requiere intervención clínica breve de hospitalización
(aspirina, antibióticos de administración oral, refulgeración, relleno vaginal). Una
complicación grave se define como algo que requiere hospitalización (transfusión
sanguínea intravenosa, administración intravenosa de antibióticos, etc.).
187
¿% de
pacientes
con CIN 1
que reciben
intervencion
es?
¿% tratado
ambulatoria
-mente?
(Además
indicar el
número de
consultas)
¿% tratado
en el
hospital?
(Además
indicar el
número de
días)
¿% con
complicacion
es menores?
¿% con
complicacio
nes graves?
Crioterapia
Electrocauteriz
ación con
colposcopía
LEEP
Cono de láser
Conización fría
con bisturí
Histerectomía
simple
Otro, indicar:
____________
___
Otro, indicar:
____________
___
38. ¿Qué porcentaje de las complicaciones graves en general requiere las
siguientes intervenciones: (Sírvase marcar e indicar el porcentaje y el número de
días)
 Sutura e intervención quirúrgica _________%
 Antibióticos por vía intravenosa y hospitalización ____% ¿Cuántos días de
hospitalización? ____días
 Transfusión sanguínea intravenosa y hospitalización ___% ¿Cuántos días de
hospitalización?___ días
 Otra intervención, sírvase indicar: ______________________________,
______%
39. ¿Qué porcentaje de todas las complicaciones en general requiere el cuidado de:
(sírvase marcar e indicar el porcentaje)
 Un médico _________%
 Un enfermero _________%
 Otro tipo de atención, sírvase indicar: _____________________________,
______%
40. ¿Cuál es el porcentaje de pacientes con CIN 2/3 que por lo general será
sometido a las siguientes intervenciones? (Sírvase escribir la respuesta en la
segunda columna del cuadro a continuación).
41. ¿Cuál es el porcentaje de pacientes con CIN 2/3 por lo general tratado en los
servicios ambulatorios? (Sírvase escribir la respuesta en la tercera columna del
cuadro a continuación. Indique el número de consultas ambulatorias).
42. ¿Cuál es el porcentaje de pacientes con CIN 2/3 por lo general tratado en el
hospital? (Sírvase escribir la respuesta en la cuarta columna del cuadro a
continuación. Indique el número de días en el hospital).
43. ¿Cuál es la tasa general de complicaciones menores y graves que resultan de
este tratamiento? (Sírvase escribir la respuesta en la quinta y sexta columnas del
cuadro a continuación). Una complicación menor se define como algo que
requiere intervención clínica breve de hospitalización (aspirina, antibióticos de
administración oral, refulgeración, relleno vaginal). Una complicación grave se
188
define como algo que requiere hospitalización (transfusión sanguínea
intravenosa, administración intravenosa de antibióticos, etc.).
¿% de
¿% tratado ¿% tratado
¿% con
¿% con
lesiones pre ambulatoria
en el
complicacion
complicacancerosas
-mente?
hospital?
es menores?
ciones
con inter(Además
(Además
graves?
venciones?
indicar el
indicar el
número de
número de
consultas)
días)
LEEP
Cono de láser
Conización fría
con bisturí
Histerectomía
simple
Otro, indicar:
____________
___
Otro, indicar:
____________
___
44. ¿Qué porcentaje de las complicaciones graves en general requiere las
siguientes intervenciones: (sírvase marcar e indicar el porcentaje y el número de
días)
 Sutura e intervención quirúrgica _________%
 Antibióticos por vía intravenosa y hospitalización _______%
¿Cuántos días
de hospitalización? _____días
 Transfusión sanguínea intravenosa y hospitalización ____% ¿Cuántos días de
hospitalización?_____ días
 Otra, sírvase indicar: ______________________________, ______%
45. ¿Qué porcentaje de todas las complicaciones en general requiere el cuidado de:
(sírvase marcar e indicar el porcentaje)
 Un médico _________%
 Un enfermero _________%
 Otro tipo de atención, sírvase indicar: _____________________________,
______%
TRATAMIENTO DEL CÁNCER
A continuación se hacen algunas preguntas sobre la clasificación en estadios del
cáncer y el tratamiento sistemático para el cáncer cervicouterino.
46. ¿Dónde se realiza por lo general la clasificación en estadios del cáncer
 Hospital de primer nivel
 Hospital de nivel secundario
 Hospital de nivel terciario
 Hospital de oncología
 Otro, sírvase indicar: ___________________
47. ¿Cuáles son las pruebas y los procedimientos de diagnóstico habituales para
determinar clínicamente los estudios del cáncer cervicouterino? (sírvase indicar)
 Análisis sanguíneos
 Radiografías
 Biopsia
 Exploración con tomografía computarizada
189
 Pruebas de medicina nuclear
 Otro, sírvase indicar: _________________
 Otro, sírvase indicar: _________________
48. ¿Con qué frecuencia se realizan estas pruebas y procedimientos de diagnóstico
durante la clasificación en estadios del cáncer cervicouterino? (Sírvase marcar e
indicar el número de pruebas o procedimientos realizados)
 Análisis sanguíneos
# _____________
 Radiografías
# _____________
 Biopsia # _____________
 Exploración con tomografía computarizada # _____________
 Pruebas de medicina nuclear
 Otro, sírvase indicar: _________________ # _____________
 Otro, sírvase indicar: _________________ # _____________
49. ¿Quién atiende por lo general a las mujeres en el estadio 1a a 2a del cáncer
cervicouterino en el entorno ambulatorio? (Sírvase marcar cada una que se
aplique e indique el número de consultas ambulatorias.)
 Oncólogo experto en ginecología, sírvase indicar el número de consultas:
____________ consultas
 Oncólogo médico, sírvase indicar el número de consultas:
________________ consultas
 Oncólogo experto en radiación médica. Sírvase indicar el número de
consultas: ________ consultas
 Otro, sírvase indicar: ______________________: ________________
consultas
 Las mujeres en el estadio 1a a 2a de cáncer cervicouterino no son atendidas
en el entorno ambulatorio.
50. ¿Donde se hospitaliza por lo general a las mujeres que padecen cáncer
cervicouterino en el estadio 1a a 2a? (Sírvase marcar cada una que se aplique e
indique la duración de la estadía)
 Pabellón de oncología, sírvase especificar la duración de la estadía:
________________ días
 Pabellón médico general y quirúrgico. Sírvase indicar la duración de la
estadía: ____________ días
 Otro, sírvase indicar: ______________________________:
________________ días
 Las mujeres en el estadio 1a a 2a del cáncer cervicouterino no son
hospitalizadas.
51. ¿Quién atiende por lo general a las mujeres en el estadio 2b a 3b del cáncer
aplique e indique el número de consultas ambulatorias correspondientes)
 Oncólogo experto en ginecología. Sírvase indicar el número de consultas:
 Oncólogo médico. Sírvase indicar el número de consultas:
________________ consultas
consultas
 Las mujeres con el estadio 2b a 3b del cáncer cervicouterino no son
atendidas en el entorno ambulatorio.
cervicouterino en el estadio 2b a 3b? (sírvase marcar cada una que se aplique
e indique la duración de la estadía correspondiente)
 Pabellón de oncología, sírvase especificar la duración de la estadía:
________________ días
190

Pabellón médico general y quirúrgico, sírvase indicar la duración de la
________________ días
 Las mujeres en el estadio 2b a 3b del cáncer cervicouterino no son
hospitalizadas.
53. ¿Quién atiende por lo general a las mujeres en el estadio 4a a 4b del cáncer
aplique e indique el número de consultas ambulatorias correspondientes.)
 Oncólogo experto en ginecología. Sírvase indicar el número de consultas:
 Oncólogo médico. Sírvase indicar el número de consultas:
________________ consultas
consultas
 Las mujeres en el estadio 4a-b del cáncer cervicouterino no son atendidas en
el entorno ambulatorio.
cervicouterino en el estadio 4a-b? (Sírvase marcar cada una que se aplique e
indique la duración de la estadía correspondiente.)
 Pabellón de oncología. Sírvase especificar la duración de la estadía:
________________ días
 Pabellón médico general y quirúrgico. Sírvase indicar la duración de la
________________ días
 Las mujeres en el estadio 4a-b del cáncer cervicouterino no son
hospitalizadas.
55. ¿Se trata a las mujeres que padecen cáncer cervicouterino con quimioterapia?
SÍ / NO (sírvase marcar uno)
56. ¿Cuándo reciben quimioterapia por lo general las mujeres que padecen cáncer
 Estadio 1a-2a
 Estadio 2b-3b
 Estadio 4a-b
 Las mujeres que padecen cáncer cervicouterino no son tratadas con
quimioterapia.
57. ¿Dónde se administra por lo general la quimioterapia en mujeres que padecen
cáncer cervicouterino? (Sírvase indicar)
 Las mujeres que padecen cáncer cervicouterino no son tratadas con
quimioterapia.
58. ¿Se trata a las mujeres que padecen cáncer cervicouterino con una
histerectomía simple?
SÍ / NO (sírvase marcar uno)
59. ¿Cuándo por lo general se trata a las mujeres que padecen cáncer
cervicouterino con una histerectomía simple? (Sírvase indicar)
 Estadio 1a-2a
 Estadio 2b-3b
191


Estadio 4a-b
Las mujeres que padecen cáncer cervicouterino no son tratadas con una
histerectomía simple.
60. ¿Dónde suele realizarse por lo general una histerectomía simple? (sírvase
indicar)
 Las mujeres que padecen cáncer cervicouterino no son tratadas con una
61. ¿Se trata a las mujeres que padecen cáncer cervicouterino con una
histerectomía radical?
62. ¿Cuándo por lo general se trata a las mujeres que padecen cáncer
cervicouterino con una histerectomía radical? (Sírvase indicar)
 Estadio 2b-3b
 Estadio 4a-b
histerectomía radical.
63. ¿Dónde suele realizarse por lo general una histerectomía radical? (sírvase
indicar)
192
64. Piense en los tipos de fármacos que usted suministra por lo general en este
establecimiento (como quimioterapia) para el cáncer cervicouterino por estadio.
Al responder a la pregunta, sírvase tener en cuenta el abastecimiento usual de
fármacos y responda a las preguntas en el cuadro a continuación. Sólo declare
varios fármacos si más de uno sería suministrado por lo general al mismo
tiempo.
¿Cuántas
¿Qué fármacos
¿Qué vía?
¿Dosis
¿Durante
veces por
suministraría por lo
(IV, IM,
por kg?
cuántos días
día
general en este
oral)
la recetaría?
 (mg /
recomendarí
establecimiento
ml)
a que se
para esta afección?
tome?
1a-2ª

2b-3b
4a-b
65. Piense en la radioterapia (XRT) que por lo general reciben las mujeres que
padecen cáncer cervicouterino por estadio en este establecimiento. Sírvase
responder a las preguntas en el cuadro a continuación por estadio.
¿Intervalo de
¿Tipo de XRT
¿Unidades de
 ¿Número de
CXRT? (¿cada
recibida por
XRT? (Rads,
XRT?
cuanto
estadio del
Centigreys)
tiempo?
cáncer
cervicouterino?
1a-2ª

2b-3b
4a-b
66. Piense sobre los tipos de procedimientos e intervenciones que por lo general
realiza para el cáncer cervicouterino por estadio. Cuando responda a la
pregunta, tenga en cuenta el tipo de procedimiento y la intervención realizada
por estadio, el número de procedimientos realizados por estadio y el lugar en
que se realizaron estos procedimientos.
193
¿Tipo de procedimiento
o intervención
realizada?
¿Número medio de
procedimientos e
intervenciones
realizadas?
¿Lugar donde se
realizaron los
procedimientos y las
intervenciones?
1a-2ª

2b-3b
4a-b
194
Appendix E. Summary of screening strategies across studied countries1
Screening
Argentina2
Brazil3
Chile4
What tests
 1 pap smear with
 1 pap smear (100%)
 Pap smear (98%)
are
cytobrush (100%)
 VPH DNA test (2%
performed?
in the private sector)
Where are
 2 outpatient services
 2 outpatient visits
tests
visits with
required with general
performed?
gynecologist
physician and/or
physician, family
nurse at the family
planning clinic, or
planning clinic, or
cervical cancer
cervical cancer
screening outreach
screening outreach
clinic
clinic
How often
 If pap (-), once every
 If pap (-), once every
 If pap (-), repeat test
are tests
3 years
3 years
every six months for
performed?  If pap (+), perform pap  If pap (+), perform
the first year to confirm
a non false-positive.
every 6 months for 3
pap every 4 months
years
for 3 years
 Pap should be done
every 3 years after the
third PAP (-)
 If pap (+), repeat pap
smear every 4 months
At what age
are tests
performed?
By whom
are tests
performed?
 Age ≥35 years
 <35 years if sexually
active
 Gynecologist
 Nurse
 Paramedic
 Age ≥20 years
active
 Gynecologist
 Primary care
physician
 25–64 years
active
 Registered midwife
(public sector)
 Gynecologist or
Colombia5
Dominican Republic6
 1–2 outpatient visits
physician, family
planning clinics, or
cervical cancer
screening outreach
clinic
 2 outpatient services
visits
 If pap (-), once every 3
years
 Follow the 1-1-3
protocol: if PAP is (-),
a second PAP should
be done one year
later to confirm a non
false-positive. If
second PAP (-),
schedule PAP every
three years after that
 25–69 years
active
 Gynecologist
 Primary care
physician
 If Pap (-) once for the
first year and after
second pap (-), once
every 3 years
 If PAP (+), repeat pap
every 4–6 months,
followed by a biopsy
with colposcopy
 35–64 years
active
 Gynecologist
 Nurse
 Paramedic
195
 Nurse
Where are
 Pathology laboratory
results
analyzed/
interpreted?
gynecologistoncologist or primary
care physician (private
sector)
 Nurse
1
Screening for cervical cancer is based on expert interviews and national treatment guidelines.
Source: Federación Argentina de Sociedades de Ginecología y Obstetricia (FASGO) – Guía de Práctica Clínica, 2002; Subprograma Nacional de Detección Precoz de Cancer de Cuello Uterino,
Ministerio de Salud 2006; expert opinion (Interview with one local oncologist).
3
Source: Condutas do Instituto Nacional de Cancer/ Ministério da Saúde, (INCA/MS), 2006; 5ª Edição – UICC, 1997; Ministério da Saúde, 1998; expert opinion (Interviews with three local
oncologists).
4
Source: Ministerio de Salud. Guía Clínica Cáncer Cervicouterino. Serie guías clínicas MINSAL NºXX, 3ª edición. Santiago: Minsal, 2006; expert opinion (Interview with one expert in charge of the
National Cervical Cancer Program, Cancer Unit, MINSAL).
5
Source: Instituto Nacional de Cancerología. Guías de Práctica Clínicas en Enfermedades Neoplásicas, 2ª edición. Bogotá D.C. – Colombia 2007; Servicio de Salud Colombia. Norma Técnica para
la detección temprana del cáncer de cuello uterino y guía de atención de lesiones preneoplásicas de cuello uterino, Resolución Número 00412 de 2000; expert opinión (Interviews with three experts
in charge of National Institute of Cancer.
6
Source: Secretaria de Estado de Salud Pública y Asistencia Social (SESPAS). Normas Nacionales para la Detección, diagnostico temprano y tratamiento de cáncer cervico uterino, 2006; expert
opinion (Interview with one expert in charge of the National Cervical Cancer Program).
2
196
Appendix E. Summary of screening strategies across studied countries (continued)1
Screening
Honduras7
Jamaica8
Mexico9
Peru10
What tests
 1 Pap smear (100%)
are
 1 visual inspection – VIA
 VPH DNA-based test (5%)  VPH DNA-based test (5%)
performed?
(only 5%)
 Visual inspection – VIA
(3%)
 Visual inspection – VILI
(2%)
Where are
 2 outpatient visits required
 1 outpatient visits required  2 outpatient visits required
tests
with general physician,
performed?
family planning clinics, or
cervical cancer screening
outreach clinic
outreach clinic)
outreach clinic
How often
 If pap (-), repeat twice for
 Once every year for the
 If PAP (-), once every 3
 If PAP (-), once every 3
are tests
the first year and after the
first three years
years
years
performed?
first year perform once
 Repeat pap smear if PAP  If pap (+), once every 6
every 3 years
(+) for the first year, and do
months Repeat once for
 If PAP (+), repeat pap
pap every three years
one year if second PAP (-),
every 6 months for 3 years
schedule PAP every three
years thereafter
At what age  30–59 years
 25–54 years
 25–64 years
 ≥20 years
are tests
 <30 years if sexually active  <25 years if sexually active  <25 years if sexually
 <20 years if sexually active
performed?
active
By whom
 Gynecologist
 Gynecologist
 Register midwife (public
 Gynecologist
are tests
sector)
 Nurse
 Primary care physician
 Primary care physician
performed?

Gynecologist
or
 Nurse
 Nurse
gynecologist-oncologist
Where are
results
analyzed/
interpreted?
1
Screening for cervical cancer is based on expert interviews and national treatment guidelines.
197
7
Source: Guidelines for the management of cervical cancer, Ministry of Health, 2004; expert opinion (Interview with one local primary care physician).
Source: Expert opinion (Interview with one local OBGYN physician).
Source: National Comprehensive Cancer Network (NCCN), Guías de Práctica Oncológica – v.1 2005; Modificación a la Norma Oficial Mexicana NOM-014-SSA2-1994, Para la Prevención,
Detección, diagnóstico, tratamiento, control y vigilancia epidemiológica del cáncer cérvico uterino; expert opinion (Interview with one local primary care physician).
10
Source: Tobar A. Costo y desempeño de las pruebas de tamizaje costos del tratamiento del cancer cervicouterino en la región de San Martín (Perú), OPS/DPC/NC, 2005; expert opinion
(Interview with one local OBGYN physician).
8
9
198
Appendix F. Summary of treatment of precancerous lesions across studied countries1
Argentina2
Brazil3
Chile4
Diagnosis - CIN 1
What
 1 colposcopy +
 2 colposcopy with
tests/procedures
biopsy
biopsy (acetic acid biopsy
are performed?
VIA)
 1 endocervical
 1 cryotherapy
curettage
 1 LEEP
 1 LEEP
 1 LEEP
 Lab tests (see
 Lab tests (see
spreadsheet for
 1 cryotherapy
spreadsheet for
details)
details)
 Lab tests (see
Follow-up:
Follow-up:
spreadsheet for
 Specialist
details)
 Specialist
consultation
(2);
Follow-up:
consultation (3);
nurse visit (1);
nurse visit (1);
 Specialist
colposcopy (2);
colposcopy (2);
consultation (4);
biopsy (1); pap
biopsy (2); pap smear
colposcopy (2);
smear (1) for the
(2) for the first year.
biopsy (1); pap
first
year.
smear (1) for the first
year.
Colombia5
Dominican Republic6
2 colposcopy and
biopsy
1 cryotherapy
1 LEEP
1 cold knife
conization
 Lab tests (see
spreadsheet for
details)
Follow-up:
Specialist
consultation (2);
nurse visit (1);
colposcopy (2);
What % receive
interventions?
 Colposcopy with
biopsy: 65%
 Endocervical
curettage: 20%
 LEEP: 10%
 Cryotherapy: 5%
biopsy: 93%
 1 LEEP: 7%
 Colposcopy and
biopsy: 70%
 Cryotherapy: 10%
 LEEP: 20%
Colposcopy and
biopsy: 75%
Cryotherapy: 10%
LEEP: 5%
Cold knife conization:
10%
2 colposcopy and
biopsy
Endocervical
curettage
Cryotherapy
LEEP
 Lab tests (see
spreadsheet for
details)
Follow-up:
 Specialist
consultation (2);
nurse visit (1);
colposcopy (2);
biopsy (1); pap
year.
Colposcopy and
biopsy: 68%
Endocervical
curettage: 2%
Cryotherapy: 10%
LEEP: 20%
What % are
treated as
outpatients?
 Endocervical
curettage: 100% (1
visit)
 Colposcopy with
biopsy: 100% (2+
visits)
 Colposcopy and
biopsy: 100% (up to 3
visits)
Colposcopy and
biopsy: 100% (up to 2
visits)
Colposcopy and
biopsy: 100% (2+
visits)
199
(specify # visits)
Argentina2
 Colposcopy with
biopsy: 100% (1 visit)
Brazil3
Chile4
 Cryotherapy: 10% (up
to 3 visits)
 LEEP: 98% (up to 3
visits)
What % are
treated in
hospital?
(specify # days)
 LEEP: 100% (1 day)
 Cryotherapy (100%)
(1 day)
 LEEP: 100% (2
days)
 Cryotherapy: 90% (2
days)
 LEEP: 8% (2 days)
What % have
minor
complications?
 None
 LEEP: 1%
 LEEP: 10%
 Infection (20%)
 None
 Cryotherapy: <10%
 LEEP: 10%
What % have
major
complications?
Colombia5
Cryotherapy: 10% (1
visit)
LEEP: 10% (1 visit)
60% (1 visit)
Cryotherapy: 90% (1
day)
LEEP: 90% (1 day)
40% (1 day)
Cryotherapy: <5%
LEEP: <5%
Dominican Republic6
Endocervical
curettage: 100% (1
visit)
 None
 None
(1 day)
 LEEP: 100 (1 day)
 None
200
Appendix F. Summary of treatment of precancerous lesions across studied countries (continued)1
Management of complications – CIN 1
What treatment
 None
is used for minor
complication?
What treatment
 Hospitalization (20%,
is used for major
2 days)
complication?
Diagnosis - CIN 2
What
 1 endocervical
tests/procedures
curettage
are performed?
 1 LEEP
 1 cold knife
conization
 1 simple
hysterectomy
 Lab tests (see
spreadsheet for
details)
Follow-up:
 Specialist
consultation (4);
nurse visit (2);
colposcopy (2);
biopsy (1); pap
year.
What % receive  LEEP: 60%
interventions?
 Cold knife conization
 Surgical intervention
and sutures (no
hospital care
required)
 None
and sutures
 Intravenous antibiotic
 Blood transfusion
Intravenous antibiotic
Blood transfusion
 None
 None
biopsy
 1 LEEP
 1 simple
hysterectomy
 Lab tests (see
spreadsheet for
details)
Follow-up:
 Specialist
consultation (2);
nurse visit (1);
colposcopy (2);
biopsy (1); pap
smear (1) for the
first year.
 1 cryotherapy
 1 LEEP
 1 Cold knife
conization
 1 simple
hysterectomy
 Lab tests (see
spreadsheet for
details)
Follow-up:
 Specialist
consultation (3);
nurse visit (1);
colposcopy (2);
1 colposcopy with
biopsy
1 cryotherapy
1 LEEP
1 cold knife
conization
 Lab tests (see
spreadsheet for
details)
Follow-up:
Specialist
consultation (3);
nurse visit (1);
colposcopy (2);
 1 LEEP
 1 simple
hysterectomy
 Lab tests (see
spreadsheet for
details)
Follow-up:
 Specialist
consultation (2);
colposcopy (2);
biopsy (2); pap
year.
 LEEP: 95%
 Simple
 Cryotherapy: 1%
 LEEP: 90%
Cryotherapy: 5%
LEEP: 90%
 LEEP: 96%
 Simple
201
(40%)
 Simple hysterectomy:
7%
hysterectomy: 5%
What % are
treated as
outpatients?
(specify # visits)
What % are
treated in
hospital?
(specify # days)
 None
 None
What % have
minor
complications?
None
 LEEP: 2%
 Simple
hysterectomy: 3%
What % have
major
complications?
None
 Simple
hysterectomy: 1%
 LEEP: 100% (1 day)  LEEP: 100% (2
days)
100% (1 day)
 Simple
hysterectomy: 100%
 Cold knife conization:
(2 days)
100% (1 day)
2%
7%
 LEEP: 99% (1 visit)
5%
day)
 LEEP: 1% (1 day)
100% (2 days)
7% (5 days)
3–4%
 Simple
hysterectomy:10%
3–1–2%
 Simple
hysterectomy:10%
Cryotherapy: 100% (1  LEEP: 100% (2
day)
days)
LEEP: 90% (≤2.25
 Simple
days)
hysterectomy: 100%
(2 days)
100% (2 days)
hysterectomy: 4%
 None
LEEP: <10%
 LEEP: 1%
 Simple
hysterectomy: 3%
None
 Simple
hysterectomy: 1%
202
What
None
treatment is
used for
minor
complication?
What
None
treatment is
used for
major
complication?
and sutures
 Intravenous
antibiotic
and sutures
and sutures
 Intravenous
antibiotic
and sutures
1
Diagnosis and management of pre cervical cancer is based on expert interviews and national treatment guidelines.
Ministerio de Salud 2006; expert opinion (Interview with 1 local oncologist).
3
oncologists).
4
Source: Ministerio de Salud. Guía Clínica Cáncer Cervicouterino. Serie guías clínicas MINSAL NºXX, 3ª edición. Santiago: Minsal, 2006; expert opinion (Interview with 1 expert in charge of the
5
la detección temprana del cáncer de cuello uterino y guía de atención de lesiones preneoplásicas de cuello uterino, Resolución Número 00412 de 2000; expert opinion (Interviews with three local
oncologists).
6
opinion (Interview with one expert in charge of the National Cervical Cancer Program).
2
203
Honduras7
Diagnosis - CIN 1
What
 2 colposcopy + biopsy
tests/procedures  Lab tests (see
are performed?
spreadsheet for details)
Follow-up:
 Specialist consultation (4);
nurse visit (1); colposcopy
(2); biopsy (2); pap smear
Jamaica8
Mexico9
Peru10
 1 LEEP
 Lab tests (see
Follow-up:
nurse visit (1); colposcopy
(2); biopsy (2); pap smear
 1 cryotherapy
 1 LEEP
 Lab tests (see
Follow-up:
colposcopy (2); biopsy (2);
pap smear (2) for the first
year.
 Colposcopy and biopsy:
70%
 LEEP: 20%
 Colposcopy and biopsy:
100% (2 visits)
visits)
 LEEP: 98% (2 visits)
 Cryotherapy: 90% (1 day)
 LEEP: 2% (1 day)
2 colposcopy and biopsy
1 cryotherapy
1 LEEP
 Lab tests (see spreadsheet
for details)
Follow-up:
Specialist consultation (4);
nurse (1); colposcopy (4);
biopsy (4); pap smear (2)
for the first year.
Colposcopy and biopsy:
80%
Cryotherapy: 10%
LEEP: 10%
Colposcopy and biopsy:
100% (1 visit)
Cryotherapy: 10% (1 visit)
 LEEP: 10%
Cryotherapy:<10%
LEEP: 1%
What % receive
interventions?
 Coloscopy + biopsy:
100%
 LEEP: 5%
 Colposcopy + biopsy: 95%
What % are
treated as
outpatients?
(specify # visits)
 Coloscopy + biopsy:
100% (1 visit)
 Coloscopy + biopsy: 95%
(1 visit)
What % are
treated in
hospital?
(specify # days)
What % have
minor
complications?
 None
 LEEP: 100% (2 days)
 VIA with colposcopy: 5%
(1 day)
 None
 LEEP: 1%
Cryotherapy: 90% (1 day)
LEEP: 90% (1 day)
204
Honduras7
What % have
major
complications?
 None
Management of complications - CIN 1
What treatment
 None
is used for minor
complication?
Treatment for
major
complication?
 None
Jamaica8
 None
 Surgical intervention and
sutures (no hospital care
required)
 None
Mexico9
 Cryotherapy: <1%
 LEEP: 1–2%
sutures
sutures
Peru10
 None
Surgical intervention and
sutures
sutures
205
Diagnosis - CIN 2
What
 1 LEEP
tests/procedures  1 simple hysterectomy
are performed?
 Lab tests (see
Follow-up:
year.
 1 LEEP
 1 simple hysterectomy
 Lab tests (see
Follow-up:
year.
What % receive
interventions?
 LEEP: 96%
 Simple hysterectomy: 4%
 LEEP: 95%
What % are
treated as
outpatients?
(specify # visits)
What % are
treated in
hospital?
(specify # days)
 None
 None
 LEEP: 100% (≤3 days)
100% (≤3 days)
 LEEP: 100% (≤4 days)
100% (≤4 days)
What % have
minor
complications?
 LEEP: 1%
 LEEP: 2%
 1 cryotherapy
 1 LEEP
 1 cold knife conization
 1 simple hysterectomy
 Lab tests (see
Follow-up:
year.
 Cryotherapy: 1%
 LEEP: 90%
 Cold knife conization: 2%
 LEEP: 99% (1 visit)
1 cryotherapy
1 LEEP
1 cold knife conization
1 simple hysterectomy
 Lab tests (see
Follow-up:
Specialist consultation (5);
year.
Cryotherapy: 5%
LEEP: 80%
Cold knife conization: 5%
Simple hysterectomy: 10%
 Cryotherapy: 100% (1 day)
 LEEP: 1% (1 day)
100% (1 day)
100% (3 days)
Cryotherapy: 100% (1 day)
LEEP: 90% (1 day)
100% (up to 2.25 days)
(up to 2.25 days)
LEEP: 1%
206
What % have
major
complications?
Management of complications - CIN 2
What
treatmentis used
for minor
complication?
What treatment
is used for major
complication?
sutures
sutures
sutures
sutures
sutures
sutures
1
Diagnosis and management of pre cervical cancer is based on expert interviews and national treatment guidelines.
Source: Expert opinion (interview with a local OBGYN physician).
9
Detección, diagnóstico, tratamiento, control y vigilancia epidemiológica del cáncer cérvico uterino; expert opinion (Interview with one local primary care physician).
10
Source: Tobar A. Costo y desempeño de las pruebas de tamizaje costos del tratamiento del cancer cervicouterino en la region de San Martín (Perú), OPS/DPC/NC, 2005; expert opinion
7
8
207
Appendix G. Diagnostic and staging procedures and treatment modalities of invasive cervical cancer by stage across studied
countries1
Argentina2
Brazil3
Chile4
Colombia5
Dominican Republic6
Diagnostic & staging for all stages7
Diagnostic & staging:
 Vaginal and rectal
Vaginal and rectal
 1 vaginal and rectal
examination (1)
examination (2)
examination (2)
examination (2)
examination (2)
 Pelvic/abdominal CT
 Colposcopy + biopsy
Colposcopy + biopsy
or urogram, IV
(2)
(1)
(1)
(1)
pyelogram (1)
 Chest x-ray (1)
IV pyelogram (up to 2)
 IV pyelogram (2)
 Abdominal US (2)
 Uretrocistofibroscopy
 Pelvic/abdominal CT
Abdominal US (up to 2)  Abdominal US (2)
 1 chest x-ray
(1)
(1)
Cystoscopy/rectoscopy  Chest x-ray (1)
 Pelvis MRI (1)
 Rectosigmoidoscopy
 Pelvis MRI (1)
(1)
 Lab tests (see
 Rectosigmoidoscopy
(1)
 Abdominal ultrasound Chest x-ray (1)
spreadsheet for details
(1)
 Chest x-ray (1)
(2)
 Lab tests (see
 Specialist consultation  Lab tests (see
 Lab tests (see
 Cystoscopy (1)
spreadsheet for
(4)
spreadsheet for
spreadsheet for
details)
details)
 Lab tests (see
details)
spreadsheet for
Specialist consultation
 Specialist consultation
details)
(4)
(2)
(3)
(4)
Treatment by stage
IA1
Treatment:
Treatment:
Treatment:
Treatment:
Treatment:
 1 cold knife conization  1 cold knife conization 1 abdominal
for continued fertility
hysterectomy (Class I
Rudledge) 8
 1 simple abdominal
 1 abdominal
 Simple hysterectomy8
hysterectomy8
hysterectomy (Class I 1 cold knife conization
(abdominal/
hysterectomy8
8
(extrafascial)
Rudledge)
laparoscopy)
(extrafascial)
9
9
9
 Medication for
 Brachytherapy
Brachytherapy
 Brachytherapy (4
 Palliative care (see
symptom control (see
(700cGy 4 week
(700cGy 4 week
week course) in high
spreadsheet)
208
Argentina2
spreadsheet)
IA2
Treatment:
 1 Wertheim
hysterectomy8, Piver III
or Schauta with pelvic
lymphadenectomy
(complete colpoanexohysterectomy)
 1 external pelvic
brachytherapy9 +
teletherapy
 If tumor is 2cm, 1
complete colpoanexohysterectomy
abdominal type Piver II
(Massi class II)
spreadsheet)
Brazil3
course)
spreadsheet)
Treatment:
 1 abdominal
hysterectomy8 Class II
Rudledge +
intraoperative
selective pelvic lymph
node biopsy
 Pelvic radiotherapy (5
week course) (distant)
(5,000cGy 25
fractions followed by
brachy-therapy9)
 Chemotherapy EV 50
mg for 5 days
spreadsheet)
Chile4
course)
Palliative care (see
spreadsheet)
Treatment:
 1 radical
hysterectomy8 (Class
II Rudledge) with
lymphoadenectomy
 Brachytherapy9
(700cGy 4 week
course)
spreadsheet)
Colombia5
risk surgical patients
spreadsheet)
Treatment:
 1 radical hysterectomy
+ pelvic
lymphadenectomy8
 Teletherapy +
brachytherapy9 in high
 1 radical hysterectomy
(modified) + pelvic
lymphadenectomy with
vascular spaces or
lymph node
involvement
spreadsheet)
Dominican Republic6
Treatment:
 1 Wertheim
lymphadenectomy
(complete colpoanexohysterectomy
 External pelvic
brachytherapy9 +
radiotherapy
 If tumor is 2cm,
complete colpoanexohysterectomy
(Massi class II)
spreadsheet)
209
countries (continued)1
IB1
IB2
Treatment:
 1 Wertheim
lymphadenectomy
(complete colpoanexohysterectomy
 External pelvic
brachytherapy9 +
teletherapy
 Surgery, medicine for
symptom control (see
spreadsheet)
complete
colpoanexohysterecto
my abdominal type
Piver II (Massi class II)
Treatment:
 Radical hysterectomy
 Chemoradiotherapy
(platinum 5 cycles)
 Teletherapy (pelvis) +
brachytherapy9
symptom control
 If tumor persists, 1
anexohysterectomy
(extrafascial)
Treatment:
 1 radical abdominal
hysterectomy8 class
III Rudledge Radical
 Pelvic
lymphadenectomy or
nodal dissection
 Pelvic radiotherapy
(distant) (5,000cGy 25
brachytherapy9)
mg for 5 days
spreadsheet)
Treatment:
 1 radical
II + III Rudledge) with
lymphoadenectomy
 Pelvic (external and
intra cavity)
radiotherapy (distant)
(5,000cGy 25
fractions
spreadsheet)
Treatment:
Treatment:
 1 radical
 1 Wertheim
hysterectomy8 + pelvic
lymphadenectomy +
paraaortic biopsy +
lymphadenectomy
oophorepexia in
(complete colpoanexowomen 40–45 years.
hysterectomy
In women >45 years
 External pelvic
bilateral oophorexia
brachytherapy9 +
 External radiotherapy
teletherapy
+ brachytherapy9 in
high risk surgical
complete
patients
colpoanexohysterecto
my abdominal type
spreadsheet)
Piver II (Massi class II)
spreadsheet)
Treatment:
hysterectomy8 class
III Rudledge +
lymphadenectomy
brachytherapy9)
mg for 5 days
Treatment:
 Chemotherapy
(cisplatin 5 cycles)
 Pelvic (external and
intra cavity)
radiotherapy (distant)
(5,000cGy 25
fractions
 Brachytherapy9
(700cGy 4 weeks)
Treatment:
 1 radical
hysterectomy8 + pelvic
lymphadenectomy +
paraaortic biopsy +
oophorepexia in
women 40–45 years.
In women >45 years
 External radiotherapy
+ brachytherapy9 in
Treatment:
(platinum 5 cycles)
brachytherapy9
anexohysterectomy
(extrafascial)
spreadsheet)
210
spreadsheet)
spreadsheet)
spreadsheet)
high risk surgical
patients
 Chemotherapy
(cisplatin 40mg/m2 6
cycles) + radiotherapy
(teletherapy +
brachytherapy9)
spreadsheet)
211
IIA
Treatment
 Radical hysterectomy
(platinum 5 cycles)
brachytherapy9
symptom control
complete colpoanexohysterectomy8
(Massi class II)
anexohysterectomy
(extrafascial)
spreadsheet)
Treatment:
hysterectomy8 class III
Rudledge +
lymphadenectomy
brachytherapy9)
mg for 5 days
spreadsheet)
Treatment:
 Chemotherapy
 Pelvic (external)
radiotherapy
(5,000cGy 25
fractions
 Brachytherapy9
(700cGy 4 weeks)
 1 radical
III Rudledge) with
lymphoadenectomy
spreadsheet)
IIB
Treatment
(platinum 5 cycles)
brachytherapy9
symptom control
 Lumboaortic irradiation
 If recurrent w/ prior
radiotherapy, 1
Treatment:
brachytherapy9)
mg for 5 days
spreadsheet)
Treatment:
 Chemotherapy
radiotherapy
(5,000cGy 25
fractions
 Brachytherapy9
(700cGy 4 weeks)
 Evaluation of
Treatment:
 1 radical hysterectomy8
+ pelvic
lymphadenectomy +
paraaortic biopsy +
oophorepexia in
In women > 45 years
 External radiotherapy +
 Chemotherapy
(teletherapy +
brachytherapy9)
spreadsheet)
Treatment:
 1 radical hysterectomy8
+ pelvic
lymphadenectomy +
paraaortic biopsy +
oophorepexia in
In women > 45 years
Treatment
(platinum 5 cycles)
brachytherapy9
complete colpoanexohysterectomy8
(Massi class II)
anexohysterectomy
(extrafascial)
spreadsheet)
Treatment
(platinum 5 cycles)
brachytherapy
radiotherapy, 1
translaparoscopy/retroperitonea
212
l minilaparatomy; if
lymph peritoneal
involvement –
palliative care (see
spreadsheet)
IIIA–IIIB
IVA
Treatment
(platinum 5 cycles)
brachytherapy9
symptom control
radiotherapy, 1
lymph peritoneal
involvement –
spreadsheet)
Treatment
(platinum 5 cycles)
brachytherapy9
hysterectomy type I
spreadsheet)
Treatment
brachytherapy9)
 Chemotherapy EV
50 mg for 5 days
spreadsheet)
Treatment:
 Chemotherapy
radiotherapy
(5,000cGy 25
fractions
 Brachytherapy9
(700cGy 4 weeks)
spreadsheet)
Treatment
brachytherapy9)
Treatment:
 Chemotherapy
radiotherapy
(5,000cGy 25
lymph peritoneal
involvement –
 Chemotherapy
spreadsheet)
(teletherapy +
brachytherapy9)
spreadsheet)
Treatment:
Treatment
 External radiotherapy +  Chemoradiotherapy
brachytherapy9
(platinum 5 cycles)
spreadsheet)
brachytherapy9
radiotherapy, 1
l minilaparatomy8; if
lymph peritoneal
involvement –
spreadsheet)
Treatment:
brachytherapy9 for
curative and symptom
control (palliative)
purposes (see
Treatment
(platinum 5 cycles)
brachytherapy9
 Selectron therapy
213
symptom control
Lumboaortic
irradiation
radiotherapy, 1
lymph peritoneal
involvement –
spreadsheet)
Treatment
 Teletherapy (5-week
course)
 Teletherapy plus HDR
or selectron plus
chemotherapy plus
spreadsheet)
spreadsheet)

IVB
Follow-up by stage10
IA1
Follow-up:
 4 ambulatory visits, 2
pap smears, 1
vaginal/rectal
examination for the
first year
IA2
Follow-up:
fractions
 Brachytherapy9
(700cGy 4 weeks)
spreadsheet)
spreadsheet)

Lumboaortic
irradiation
radiotherapy, 1
lymph peritoneal
involvement –
spreadsheet)
Treatment:
 Pelvic irradiation
(teletherapy +
brachytherapy)plus
concurrent
chemotherapy
spreadsheet)
Treatment:
 Chemotherapy
radiotherapy
(5,000cGy 25
fractions
 Brachytherapy9
(700cGy 4 weeks)
 Palliative radiotherapy
 Other palliative care
(see spreadsheet)
Treatment:
 Palliative
chemotherapy
 Other palliative care
(see spreadsheet)
Treatment
course)
 Teletherapy plus HDR
or selectron plus
chemotherapy plus
spreadsheet)
Follow-up:
pap smears, 2
vaginal/rectal
examination for the
first year
Follow-up:
Follow-up:
pap smears, 6
vaginal/rectal
examination for the
first year
Follow-up:
Follow-up:
pap smears, 6
vaginal/rectal
examination for the
first year
Follow-up:
Follow-up:
pap smears, 2
vaginal/rectal
examination for the
first year
Follow-up:
214
IB1
pap smears, 1
vaginal/rectal
examination for the
first year
Follow-up:
pap smears, 1
vaginal/rectal
examination for the
first year
pap smears, 2
vaginal/rectal
examination for the
first year
Follow-up:
pap smears, 2
vaginal/rectal
examination for the
first year
pap smears, 6
vaginal/rectal
examination for the
first year
Follow-up:
6 ambulatory visits, 3
pap smears, 6
vaginal/rectal
examination for the first
year
pap smears, 6
vaginal/rectal
examination for the
first year
Follow-up:
pap smears, 2
vaginal/rectal
examination for the
first year
pap smears, 2
vaginal/rectal
examination for the
first year
Follow-up:
pap smears, 2
vaginal/rectal
examination for the
first year
215
IB2
Follow-up:
pap smears, 1
vaginal/rectal
examination for the
first year
Follow-up:
pap smears, 3
vaginal/rectal
examination for the
first year
Follow-up:
pap smears, 3
vaginal/rectal
examination for the
first year
Follow-up:
pap smears, 4
vaginal/rectal
examination for the
first year
Follow-up:
pap smears, 3
vaginal/rectal
examination for the
first year
IIA
Follow-up:
pap smears, 1
vaginal/rectal
examination for the
first year
Follow-up:
pap smears, 2
vaginal/rectal
examination for the
first year
Follow-up:
pap smears, 2
vaginal/rectal
examination for the
first year
Follow-up:
pap smears, 2
vaginal/rectal
Follow-up:
pap smears, 3
vaginal/rectal
examination for the
first year
Follow-up:
pap smears, 4
vaginal/rectal
examination for the
first year
Follow-up:
pap smears, 4
vaginal/rectal
examination for the
first year
Follow-up:
pap smears, 12
vaginal/rectal
Follow-up:
pap smears, 3
vaginal/rectal
examination for the
first year
Follow-up:
pap smears, 3
vaginal/rectal
examination for the
first year
Follow-up:
pap smears, 3
vaginal/rectal
examination for the
first year
Follow-up:
pap smears, 12
vaginal/rectal
Follow-up:
pap smears, 3
vaginal/rectal
examination for the
first year
Follow-up:
pap smears, 6
vaginal/rectal
examination for the
first year
Follow-up:
pap smears, 3
vaginal/rectal
examination for the
first year
Follow-up:
pap smears, 12
vaginal/rectal
Follow-up:
pap smears, 3
vaginal/rectal
examination for the
first year
Follow-up:
pap smears, 3
vaginal/rectal
examination for the
first year
Follow-up:
pap smears, 3
vaginal/rectal
examination for the
first year
Follow-up:
pap smears, 6
vaginal/rectal
IIB
IIIA-IIIB
IVA
216
IVB
examinations for the
first year
Follow-up:
pap smears, 2
vaginal/rectal
examinations for the
first year

examination for the
first year
Follow-up:
pap smears, 12
vaginal/rectal
examination for the
first year
examination for the
first year
Follow-up:
pap smears, 12
vaginal/rectal
examination for the
first year
examination for the
first year
Follow-up:
pap smears, 12
vaginal/rectal
examination for the
first year
examination for the
first year
Follow-up:
pap smears, 6
vaginal/rectal
examination for the
first year
1
Management of invasive cervical cancer is based on expert interviews and national treatment guidelines.
Ministerio de Salud 2006; expert opinion (Interview with one local oncologist).
3
oncologists).
4
Source: Ministerio de Salud. Guía Clínica Cáncer Cervicouterino. Serie guías clínicas MINSAL NºXX, 3ª edición. Santiago: Minsal, 2006; expert opinion (1 interview with the person in charge of the
5
la detección temprana del cáncer de cuello uterino y guía de atención de lesiones preneoplásicas de cuello uterino, Resolución Número 00412 de 2000; expert opinión (Interviews with three local
oncologists).
6
opinion (one interview with the person in charge of the National Cervical Cancer Program).
7
Some assumptions made for the diagnostics and staging of invasive cervical cancer are conservative. For example, the frequency (how often they are performed) of laboratory tests (urea,
hemogram, etc.) and radiography/radiology (x-ray, CT, etc.) were assumed to be the same for each country, based on expert opinion and treatment guidelines.
8
For surgical procedures, we assumed the same length of stay in the hospital (7–10 days), based on WHO guidelines (2006).
9
For brachytherapy, we assumed the same length of stay in the hospital (2 days) and the same number of outpatient visits (one lasting one hour). These assumptions were based on an average
estimate (WHO guidelines, 2006). For teletherapy and chemotherapy, we assumed the same number of outpatient visits (one outpatient visit).
10
Patient follow-up was generally assumed to be for the first year.
2
217
Honduras11
Diagnostic & staging for all stages7
examination (1)
 Colposcopy + biopsy (1)
 Cystoscopy (1)
 Proctoscopy (1)
 Chest x-ray (1)
 Pelvis MRI (1)
 Rectosigmoidoscopy (1)
for details)
 Specialist consultation (2)
Treatment by stage
IA1
Treatment:
 1 cold knife conization for
continued fertility
hysterectomy8 (extrafascial)
spreadsheet)
Jamaica12
Mexico13
Peru14
examination (1)
 1 Abdominal ultrasound (2)
 Cystoscopy (1)
 Proctoscopy (1)
 Chest x-ray (1)
 Pelvic MRI (1)
 Rectosygmoidoscopy (1)
for details)
examination (2)
Cystoscopy (1)
Proctoscopy (1)
Cone biopsy (1)
Chest x-ray (1)
Pelvis MRI (1)
Rectosigmoidoscopy (1)
for details)
examination (2)
 Cystoscopy (1)
 Proctoscopy (1)
 Cone biopsy (1)
 Chest x-ray (1)
 Pelvis MRI (1)
for details)
Treatment:
continued fertility
 1 radical hysterectomy 8
 Teletherapy and
brachytherapy9 (Cobalt
60/cesium 5 days for 5
weeks)
 Chemotherapy (cisplatin or
carboplatin, every 3 weeks,
6 cycles)
Treatment:
1 simple abdominal
hysterectomy8 (extrafascial)
1 cold knife conization for
continued fertility
Palliative care (see
spreadsheet)
Treatment:
continued fertility
 Simple hysterectomy8
(abdominal/ laparoscopy)
spreadsheet)
218
Honduras11
IA2
Treatment:
 1 Wertheim hysterectomy8,
Piver III with pelvic
lymphadenectomy
 External pelvic
brachytherapy9 (4 week
course) + teletherapy (5
week course)
spreadsheet)
Jamaica12
spreadsheet)
Treatment:
 1 radical hysterectomy 8
 Teletherapy and
weeks)
6 cycles)
spreadsheet)
Mexico13
Treatment:
 1 radical hysterectomy8 +
pelvic lymphoadenectomy
 Brachytherapy9 + pelvic
radiotherapy (75–80 Gy 4
week course)
spreadsheet)
Peru14
Treatment:
 1 radical hysterectomy +
pelvic lymphadenectomy8
 Teletherapy +
brachytherapy9
spreadsheet)
219
IB1
Treatment:
 1 Wertheim hysterectomy8,
Piver III with pelvic
lymphadenectomy
 External pelvic
brachytherapy9 (4-week
course) + teletherapy (5week course)
spreadsheet)
IB2
Treatment:
(platinum 5 cycles)
brachytherapy9
spreadsheet)
IIA
Treatment:
(platinum 5 cycles)
Treatment:
Rudledge Radical
 Teletherapy and
weeks)
6 cycles)
spreadsheet)
Treatment:
Rudledge
 Teletherapy and
weeks)
6 cycles)
spreadsheet)
Treatment:
Treatment:
 Pelvic radiotherapy +
brachytherapy9 (80–85 Gy
4-week course)
spreadsheet)
Treatment:
 Teletherapy +
brachytherapy9
spreadsheet)
Treatment:
chemotherapy (cisplatin) +
brachytherapy9 (85Gy)
brachytherapy9 (75–80Gy)
+ adjuvant hysterectomy
spreadsheet)
Treatment:
 Teletherapy +
brachytherapy9
spreadsheet)
Treatment:
chemotherapy (cisplatin)
Treatment:
220
brachytherapy9
spreadsheet)
IIB
Treatment:
(platinum 5 cycles)
brachytherapy9
spreadsheet)
IIIA–IIIB
Treatment:
(platinum 5 cycles)
brachytherapy9
spreadsheet)
Rudledge
 Teletherapy and
weeks)
6 cycles)
spreadsheet)
Treatment:
 Teletherapy and
weeks)
6 cycles)
spreadsheet)
Treatment:
 Teletherapy and
weeks)
 Chemotherapy (cisplatin
or carboplatin, every 3
weeks, 6 cycles)
spreadsheet)
spreadsheet)
 Teletherapy +
brachytherapy9
40mg/m2 6 cycles) +
radiotherapy (teletherapy +
brachytherapy9)
spreadsheet)
Treatment:
spreadsheet)
Treatment:
 Teletherapy +
brachytherapy9
40mg/m2 6 cycles) +
brachytherapy9)
spreadsheet)
Treatment:
spreadsheet)
Treatment:
 Teletherapy +
brachytherapy9
40mg/m2 6 cycles) +
brachytherapy9)
spreadsheet)
221
IVA
Treatment:
(platinum 5 cycles)
brachytherapy9
spreadsheet)
IVB
Treatment:
course)
spreadsheet)
Follow-up by stage10
IA1
Follow-up:
 6 ambulatory visits, 2 pap
smears, 2 vaginal/rectal
examination for the first year
IA2
Follow-up:
Treatment:
 Teletherapy and
weeks)
6 cycles)
spreadsheet)
Treatment:
 Teletherapy and
weeks)
6 cycles)
spreadsheet)
Treatment:
spreadsheet)
Treatment:
brachytherapy9 for curative
and symptom control
(palliative) purposes (see
spreadsheet)
Treatment:
 Palliative radiotherapy
spreadsheet)
Treatment:
 Palliative chemotherapy
 Other palliative care (see
spreadsheet)
Follow-up:
Follow-up:
Follow-up:
Follow-up:
Follow-up:
Follow-up:
222
IB1
IB2
IIA
IIB
Follow-up:
Follow-up:
Follow-up:
Follow-up:
Follow-up:
Follow-up:
Follow-up:
Follow-up:
Follow-up:
2 ambulatory visits, 2 pap
Follow-up:
Follow-up:
Follow-up:
Follow-up:
Follow-up:
Follow-up:
Follow-up:
223
IIIA–IIIB
IVA
IVB
Follow-up:
Follow-up:
Follow-up:
Follow-up:
Follow-up:
Follow-up:
Follow-up:
Follow-up:
Follow-up:
Follow-up:
Follow-up:
Follow-up:
1
Management of invasive cervical cancer is based on expert interviews and national treatment guidelines. The cost components associated with the management of invasive cervical cancer are
described in more detail in the Cost of HPV document.
7
Some assumptions made for the diagnostics and staging of invasive cervical cancer are conservative. For example, the frequency (how often they are performed) of laboratory tests (urea,
hemogram, etc.) and radiography/radiology (x-ray, CT, etc.) were assumed to be the same for each country, based on expert opinion.
8
For surgical procedures, we assumed the same length of stay in the hospital (7–10 days), based on WHO guidelines (2006).
9
For brachytherapy, we assumed the same length of stay in the hospital (2 days) and the same number of outpatient visits (one lasting one hour). These assumptions were based on an average
estimate (WHO guidelines, 2006). For teletherapy and chemotherapy, we assumed the same number of outpatient visits (one outpatient visit).
10
Patient follow-up was generally assumed to be for the first year.
11
12
Source: Expert opinion (Interview with one local OBGYN physician).
13
Detección, diagnóstico, tratamiento, control y vigilancia epidemiológica del cáncer cérvico uterino; expert opinion (interview with one local primary care physician).
14
Source: Tobar A. Costo y desempeño de las pruebas de tamizaje costos del tratamiento del cancer cervicouterino en la region de San Martín (Perú), OPS/DPC/NC, 2005; expert opinion
224
Appendix H. Unit costs associated with the detection and treatment of
precancerous lesions and treatment of cervical cancer by stage and country
Argentina
Unit cost
(International $,
2005)
% used1
Screening for cervical cancer
Screening tests
Pap smear
11.00
100%
VPH DNA-based test
0%
Visual inspection – VIA
0%
Visual inspection – VILI
0%
Follow-up
General practitioner visit
17.83
0%
Nurse visit
12.00
0%
Specialist consultation
35.00
100%
Average cost per event (screening for cervical cancer)
Diagnosis, management, and follow-up of precervical cancer
Diagnosis – CIN 1
Colposcopy
11.00
65%
Biopsy – sample
60.00
65%
Biopsy – histopathology study
23.00
65%
Treatment – CIN 1
Blood typing
1.52
0%
Complete blood test
2.63
70%
Prothrombin time
2.19
0%
Blood glucose
1.52
70%
Creatinine
2.19
70%
Complete urine test
2.78
70%
Urine culture
1.81
0%
Endocervical curettage
60.00
20%
Cryotherapy
206.62
5%
LEEP
170.55
10%
Cold knife conization
274.08
0%
Observation ward
0%
Regular ward
399.37
20%
ECG
0%
Follow-up – CIN 1
17.83
0%
Nurse visit
12.00
0%
17.83
100%
Colposcopy
11.00
100%
Biopsy – sample
60.00
100%
23.00
100%
Pap smear
11.00
100%
Surgical intervention/sutures
0%
IV antibiotics
3.65
0%
Blood transfusion
9.80
0%
Regular ward
399.37
20%
Average cost per event (CIN 1)
Frequency2
Cost per event
(International
$, 2005)3
1.00
-
11.00
-
2.00
70.00
81.00
1.00
1.00
1.00
7.15
39.00
14.95
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
-
1.84
1.06
1.53
1.95
12.00
10.33
17.06
79.87
-
4.00
2.00
1.00
1.00
1.00
71.32
22.00
60.00
23.00
11.00
2.00
159.75
533.81
225
Diagnosis – CIN 2
Colposcopy
11.00
100%
Biopsy – sample
60.00
100%
23.00
100%
Treatment – CIN 2
Blood typing
1.52
0%
Complete blood test
2.63
70%
Prothrombin time
2.19
0%
Blood glucose
1.52
70%
Creatinine
2.19
70%
Complete urine test
2.78
70%
Urine culture
1.81
0%
60.00
95%
Cryotherapy
206.62
0%
LEEP
170.55
60%
274.08
40%
Simple hysterectomy
1,656.00
7%
Short-stay hospitalization
0%
Long-stay hospitalization
399.37
60%
ECG
150.00
70%
Follow-up – CIN 2
17.83
0%
Nurse visit
12.00
100%
17.83
100%
Colposcopy
11.00
100%
Biopsy – sample
60.00
100%
23.00
100%
Pap smear
11.00
100%
0%
IV antibiotics
3.65
0%
Blood transfusion
9.80
0%
Regular ward
0%
Average cost per event – CIN 2
Staging, management and follow-up of invasive cervical cancer
Staging of invasive cervical cancer (all stages)
Vaginal/rectal examination
829.49
100%
Colposcopy
11.00
100%
Biopsy – sample
60.00
100%
23.00
100%
Intravenous pyelogram
0%
Abdominal ultrasound
0%
ECG
0%
Cystoscopy
0%
Proctoscopy
0%
Cone biopsy
0%
Endocervical curettage/smear
0%
Chest x-ray (front/lateral)
13.77
100%
Bone scan
251.71
0%
Abdomen/pelvis CT scan
185.71
100%
Pelvis MRI
321.71
0%
Urethrocistofibroscopy
97.82
50%
Rectosigmoidoscopy
112.72
50%
2.00
1.50
1.50
22.00
90.00
34.50
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.84
1.06
1.53
1.95
57.00
102.33
109.63
115.92
239.62
105.00
2.00
4.00
2.00
1.00
1.00
1.00
24.00
71.32
22.00
60.00
23.00
11.00
-
1,093.71
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
829.49
11.00
60.00
23.00
13.77
185.71
48.91
56.36
226
Urography
75.82
Complete hemogram
12.50
Complete urine test
2.78
Urine culture
1.81
Electrolyte
5.79
Serum creatinine
2.19
Prothrombin time
2.19
Glycemia
1.52
Ionogram
1.52
HIV test
10.50
ALT serum
AST (TGO)
Ureic nitrogen
1.81
Nurse visit
12.00
35.00
Treatment of invasive cervical cancer by stage
Surgery – IA1
170.55
Simple hysterectomy
1,656.00
Radical hysterectomy
2,566.00
Pelvic lymphadenectomy
695.75
Trachelectomy
Hospitalization (short-stay)
Hospitalization (regular ward)
Hospitalization (intermediate
399.37
care ward)
Hospitalization (ICU)
35.00
Radiotherapy – IA1
Pelvic teletherapy
3,250.00
Intravaginal brachytherapy
3,250.00
399.37
care ward)
Chemotherapy – IA1
1,500.00
Palliative care – IA1
Palliative radiotherapy
Palliative surgery
905.06
Palliative medicine
485.91
Palliative care (other)
47.00
Follow-up – IA1
35.00
Pap smear
11.00
829.49
Average cost per event – IA1
Surgery – IA2
Simple hysterectomy
1,656.00
2,566.00
695.75
Trachelectomy
399.37
care ward)
0%
100%
100%
100%
100%
100%
0%
100%
0%
0%
0%
0%
100%
100%
100%
5.00
1.00
1.00
6.00
1.00
1.00
1.00
1.00
2.00
3.00
62.50
2.78
1.81
34.74
2.19
1.52
1.81
24.00
105.00
100%
100%
0%
0%
0%
0%
0%
100%
1.00
1.00
2.00
170.55
1,656.00
798.74
0%
100%
1.00
35.00
0%
0%
0%
-
-
0%
-
-
0%
0%
100%
100%
0.50
1.00
242.96
47.00
100%
98%
70%
4.00
2.00
1.00
140.00
21.56
580.64
5,157.04
0%
100%
100%
0%
0%
0%
100%
1.00
1.00
2.00
2,566.00
695.75
798.74
227
Pelvic teletherapy
care ward)
Palliative surgery
Palliative medicine
Follow-up – IA2
Pap smear
Surgery – IB1
Simple hysterectomy
Trachelectomy
care ward)
Radiotherapy – IB1
Pelvic teletherapy
care ward)
Chemotherapy - IB1
Palliative care – IB1
Palliative surgery
Palliative medicine
Follow-up – IB1
Pap smear
Average cost per event – IB1
Surgery – IB2
Simple hysterectomy
Trachelectomy
35.00
0%
100%
1.00
35.00
3,250.00
3,250.00
399.37
50%
50%
50%
1.00
1.00
1.00
1,625.00
1,625.00
199.69
1,500.00
0%
-
-
905.06
485.91
47.00
0%
0%
50%
100%
1.00
1.00
242.96
47.00
35.00
11.00
829.49
100%
100%
70%
4.00
1.00
1.00
140.00
11.00
580.64
10,031.36
1,656.00
2,566.00
695.75
399.37
0%
100%
100%
0%
0%
0%
100%
1.00
1.00
2.00
2,566.00
695.75
798.74
35.00
0%
100%
2.00
70.00
3,250.00
3,250.00
399.37
100%
100%
100%
1.00
1.00
1.00
3,250.00
3,250.00
399.37
1,500.00
0%
-
-
905.06
485.91
47.00
0%
0%
50%
100%
1.00
1.00
242.96
47.00
35.00
11.00
829.49
100%
100%
50%
4.00
1.00
1.00
140.00
11.00
414.75
13,350.15
1,656.00
2,566.00
695.75
399.37
0%
50%
0%
0%
0%
0%
50%
1.00
2.00
1,283.00
399.37
228
care ward)
Pelvic teletherapy
care ward)
Chemotherapy – IB2
Palliative surgery
Palliative medicine
Follow-up – IB2
Pap smear
Surgery – IIA
Simple hysterectomy
Trachelectomy
care ward)
Radiotherapy – IIA
Pelvic teletherapy
care ward)
Chemotherapy – IIA
Palliative care – IIA
Palliative surgery
Palliative medicine
Follow-up – IIA
Pap smear
Average cost per event – IIA
Surgery – IIB
Simple hysterectomy
Trachelectomy
35.00
0%
100%
2.00
70.00
3,250.00
3,250.00
399.37
100%
100%
100%
1.00
1.00
3.00
3,250.00
3,250.00
1,198.11
1,500.00
100%
1.00
1,500.00
905.06
485.91
47.00
0%
0%
50%
100%
1.00
1.00
242.96
47.00
35.00
11.00
829.49
100%
100%
60%
6.00
1.00
1.00
210.00
11.00
497.69
13,423.72
1,656.00
2,566.00
695.75
399.37
0%
70%
0%
0%
0%
0%
70%
1.00
3.00
1,796.20
838.68
35.00
0%
100%
2.00
70.00
3,250.00
3,250.00
399.37
100%
100%
100%
1.00
1.00
1.00
3,250.00
3,250.00
399.37
1,500.00
100%
1.00
1,500.00
905.06
485.91
47.00
0%
0%
50%
100%
1.00
1.00
242.96
47.00
35.00
11.00
829.49
100%
100%
60%
6.00
1.00
1.00
210.00
11.00
497.69
13,577.49
1,656.00
2,566.00
695.75
-
0%
0%
0%
0%
0%
0%
-
229
care ward)
Radiotherapy – IIB
Pelvic teletherapy
care ward)
Chemotherapy – IIB
Palliative care – IIB
Palliative surgery
Palliative medicine
Follow-up – IIB
Pap smear
Average cost per event – IIB
Surgery – IIIA–IIIB
Simple hysterectomy
Trachelectomy
care ward)
Radiotherapy – IIIA–IIIB
Pelvic teletherapy
care ward)
Chemotherapy – IIIA–IIIB
Palliative care – IIIA–IIIB
Palliative surgery
Palliative medicine
Follow-up – IIIA–IIIB
Pap smear
Average cost per event IIIA–IIIB
Surgery – IVA
Simple hysterectomy
Trachelectomy
399.37
0%
-
-
35.00
0%
0%
-
-
3,250.00
3,250.00
399.37
100%
100%
100%
1.00
1.00
4.00
3,250.00
3,250.00
1,597.48
1,500.00
100%
1.00
1,500.00
905.06
545.80
47.00
0%
0%
100%
100%
1.00
1.00
545.80
47.00
35.00
11.00
829.49
100%
100%
100%
8.00
2.00
2.00
280.00
22.00
1,658.98
13,615.85
1,656.00
2,566.00
695.75
399.37
0%
0%
0%
0%
0%
0%
0%
-
-
35.00
0%
0%
-
-
3,250.00
3,250.00
399.37
100%
100%
100%
1.00
1.00
2.00
3,250.00
3,250.00
798.74
1,500.00
100%
1.00
1,500.00
905.06
545.80
778.66
0%
0%
100%
100%
1.00
1.00
545.80
778.66
35.00
11.00
829.49
100%
100%
100%
22.00
2.00
2.00
770.00
22.00
1,658.98
14,038.77
1,656.00
2,566.00
695.75
-
0%
0%
0%
0%
0%
-
-
-
230
care ward)
Radiotherapy – IVA
Pelvic teletherapy
care ward)
Chemotherapy – IVA
Palliative care – IVA
Palliative surgery
Palliative medicine
Follow-up – IVA
Pap smear
Average cost per event – IVA
Surgery – IVB
Simple hysterectomy
Trachelectomy
care ward)
Radiotherapy – IVB
Pelvic teletherapy
care ward)
Chemotherapy – IVB
Palliative care – IVB
Palliative surgery
Palliative medicine
Follow-up – IVB
Pap smear
Average cost per event – IVB
399.37
0%
0%
-
-
35.00
0%
0%
-
-
3,250.00
3,250.00
399.37
100%
100%
100%
1.00
1.00
2.00
3,250.00
3,250.00
798.74
1,500.00
100%
1.00
1,500.00
905.06
545.80
778.66
0%
0%
100%
100%
1.00
1.00
545.80
778.66
35.00
11.00
829.49
100%
100%
100%
22.00
4.00
2.00
770.00
44.00
1,658.98
14,060.77
1,656.00
2,566.00
695.75
399.37
0%
0%
0%
0%
0%
0%
0%
-
-
35.00
0%
0%
-
-
3,250.00
3,250.00
399.37
100%
100%
100%
1.00
1.00
3.00
3,250.00
3,250.00
1,198.11
1,500.00
100%
1.00
1,500.00
905.06
545.80
778.66
0%
0%
100%
100%
1.00
1.00
545.80
778.66
35.00
11.00
829.49
100%
100%
100%
22.00
2.00
2.00
770.00
22.00
1,658.98
14,438.14
-
1
Proportion of treatment-related events (visits, diagnostics, medications) occurring (e.g., 100% hospitalized patients
are admitted to the regular ward; 20% ambulatory patients are seen by their gynecologist; 20% hospitalized patients
receive chest x-rays).
2
Number of events (visits, diagnostics, medications) occurring (e.g., the average length of stay in the hospital is 3.5
days; an average of two pap smears are performed in patients).
3
2005 World Development Indicators, 2005 international dollars (LCU per international dollar, period average
vaginal/rectal examinations) for the first four years. These costs are based on an average patient who does not have
231
any special circumstances (e.g., pregnancy, menstruation, PID, or HIV). Palliative care is assumed to be given at
every stage of treatment and considers only the first year of palliative therapy.
Sources:
1. Federación Argentina de Sociedades de Ginecología y Obstetricia (FASGO) – Guía de Práctica Clínica, 2002;
Subprograma Nacional de Detección Precoz de Cancer de Cuello Uterino, Ministerio de Salud 2006.
2. Agencia de Evaluación de Tecnologías Sanitarias (AETS/IECS), 2005.
3. Expert opinion (Interviews with 2 experts in charge of the National Cervical Cancer Program and interviews with
participants of the GSK HPV project in Argentina).
232
Brazil
Unit cost
(International $,
2005)
% used1
Screening tests
Pap smear
5.37
100%
VPH DNA-based test
0%
0%
Visual inspection –VILI
0%
Follow-up
7.55
30%
Nurse visit
3.54
70%
7.56
0%
Diagnosis – CIN 1
Colposcopy
45.00
93%
Biopsy – sample
14.66
93%
11.28
93%
Treatment – CIN 1
Blood typing
3.51
70%
Complete blood test
4.11
70%
Prothrombin time
2.85
70%
Blood glucose
1.85
70%
Creatinine
3.51
70%
Complete urine test
15.65
70%
Urine culture
5.65
70%
141.27
0%
Cryotherapy
160.42
0%
LEEP
308.02
7%
935.35
0%
Observation ward
136.62
100%
Regular ward
359.52
100%
ECG
10.73
70%
Follow-up – CIN 1
7.55
0%
Nurse visit
3.54
100%
7.56
100%
Colposcopy
45.00
100%
Biopsy – sample
14.66
100%
11.28
100%
Pap smear
5.37
100%
164.09
1%
IV antibiotics
0.85
0%
Blood transfusion
8.09
0%
Regular ward
179.76
0%
Diagnosis – CIN 2
Colposcopy
45.00
87%
Biopsy – sample
14.66
87%
Frequency2
Cost per event
(International
$, 2005)3
1.00
-
5.37
-
1.00
1.00
-
2.27
2.48
10.11
2.00
2.00
2.00
83.70
27.27
20.98
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
2.00
2.46
2.88
2.00
1.30
2.46
10.96
3.96
21.56
136.62
359.52
15.02
1.00
2.00
2.00
2.00
2.00
2.00
3.54
15.12
90.00
29.32
22.56
10.74
1.00
-
1.64
863.58
2.00
2.00
78.30
25.51
233
11.28
87%
Treatment – CIN 2
Blood typing
3.51
70%
Complete blood test
4.11
70%
Prothrombin time
2.85
70%
Blood glucose
1.85
70%
Creatinine
3.51
70%
Complete urine test
15.65
70%
Urine culture
5.65
70%
141.27
0%
Cryotherapy
160.42
0%
LEEP
308.02
95%
935.35
0%
Simple hysterectomy
1,149.36
5%
136.62
0%
359.52
100%
ECG
10.73
65%
Follow-up – CIN 2
7.55
0%
Nurse visit
3.54
100%
7.56
100%
Colposcopy
45.00
100%
Biopsy – sample
14.66
100%
11.28
100%
Pap smear
5.37
100%
IV antibiotics
Blood transfusion
8.09
0%
Regular ward
179.76
0%
Staging, management, and follow-up of invasive cervical cancer
26.71
100%
Colposcopy
45.00
100%
Biopsy – sample
14.66
100%
11.28
100%
52.12
0%
54.04
70%
ECG
10.73
50%
Cystoscopy
31.70
50%
Proctoscopy
58.84
0%
Cone biopsy
935.35
0%
182.31
0%
9.50
70%
Bone scan
206.63
0%
138.63
70%
Pelvis MRI
269.13
70%
25.62
0%
Rectosigmoidoscopy
18.56
0%
Urography
14.52
0%
Complete hemogram
4.11
100%
Complete urine test
15.65
100%
2.00
19.63
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
2.00
1.00
2.46
2.88
2.00
1.30
2.46
10.96
3.96
292.62
57.47
719.04
6.97
1.00
2.00
2.00
2.00
2.00
2.00
3.54
15.12
90.00
29.32
22.56
10.74
-
4.92
0.03
1,401.76
2.00
0.60
1.00
1.00
2.00
2.00
1.00
1.00
1.00
1.00
1.00
2.00
2.00
53.42
27.00
14.66
11.28
75.66
5.37
15.85
6.65
97.04
188.39
8.22
31.30
234
Urine culture
5.65
Electrolyte
8.75
Serum creatinine
3.51
Prothrombin time
2.85
Glycemia
1.85
Ionogram
6.48
HIV test
65.00
ALT serum
5.65
AST (TGO)
5.65
Ureic nitrogen
5.65
Nurse visit
3.54
7.56
Surgery – IA1
935.35
Simple hysterectomy
1,149.36
2,966.19
966.19
Trachelectomy
529.87
136.62
248.33
359.52
care ward)
636.47
7.56
Pelvic teletherapy
674.71
556.60
520.48
care ward)
355.08
674.71
Palliative surgery
376.13
Palliative medicine
904.29
Follow-up – IA1
7.56
Pap smear
5.37
26.71
Surgery – IA2
Simple hysterectomy
1,149.36
2,966.19
966.19
Trachelectomy
529.87
136.62
248.33
359.52
care ward)
636.47
7.56
100%
100%
100%
100%
100%
0%
0%
0%
0%
0%
100%
100%
2.00
2.00
2.00
1.00
1.00
2.00
4.00
11.30
17.50
7.02
2.85
1.85
7.08
30.24
5%
95%
0%
0%
0%
0%
100%
100%
1.00
1.00
2.00
2.00
46.77
1,091.89
496.66
719.04
15%
100%
1.00
2.00
95.47
15.12
0%
100%
100%
1.00
1.00
556.60
520.48
0%
-
-
0%
0%
100%
100%
1.00
1.00
904.29
100%
100%
100%
6.00
2.00
2.00
45.36
10.74
53.42
5,168.51
0%
100%
100%
0%
0%
100%
100%
1.00
1.00
2.00
1.00
2,966.19
966.19
496.66
359.52
15%
100%
1.00
1.00
95.47
7.56
235
Pelvic teletherapy
care ward)
Palliative surgery
Palliative medicine
Follow-up – IA2
Pap smear
Surgery – IB1
Simple hysterectomy
Trachelectomy
care ward)
Pelvic teletherapy
care ward)
Palliative surgery
Palliative medicine
Follow-up – IB1
Pap smear
Surgery – IB2
Simple hysterectomy
Trachelectomy
care ward)
674.71
556.60
520.48
100%
100%
100%
1.00
1.00
1.00
674.71
556.60
520.48
355.08
50%
1.00
177.54
674.71
376.13
unknown
904.29
0%
0%
100%
100%
1.00
1.00
904.29
7.56
5.37
26.71
100%
100%
100%
6.00
2.00
2.00
45.36
10.74
53.42
8,447.40
1,149.36
2,966.19
966.19
529.87
136.62
248.33
359.52
0%
100%
100%
0%
0%
100%
100%
1.00
1.00
2.00
1.00
2,966.19
966.19
496.66
359.52
636.47
7.56
15%
100%
1.00
2.00
95.47
15.12
674.71
556.60
520.48
100%
100%
100%
1.00
1.00
1.00
674.71
556.60
520.48
355.08
100%
1.00
355.08
674.71
376.13
904.29
0%
0%
100%
100%
1.00
1.00
904.29
7.56
5.37
26.71
100%
100%
100%
6.00
2.00
2.00
45.36
10.74
53.42
8,632.50
1,149.36
2,966.19
966.19
529.87
136.62
248.33
359.52
0%
100%
100%
0%
0%
100%
100%
1.00
1.00
3.00
1.00
2,966.19
966.19
744.99
359.52
636.47
7.56
15%
100%
1.00
1.00
95.47
7.56
236
Pelvic teletherapy
care ward)
Palliative surgery
Palliative medicine
Follow-up – IB2
Pap smear
Average cost per event - IB2
Surgery – IIA
Simple hysterectomy
Trachelectomy
care ward)
Pelvic teletherapy
care ward)
Palliative surgery
Palliative medicine
Follow-up – IIA
Pap smear
Surgery – IIB
Simple hysterectomy
Trachelectomy
care ward)
674.71
556.60
520.48
100%
100%
100%
1.00
1.00
1.00
674.71
556.60
520.48
355.08
100%
1.00
355.08
674.71
376.13
904.29
0%
0%
100%
100%
1.00
1.00
904.29
7.56
5.37
26.71
100%
100%
100%
22.00
3.00
3.00
166.32
16.11
80.13
9,026.31
1,149.36
2,966.19
966.19
529.87
136.62
248.33
359.52
0%
100%
100%
0%
0%
100%
100%
1.00
1.00
2.00
1.00
2,966.19
966.19
496.66
359.52
636.47
7.56
15%
100%
1.00
1.00
95.47
7.56
674.71
556.60
520.48
100%
100%
100%
1.00
1.00
1.00
674.71
556.60
520.48
355.08
100%
1.00
355.08
674.71
376.13
904.29
0%
0%
50%
30%
1.00
1.00
271.29
7.56
5.37
26.71
100%
100%
100%
22.00
3.00
3.00
166.32
16.11
80.13
8,144.98
1,149.36
2,966.19
966.19
529.87
136.62
248.33
359.52
0%
0%
0%
0%
0%
0%
0%
-
-
636.47
0%
-
-
-
237
Pelvic teletherapy
care ward)
Palliative surgery
Palliative medicine
Follow-up – IIB
Pap smear
Simple hysterectomy
Trachelectomy
care ward)
Pelvic teletherapy
care ward)
Chemotherapy – IIIA-IIIB
Palliative care – IIIA-IIIB
Palliative surgery
Palliative medicine
Pap smear
Surgery – IVA
Simple hysterectomy
Trachelectomy
care ward)
7.56
100%
4.00
30.24
674.71
556.60
520.48
100%
100%
100%
1.00
1.00
2.00
674.71
556.60
1,040.96
355.08
100%
1.00
355.08
674.71
376.13
904.29
0%
70%
100%
100%
1.00
1.00
5.00
263.29
4,521.45
7.56
5.37
26.71
100%
100%
100%
22.00
4.00
4.00
166.32
21.48
106.84
8,349.64
1,149.36
2,966.19
966.19
529.87
136.62
248.33
359.52
0%
0%
0%
0%
0%
0%
0%
-
-
636.47
7.56
0%
0%
-
-
674.71
556.60
520.48
100%
100%
100%
1.00
1.00
2.00
674.71
556.60
1,040.96
355.08
100%
1.00
355.08
674.71
376.13
904.29
65%
65%
100%
100%
1.00
1.00
1.00
5.00
438.56
244.48
4,521.45
7.56
5.37
26.71
100%
100%
100%
22.00
4.00
4.00
166.32
21.48
106.84
8,739.16
1,149.36
2,966.19
966.19
529.87
136.62
248.33
359.52
0%
0%
0%
0%
0%
0%
0%
-
-
-
-
238
Pelvic teletherapy
care ward)
Palliative surgery
Palliative medicine
Follow-up – IVA
Pap smear
Average cost per event - IVA
Surgery – IVB
Simple hysterectomy
Trachelectomy
care ward)
Pelvic teletherapy
care ward)
Palliative surgery
Palliative medicine
Follow-up – IVB
Pap smear
636.47
7.56
0%
0%
-
-
674.71
556.60
520.48
100%
100%
100%
1.00
1.00
1.00
674.71
556.60
520.48
355.08
100%
2.00
710.16
674.71
376.13
904.29
70%
70%
100%
100%
1.00
1.00
1.00
5.00
472.30
263.29
4,521.45
7.56
5.37
26.71
100%
100%
100%
22.00
6.00
12.00
166.32
32.22
320.52
8,850.72
1,149.36
2,966.19
966.19
529.87
136.62
248.33
359.52
0%
0%
0%
0%
0%
0%
0%
-
-
636.47
7.56
0%
0%
-
-
674.71
556.60
520.48
100%
100%
100%
1.00
1.00
2.00
674.71
556.60
1,040.96
355.08
100%
1.00
355.08
674.71
376.13
904.29
85%
50%
100%
100%
1.00
1.00
2.00
5.00
573.50
188.07
4,521.45
7.56
5.37
26.71
100%
100%
100%
22.00
6.00
12.00
166.32
32.22
320.52
9,042.10
-
1
2
3
2005 World Development Indicators, 2005 international dollars (LCU per international dollar, period average for
year 2005). Costs are based on the first year of treatment and include follow-up care (e.g. ambulatory visits,
every stage of treatment and only considers the first year of palliative therapy.
Sources:
239
1. Condutas do Instituto Nacional de Cancer/ Ministério da Saúde, (INCA/MS), 2006; 5ª Edição – UICC, 1997;
Ministério da Saúde, 1998.
2.Tabela de Procedimentos o Sistema Ambulatorial e Hospitalario del Sistema Único de Salud (SIA/SUS; SIH/SUS).
DATASUS, 2005.
3. Expert opinion (Interviews with three experts in charge of the National Cervical Cancer Program, Sao Paulo,
Brazil.
240
Chile
Unit cost
(International $,
2005)
% used1
Screening tests
Pap smear
10.55
98%
VPH DNA-based test
925.65
2%
0%
0%
Follow-up
9.24
30%
Nurse visit
2.46
70%
18.60
0%
Diagnosis, management and follow-up of pre-cervical cancer
Diagnosis – CIN 1
Colposcopy
13.89
70%
Biopsy – sample
39.39
70%
21.49
70%
Treatment – CIN 1
Blood typing
3.89
70%
Complete blood test
4.92
70%
Prothrombin time
2.40
70%
Blood glucose
2.16
70%
Creatinine
2.16
70%
Complete urine test
3.07
70%
Urine culture
5.99
20%
16.05
0%
Cryotherapy
40.12
10%
LEEP
82.86
20%
275.26
0%
Observation ward
24.41
100%
Regular ward
72.74
100%
ECG
10.79
70%
Follow-up – CIN 1
9.24
0%
Nurse visit
2.46
100%
18.60
100%
Colposcopy
13.89
100%
Biopsy – sample
39.39
100%
21.49
100%
Pap smear
10.55
100%
46.81
10%
IV antibiotics
2.46
10%
Blood transfusion
18.60
10%
Regular ward
72.74
0%
Diagnosis – CIN 2
Colposcopy
13.89
100%
Biopsy – sample
39.39
100%
Frequency2 Cost per event
(International
$, 2005)3
1.00
1.00
-
10.34
18.51
-
1.00
1.00
-
2.77
1.72
33.34
2.00
2.00
2.00
19.45
55.15
30.09
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
2.00
1.00
2.72
3.45
1.68
1.51
1.51
2.15
1.20
4.01
16.57
24.41
145.47
7.55
1.00
3.00
2.00
2.00
2.00
2.00
2.46
55.81
27.78
78.78
42.98
21.09
1.00
1.00
1.00
-
4.68
0.25
1.86
552.61
2.00
2.00
27.78
78.78
241
21.49
100%
Treatment – CIN 2
Blood typing
3.89
70%
Complete blood test
4.92
70%
Prothrombin time
2.40
70%
Blood glucose
2.16
70%
Creatinine
2.16
70%
Complete urine test
3.07
70%
Urine culture
5.99
70%
16.05
0%
Cryotherapy
40.12
1%
LEEP
82.86
90%
275.26
2%
Simple hysterectomy
839.00
7%
24.41
100%
72.74
100%
ECG
10.79
70%
Follow-up – CIN 2
9.24
0%
Nurse visit
2.46
100%
18.60
100%
Colposcopy
13.89
100%
Biopsy – sample
39.39
100%
21.49
100%
Pap smear
10.55
100%
46.81
10%
IV antibiotics
2.46
10%
Blood transfusion
18.60
10%
Regular ward
72.74
10%
13.89
70%
Colposcopy
13.89
100%
Biopsy – sample
39.39
100%
21.49
100%
23.25
70%
225.26
70%
ECG
10.79
70%
Cystoscopy
96.14
70%
Proctoscopy
89.45
0%
Cone biopsy
164.19
0%
16.05
0%
30.12
70%
Bone scan
128.57
0%
139.51
0%
Pelvis MRI
265.32
0%
99.48
0%
Rectosigmoidoscopy
119.33
0%
Urography
71.61
0%
Complete hemogram
4.92
100%
Complete urine test
3.07
100%
2.00
42.98
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
2.00
5.00
1.00
2.72
3.45
1.68
1.51
1.51
2.15
4.19
0.40
74.57
5.51
58.73
48.81
363.68
7.55
1.00
3.00
2.00
2.00
2.00
2.00
2.46
55.81
27.78
78.78
42.98
21.09
1.00
1.00
1.00
1.00
4.68
0.25
1.86
7.27
968.98
2.00
1.00
1.00
1.00
2.00
2.00
1.00
1.00
1.00
5.00
1.00
19.45
13.89
39.39
21.49
32.55
315.36
7.55
67.30
21.09
24.62
3.07
242
Urine culture
5.99
Electrolyte
2.01
Serum creatinine
2.16
Prothrombin time
9.70
Glycemia
2.16
Ionogram
2.89
HIV test
21.49
ALT serum
2.16
AST (TGO)
2.16
Ureic nitrogen
1.88
Nurse visit
2.46
18.60
Surgery – IA1
275.26
Simple hysterectomy
839.00
1,145.41
316.44
Trachelectomy
24.41
72.74
146.11
care ward)
302.43
18.60
Pelvic teletherapy
2,022.52
1,834.04
146.11
care ward)
598.48
2,022.52
Palliative surgery
1,145.41
Palliative medicine
62.64
21.06
Follow-up – IA1
18.60
Pap smear
10.55
13.89
Surgery – IA2
Simple hysterectomy
839.00
1,145.41
316.44
Trachelectomy
24.41
72.74
146.11
care ward)
302.43
18.60
100%
100%
100%
100%
100%
0%
0%
0%
0%
0%
100%
100%
1.00
6.00
1.00
1.00
1.00
1.00
4.00
5.99
12.04
2.16
9.70
2.16
2.46
74.41
30%
100%
0%
0%
0%
0%
100%
100%
1.00
1.00
8.00
2.00
82.58
839.00
581.88
292.22
30%
100%
2.00
2.00
181.46
37.20
0%
100%
100%
1.00
3.00
1,834.04
438.33
0%
-
-
0%
0%
100%
100%
1.00
2.00
62.64
42.13
100%
98%
70%
6.00
3.00
6.00
111.61
31.01
58.34
5,267.11
0%
100%
100%
0%
0%
100%
100%
1.00
1.00
8.00
2.00
1,145.41
316.44
581.88
292.22
15%
100%
2.00
2.00
90.73
37.20
243
Pelvic teletherapy
care ward)
Palliative surgery
Palliative medicine
Follow-up – IA2
Pap smear
Surgery – IB1
Simple hysterectomy
Trachelectomy
care ward)
Pelvic teletherapy
care ward)
Palliative surgery
Palliative medicine
Follow-up – IB1
Pap smear
Surgery – IB2
Simple hysterectomy
Trachelectomy
care ward)
2,022.52
1,834.04
146.11
0%
100%
100%
1.00
3.00
1,834.04
438.33
598.48
0%
-
-
2,022.52
1,145.41
62.64
21.06
0%
0%
100%
100%
1.00
3.00
62.64
63.19
18.60
10.55
13.89
100%
98%
70%
6.00
3.00
6.00
111.61
31.01
58.34
5,737.72
839.00
1,145.41
316.44
24.41
72.74
146.11
0%
100%
100%
0%
0%
100%
100%
1.00
1.00
8.00
2.00
1,145.41
316.44
581.88
292.22
302.43
18.60
15%
100%
2.00
2.00
90.73
37.20
2,022.52
1,834.04
146.11
100%
100%
0%
1.00
1.00
-
2,022.52
1,834.04
-
598.48
0%
-
-
2,022.52
1,145.41
62.64
21.06
0%
0%
100%
100%
1.00
2.00
62.64
42.13
18.60
10.55
13.89
100%
98%
70%
6.00
3.00
6.00
111.61
31.01
58.34
7,300.85
839.00
1,145.41
316.44
24.41
72.74
146.11
0%
0%
0%
0%
0%
0%
0%
-
-
302.43
18.60
0%
0%
-
244
Pelvic teletherapy
care ward)
Palliative surgery
Palliative medicine
Follow-up – IB2
Pap smear
Surgery – IIA
Simple hysterectomy
Trachelectomy
care ward)
Pelvic teletherapy
care ward)
Palliative surgery
Palliative medicine
Follow-up – IIA
Pap smear
Surgery – IIB
Simple hysterectomy
Trachelectomy
care ward)
2,022.52
1,834.04
146.11
100%
100%
100%
1.00
1.00
6.00
2,022.52
1,834.04
876.66
598.48
100%
1.00
598.48
2,022.52
1,145.41
62.64
131.73
0%
0%
100%
100%
2.00
8.00
125.29
1,053.86
18.60
10.55
13.89
100%
98%
70%
22.00
3.00
3.00
409.24
31.01
29.17
7,654.94
839.00
1,145.41
316.44
24.41
72.74
146.11
0%
100%
100%
0%
0%
100%
100%
1.00
1.00
8.00
2.00
1,145.41
316.44
581.88
292.22
302.43
18.60
15%
100%
1.00
1.00
45.36
18.60
2,022.52
1,834.04
146.11
100%
100%
100%
1.00
1.00
2.00
2,022.52
1,834.04
292.22
598.48
100%
1.00
598.48
2,022.52
1,145.41
62.64
131.73
0%
0%
100%
100%
1.00
1.00
62.64
131.73
18.60
10.55
13.89
100%
98%
70%
22.00
3.00
3.00
409.24
31.01
29.17
8,485.65
839.00
1,145.41
316.44
24.41
72.74
146.11
0%
0%
0%
0%
0%
0%
0%
-
-
302.43
0%
-
-
-
245
Pelvic teletherapy
care ward)
Palliative surgery
Palliative medicine
Follow-up – IIB
Pap smear
Simple hysterectomy
Trachelectomy
care ward)
Pelvic teletherapy
care ward)
Palliative surgery
Palliative medicine
Pap smear
Surgery – IVA
Simple hysterectomy
Trachelectomy
care ward)
18.60
100%
4.00
74.41
2,022.52
1,834.04
146.11
100%
100%
100%
1.00
1.00
8.00
2,022.52
1,834.04
1,168.88
598.48
100%
1.00
598.48
2,022.52
1,145.41
62.64
131.73
0%
70%
100%
100%
1.00
2.00
8.00
801.79
125.29
1,053.86
18.60
10.55
13.89
100%
100%
100%
22.00
3.00
3.00
409.24
31.64
41.67
8,836.48
839.00
1,145.41
316.44
24.41
72.74
146.11
0%
0%
0%
0%
0%
0%
0%
-
-
302.43
18.60
0%
0%
-
-
2,022.52
1,834.04
146.11
100%
100%
100%
1.00
1.00
4.00
2,022.52
1,834.04
584.44
598.48
100%
1.00
598.48
2,022.52
1,145.41
62.64
131.73
65%
65%
100%
100%
1.00
1.00
2.00
8.00
1,314.64
744.52
125.29
1,053.86
18.60
10.55
13.89
100%
98%
70%
22.00
3.00
3.00
409.24
31.01
29.17
9,421.87
839.00
1,145.41
316.44
24.41
72.74
146.11
0%
0%
0%
0%
0%
0%
0%
-
-
-
-
246
Pelvic teletherapy
care ward)
Palliative care –IVA
Palliative surgery
Palliative medicine
Follow-up – IVA
Pap smear
Surgery – IVB
Simple hysterectomy
Trachelectomy
care ward)
Pelvic teletherapy
care ward)
Palliative surgery
Palliative medicine
Follow-up – IVB
Pap smear
302.43
18.60
0%
0%
-
-
2,022.52
1,834.04
146.11
100%
100%
100%
1.00
1.00
8.00
2,022.52
1,834.04
1,168.88
598.48
100%
1.00
598.48
2,022.52
1,145.41
62.64
131.73
65%
50%
100%
100%
1.00
1.00
4.00
8.00
1,314.64
572.71
250.58
1,053.86
18.60
10.55
13.89
100%
98%
70%
22.00
6.00
12.00
409.24
62.02
116.68
10,078.31
839.00
1,145.41
316.44
24.41
72.74
146.11
0%
0%
0%
0%
0%
0%
0%
-
-
302.43
18.60
0%
0%
-
-
2,022.52
1,834.04
146.11
100%
100%
100%
1.00
1.00
8.00
2,022.52
1,834.04
1,168.88
598.48
100%
1.00
598.48
2,022.52
1,145.41
62.64
131.73
85%
50%
100%
100%
1.00
1.00
4.00
8.00
1,719.14
572.71
250.58
1,053.86
18.60
10.55
13.89
100%
100%
100%
22.00
6.00
12.00
409.24
63.28
166.69
10,534.08
-
1
2
3
Sources:
247
1. FONASA, Arancel de Prestaciones de Salud . Modalidad Libre Elección, 2005.
2. Ministerio de Salud. Guía Clínica Cáncer Cervicouterino. Serie guías clínicas MINSAL NºXX, 3ª edición. Santiago:
Minsal, 2006.
3. Expert opinion (Interview with one expert in charge of the National Cervical Cancer Program, Cancer Unit, Minsal,
2006.
248
Colombia
Unit cost
(International $,
2005)
% used1
Screening tests
Pap smear
15.32
70%
VPH DNA-based test
0%
Visual inspection - VIA
0%
Visual inspection - VILI
0%
Follow-up
19.15
60%
Nurse visit
9.58
40%
27.62
40%
Diagnosis, management, and follow-up of pre-cervical cancer
Diagnosis – CIN 1
Colposcopy
31.92
75%
Biopsy – sample
56.67
70%
75.18
70%
Treatment – CIN 1
Blood typing
13.41
70%
Complete blood test
15.96
70%
Prothrombin time
19.37
70%
Blood glucose
7.98
70%
Creatinine
7.63
70%
Complete urine test
8.45
70%
Urine culture
34.98
20%
0%
Cryotherapy
56.19
10%
LEEP
79.81
5%
79.81
10%
Observation ward
45.17
60%
Regular ward
57.46
90%
ECG
26.18
40%
Follow-up – CIN 1
19.15
0%
Nurse visit
9.58
100%
27.62
100%
Colposcopy
31.92
100%
Biopsy – sample
56.67
100%
75.18
100%
Pap smear
15.32
100%
0%
IV antibiotics
15.96
5%
Blood transfusion
126.10
5%
Regular ward
57.46
0%
Diagnosis – CIN 2
Colposcopy
31.92
80%
Biopsy – sample
56.67
60%
(International
$, 2005)3
1.00
-
10.72
-
1.00
1.00
1.00
11.49
3.83
11.05
37.09
2.00
2.00
2.00
47.88
79.34
105.25
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
9.39
11.17
13.56
5.59
5.34
5.92
7.00
5.62
3.99
7.98
27.10
51.71
10.47
1.00
5.00
4.00
2.00
2.00
2.00
9.58
138.10
127.68
113.34
150.36
30.64
1.00
1.00
-
0.80
6.31
974.11
2.00
2.00
51.07
68.00
249
75.18
70%
Treatment – CIN 2
Blood typing
13.41
70%
Complete blood test
15.96
70%
Prothrombin time
19.37
70%
Blood glucose
7.98
70%
Creatinine
7.63
70%
Complete urine test
8.45
70%
Urine culture
34.98
20%
0%
Cryotherapy
56.19
5%
LEEP
79.81
90%
79.81
5%
Simple hysterectomy
0%
47.89
60%
127.70
100%
ECG
26.18
70%
Follow-up – CIN 2
19.15
0%
Nurse visit
9.58
100%
27.62
100%
Colposcopy
31.92
100%
Biopsy – sample
56.67
100%
75.18
100%
Pap smear
15.32
100%
0%
IV antibiotics
15.96
10%
Blood transfusion
126.10
10%
Regular ward
0%
27.62
70%
Colposcopy
31.92
100%
Biopsy – sample
56.67
100%
75.18
100%
96.25
70%
124.03
70%
ECG
26.18
50%
Cystoscopy
95.77
50%
Proctoscopy
47.89
0%
Cone biopsy
389.64
0%
0%
38.31
50%
Bone scan
0%
366.02
0%
Pelvis MRI
0%
95.77
0%
Rectosigmoidoscopy
95.77
0%
Urography
0%
Complete hemogram
20.75
100%
Complete urine test
8.45
100%
2.00
105.25
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
2.25
1.00
9.39
11.17
13.56
5.59
5.34
5.92
7.00
2.81
71.83
3.99
28.73
287.33
18.33
1.00
4.00
4.00
2.00
2.00
2.00
9.58
110.48
127.68
113.34
150.36
30.64
1.00
1.00
-
1.60
12.61
1,251.58
2.00
1.00
1.00
1.00
2.00
2.00
1.00
1.00
1.00
5.00
1.00
38.67
31.92
56.67
75.18
134.75
173.64
13.09
47.89
19.16
103.75
8.45
250
Urine culture
34.98
Electrolyte
40.73
Serum creatinine
12.32
Prothrombin time
19.37
Glycemia
7.98
Ionogram
38.26
HIV test
45.77
ALT serum
AST (TGO)
Ureic nitrogen
7.04
Nurse visit
9.58
27.62
Surgery – IA1
79.81
Simple hysterectomy
1,248.26
1,424.65
1,424.65
Trachelectomy
307.92
45.17
426.84
care ward)
793.49
27.62
Pelvic teletherapy
990.31
580.55
426.84
care ward)
180.38
473.77
Palliative surgery
1,336.38
Palliative medicine
159.62
Follow-up – IA1
27.62
Pap smear
15.32
27.62
Surgery – IA2
Simple hysterectomy
1,248.26
1,424.65
1,424.65
Trachelectomy
307.92
45.17
426.84
care ward)
793.49
27.62
100%
100%
100%
100%
100%
0%
0%
0%
0%
0%
100%
100%
1.00
6.00
1.00
1.00
1.00
1.00
4.00
34.98
244.38
12.32
19.37
7.98
9.58
110.48
2%
98%
0%
0%
0%
0%
100%
100%
1.00
1.00
8.00
2.00
1.60
1,223.29
361.36
853.68
15%
100%
1.00
2.00
119.02
55.24
0%
100%
0%
1.00
-
580.55
-
0%
-
-
0%
0%
100%
0%
1.00
-
159.62
-
100%
98%
70%
6.00
3.00
6.00
165.72
45.04
116.00
4,823.38
0%
100%
100%
0%
0%
100%
100%
1.00
1.00
8.00
2.00
1,424.65
1,424.65
361.36
853.68
15%
100%
2.00
1.00
238.05
27.62
251
Pelvic teletherapy
care ward)
Palliative surgery
Palliative medicine
Follow-up – IA2
Pap smear
Surgery – IB1
Simple hysterectomy
Trachelectomy
care ward)
Pelvic teletherapy
care ward)
Palliative surgery
Palliative medicine
Follow-up – IB1
Pap smear
Surgery – IB2
Simple hysterectomy
Trachelectomy
care ward)
990.31
580.55
426.84
0%
100%
0%
1.00
-
580.55
-
180.38
0%
-
-
473.77
1,336.38
159.62
-
0%
0%
100%
0%
1.00
-
159.62
-
27.62
15.32
27.62
100%
100%
70%
6.00
3.00
6.00
165.72
45.96
116.00
6,540.11
1,248.26
1,424.65
1,424.65
307.92
45.17
426.84
0%
100%
100%
0%
0%
100%
100%
1.00
1.00
2.00
1.00
1,424.65
1,424.65
90.34
426.84
793.49
27.62
15%
100%
1.00
2.00
119.02
55.24
990.31
580.55
426.84
100%
100%
0%
1.00
1.00
-
990.31
580.55
-
180.38
0%
-
-
473.77
1,336.38
159.62
-
0%
0%
100%
0%
1.00
-
159.62
-
27.62
15.32
27.62
100%
98%
70%
6.00
2.00
2.00
165.72
30.03
38.67
6,647.89
1,248.26
1,424.65
1,424.65
307.92
45.17
426.84
0%
100%
0%
0%
0%
100%
100%
1.00
4.00
3.00
1,424.65
180.68
1,280.52
793.49
27.62
15%
100%
2.00
1.00
238.05
27.62
252
Pelvic teletherapy
care ward)
Palliative surgery
Palliative medicine
Follow-up – IB2
Pap smear
Surgery – IIA
Simple hysterectomy
Trachelectomy
care ward)
Pelvic teletherapy
care ward)
Palliative surgery
Palliative medicine
Follow-up – IIA
Pap smear
Surgery – IIB
Simple hysterectomy
Trachelectomy
care ward)
990.31
580.55
426.84
100%
100%
0%
1.00
1.00
-
990.31
580.55
-
180.38
100%
1.00
180.38
473.77
1,336.38
159.62
-
0%
0%
100%
0%
1.00
-
159.62
-
27.62
15.32
27.62
100%
100%
100%
22.00
4.00
4.00
607.64
61.28
110.48
6,984.03
1,248.26
1,424.65
1,424.65
307.92
45.17
426.84
0%
100%
100%
0%
0%
100%
100%
1.00
1.00
1.00
1.00
1,424.65
1,424.65
45.17
426.84
793.49
27.62
15%
100%
1.00
1.00
119.02
27.62
990.31
580.55
426.84
100%
100%
0%
1.00
1.00
-
990.31
580.55
-
180.38
100%
1.00
180.38
473.77
1,336.38
159.62
-
0%
0%
100%
0%
1.00
-
159.62
-
27.62
15.32
27.62
100%
98%
70%
22.00
3.00
3.00
607.64
45.04
58.00
7,231.75
1,248.26
1,424.65
1,424.65
307.92
45.17
426.84
0%
100%
100%
0%
0%
100%
100%
1.00
1.00
3.00
1.00
1,424.65
1,424.65
135.51
426.84
793.49
15%
1.00
119.02
253
Pelvic teletherapy
care ward)
Palliative surgery
Palliative medicine
Follow-up – IIB
Pap smear
Simple hysterectomy
Trachelectomy
care ward)
Pelvic teletherapy
care ward)
Palliative surgery
Palliative medicine
Pap smear
Surgery – IVA
Simple hysterectomy
Trachelectomy
care ward)
27.62
100%
1.00
27.62
990.31
580.55
426.84
100%
100%
0%
1.00
1.00
-
990.31
580.55
-
180.38
100%
1.00
180.38
473.77
1,336.38
159.62
-
0%
0%
100%
0%
1.00
-
159.62
-
27.62
15.32
27.62
100%
98%
70%
22.00
3.00
6.00
607.64
45.04
116.00
7,380.09
1,248.26
1,424.65
1,424.65
307.92
45.17
426.84
0%
0%
0%
0%
0%
0%
0%
-
-
793.49
27.62
0%
0%
-
-
990.31
580.55
426.84
100%
100%
100%
1.00
1.00
5.00
990.31
580.55
2,134.20
180.38
100%
1.00
180.38
473.77
1,336.38
159.62
-
100%
100%
100%
0%
1.00
1.00
1.00
-
473.77
1,336.38
159.62
-
27.62
15.32
27.62
100%
100%
100%
22.00
3.00
3.00
607.64
45.96
82.86
7,733.92
1,248.26
1,424.65
1,424.65
307.92
45.17
426.84
0%
0%
0%
0%
0%
0%
0%
-
-
-
-
254
Pelvic teletherapy
care ward)
Palliative care –IVA
Palliative surgery
Palliative medicine
Follow-up – IVA
Pap smear
Surgery – IVB
Simple hysterectomy
Trachelectomy
care ward)
Pelvic teletherapy
care ward)
Palliative surgery
Palliative medicine
Follow-up – IVB
Pap smear
793.49
27.62
0%
0%
-
-
990.31
580.55
426.84
100%
100%
100%
1.00
1.00
5.00
990.31
580.55
2,134.20
180.38
100%
1.00
180.38
473.77
1,336.38
159.62
-
100%
100%
100%
0%
1.00
1.00
1.00
-
473.77
1,336.38
159.62
-
27.62
15.32
27.62
100%
100%
100%
22.00
6.00
12.00
607.64
91.92
331.44
8,028.46
1,248.26
1,424.65
1,424.65
307.92
45.17
426.84
0%
0%
0%
0%
0%
0%
0%
-
-
793.49
27.62
0%
0%
-
-
990.31
580.55
426.84
100%
100%
100%
1.00
1.00
6.00
990.31
580.55
2,561.04
180.38
100%
1.00
180.38
473.77
1,336.38
159.62
-
100%
100%
100%
0%
1.00
1.00
1.00
-
473.77
1,336.38
159.62
-
27.62
15.32
27.62
100%
100%
100%
22.00
6.00
12.00
607.64
91.92
331.44
8,455.30
-
1
2
3
Sources:
255
1. Decreto 2423 de 1996. Manual Tarifario ajustado a 2005.
2. Ministerio de Protección Social. Serie Guías Clínicas.
3. Expert opinion (Interviews with 3 experts in charge of the National Cervical Cancer Program, Universidad de
Cartagena, Cartagena, Colombia.
256
Mexico
Unit cost
(International $,
2005)
% used1
Screening tests
Pap smear
22.13
95%
VPH DNA-based test
187.50
5%
0%
0%
Follow-up
22.00
100%
Nurse visit
10.81
0%
32.93
0%
Diagnosis, management, and follow-up of pre-cervical cancer
Diagnosis – CIN 1
Colposcopy
49.75
70%
Biopsy – sample
34.25
70%
0%
Treatment – CIN 1
Blood typing
0%
Complete blood test
2.56
100%
Prothrombin time
2.56
100%
Blood glucose
2.56
100%
Creatinine
2.56
100%
Complete urine test
2.56
100%
Urine culture
2.56
100%
200.00
0%
Cryotherapy
165.00
10%
LEEP
133.75
20%
200.00
0%
Observation ward
32.93
100%
Regular ward
77.75
100%
ECG
0%
Follow-up – CIN 1
22.00
0%
Nurse visit
10.81
100%
32.93
100%
Colposcopy
49.75
100%
Biopsy – sample
34.25
100%
100%
Pap smear
22.13
100%
20.38
10%
IV antibiotics
17.90
10%
Blood transfusion
28.75
10%
Regular ward
77.75
0%
Diagnosis – CIN 2
Colposcopy
49.75
100%
Biopsy – sample
34.25
100%
(International
$, 2005)3
1.00
1.00
-
21.02
9.38
-
1.00
-
22.00
52.39
2.00
2.00
-
69.65
47.95
-
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
-
2.56
2.56
2.56
2.56
2.56
2.56
16.50
26.75
32.93
77.75
-
1.00
4.00
2.00
2.00
2.00
10.81
131.72
99.50
68.50
44.25
1.00
1.00
1.00
-
2.04
1.79
2.88
648.37
2.00
2.00
99.50
68.50
257
0%
Treatment – CIN 2
Blood typing
70%
Complete blood test
2.56
70%
Prothrombin time
2.56
70%
Blood glucose
2.56
70%
Creatinine
2.56
70%
Complete urine test
2.56
70%
Urine culture
2.56
20%
200.00
0%
Cryotherapy
165.00
1%
LEEP
133.75
90%
200.00
2%
Simple hysterectomy
1,079.75
7%
77.75
60%
510.38
25%
ECG
0%
Follow-up – CIN 2
22.00
0%
Nurse visit
10.81
0%
32.93
100%
Colposcopy
49.75
100%
Biopsy – sample
34.25
100%
0%
Pap smear
22.13
100%
20.38
10%
IV antibiotics
17.90
10%
Blood transfusion
28.75
10%
Regular ward
77.75
0%
1,273.50
70%
Colposcopy
49.75
100%
Biopsy – sample
34.25
100%
0%
0%
61.13
70%
ECG
0%
Cystoscopy
139.75
70%
Proctoscopy
147.63
70%
Cone biopsy
133.75
100%
200.00
0%
41.75
70%
Bone scan
0%
0%
Pelvis MRI
108.88
70%
0%
Rectosigmoidoscopy
84.63
70%
Urography
0%
Complete hemogram
2.56
100%
Complete urine test
2.56
100%
-
-
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
3.00
-
1.79
1.79
1.79
1.79
1.79
0.51
1.65
120.38
4.00
75.58
46.65
382.78
-
4.00
2.00
2.00
2.00
131.72
99.50
68.50
44.25
1.00
1.00
1.00
-
2.04
1.79
2.88
1,159.18
2.00
1.00
1.00
2.00
1.00
1.00
1.00
1.00
1.00
1.00
4.00
1.00
1,782.90
49.75
34.25
85.58
97.83
103.34
133.75
29.23
76.21
59.24
10.24
2.56
258
Urine culture
2.56
Electrolyte
2.56
Serum creatinine
2.56
Prothrombin time
2.56
Glycemia
2.56
Ionogram
HIV test
ALT serum
AST (TGO)
Ureic nitrogen
Nurse visit
10.81
32.93
Surgery – IA1
133.75
Simple hysterectomy
1,079.75
1,515.38
1,526.75
Trachelectomy
1,310.25
77.75
510.38
care ward)
32.93
Pelvic teletherapy
499.88
744.50
510.38
care ward)
365.63
772.50
Palliative surgery
1,079.75
Palliative medicine
26.45
32.93
Follow-up – IA1
32.93
Pap smear
22.13
123.50
Surgery – IA2
Simple hysterectomy
1,079.75
1,515.38
1,526.75
Trachelectomy
1,310.25
77.75
510.38
care ward)
32.93
100%
100%
100%
100%
100%
0%
0%
0%
0%
0%
100%
100%
1.00
2.00
1.00
1.00
1.00
1.00
4.00
2.56
5.12
2.56
2.56
2.56
10.81
131.72
30%
100%
0%
0%
0%
0%
0%
100%
1.00
1.00
1.00
40.13
1,079.75
510.38
0%
100%
2.00
65.86
0%
0%
0%
-
-
0%
-
-
0%
0%
100%
100%
1.00
1.00
26.45
32.93
100%
98%
70%
6.00
3.00
3.00
197.58
65.05
259.35
4,900.22
0%
100%
100%
0%
0%
0%
100%
1.00
1.00
1.00
1,515.38
1,526.75
510.38
0%
100%
1.00
32.93
259
Pelvic teletherapy
care ward)
Palliative surgery
Palliative medicine
Follow-up - IA2
Pap smear
Surgery – IB1
Simple hysterectomy
Trachelectomy
care ward)
Pelvic teletherapy
care ward)
Palliative surgery
Palliative medicine
Follow-up – IB1
Pap smear
Average cost per event - IB1
Surgery – IB2
Simple hysterectomy
Trachelectomy
care ward)
499.88
744.50
510.38
100%
100%
50%
1.00
1.00
0.50
499.88
744.50
127.59
365.63
0%
-
-
772.50
1,079.75
26.45
32.93
0%
0%
100%
100%
1.00
1.00
26.45
32.93
32.93
22.13
123.50
100%
98%
70%
4.00
2.00
2.00
131.72
43.37
172.90
7,987.51
1,079.75
1,515.38
1,526.75
1,310.25
77.75
510.38
0%
100%
100%
0%
0%
0%
100%
1.00
1.00
1.00
1,515.38
1,526.75
510.38
32.93
0%
100%
2.00
65.86
499.88
744.50
510.38
100%
100%
30%
1.00
1.00
0.50
499.88
744.50
76.56
365.63
50%
1.00
182.81
772.50
1,079.75
26.45
32.93
0%
0%
100%
100%
1.00
1.00
26.45
32.93
32.93
22.13
123.50
100%
50%
50%
2.00
2.00
1.00
65.86
22.13
61.75
7,953.97
1,079.75
1,515.38
1,526.75
1,310.25
77.75
510.38
0%
100%
100%
0%
0%
0%
60%
1.00
1.00
1.00
1,515.38
1,526.75
306.23
32.93
0%
100%
2.00
65.86
260
Pelvic teletherapy
care ward)
Palliative surgery
Palliative medicine
Follow-up – IB2
Pap smear
Surgery – IIA
Simple hysterectomy
Trachelectomy
care ward)
Pelvic teletherapy
care ward)
Palliative surgery
Palliative medicine
Follow-up – IIA
Pap smear
Surgery – IIB
Simple hysterectomy
Trachelectomy
care ward)
499.88
744.50
510.38
100%
100%
65%
1.00
1.00
0.50
499.88
744.50
165.87
365.63
50%
1.00
182.81
772.50
1,079.75
26.45
32.93
0%
0%
5%
5%
1.00
1.00
1.32
1.65
32.93
22.13
123.50
100%
98%
70%
4.00
2.00
2.00
131.72
43.37
172.90
7,980.97
1,079.75
1,515.38
1,526.75
1,310.25
77.75
510.38
0%
0%
0%
0%
0%
0%
0%
-
-
32.93
0%
0%
-
-
699.88
944.50
510.38
100%
100%
100%
1.00
1.00
4.00
699.88
944.50
2,041.50
365.63
100%
1.00
365.63
772.50
1,079.75
26.45
32.93
0%
0%
100%
100%
4.00
4.00
105.80
131.72
32.93
22.13
123.50
100%
100%
100%
22.00
3.00
3.00
724.46
66.38
370.50
8,073.10
1,079.75
1,515.38
1,526.75
1,310.25
77.75
510.38
0%
0%
0%
0%
0%
0%
0%
-
-
-
0%
-
-
-
261
Pelvic teletherapy
care ward)
Palliative surgery
Palliative medicine
Follow-up – IIB
Pap smear
Simple hysterectomy
Trachelectomy
care ward)
Pelvic teletherapy
care ward)
Palliative surgery
Palliative medicine
Pap smear
Surgery – IVA
Simple hysterectomy
Trachelectomy
care ward)
32.93
0%
Radiotherapy - IIB
699.88
100%
944.50
100%
510.38
100%
-
-
1.00
1.00
4.00
699.88
944.50
2,041.50
365.63
75%
1.00
274.22
772.50
1,079.75
26.45
32.93
0%
70%
100%
100%
1.00
1.00
1.00
755.83
26.45
32.93
32.93
22.13
123.50
100%
100%
100%
22.00
3.00
3.00
724.46
66.38
370.50
8,559.38
1,079.75
1,515.38
1,526.75
1,310.25
77.75
510.38
0%
0%
0%
0%
0%
0%
0%
-
-
32.93
0%
0%
-
-
699.88
944.50
510.38
100%
100%
100%
1.00
1.00
4.00
699.88
944.50
2,041.50
365.63
75%
1.00
274.22
772.50
1,079.75
26.45
32.93
65%
65%
100%
100%
1.00
1.00
1.00
1.00
502.13
701.84
26.45
32.93
32.93
22.13
123.50
100%
98%
70%
22.00
3.00
3.00
724.46
65.05
259.35
8,895.04
1,079.75
1,515.38
1,526.75
1,310.25
77.75
510.38
0%
0%
0%
0%
0%
0%
0%
-
-
-
-
262
Pelvic teletherapy
care ward)
Palliative surgery
Palliative medicine
Follow-up – IVA
Pap smear
Surgery – IVB
Simple hysterectomy
Trachelectomy
care ward)
Pelvic teletherapy
care ward)
Palliative surgery
Palliative medicine
Follow-up – IVB
Pap smear
32.93
0%
0%
-
-
699.88
944.50
510.38
100%
100%
100%
1.00
1.00
4.00
699.88
944.50
2,041.50
365.63
100%
1.00
365.63
772.50
1,079.75
26.45
32.93
65%
50%
100%
100%
1.00
1.00
1.00
1.00
502.13
539.88
26.45
32.93
32.93
22.13
123.50
100%
98%
70%
22.00
6.00
6.00
724.46
130.10
518.70
9,148.88
1,079.75
1,515.38
1,526.75
1,310.25
77.75
510.38
0%
0%
0%
0%
0%
0%
0%
-
-
32.93
0%
0%
-
-
699.88
944.50
510.38
100%
100%
100%
1.00
1.00
4.00
699.88
944.50
2,041.50
365.63
100%
1.00
365.63
772.50
1,079.75
26.45
32.93
85%
50%
100%
100%
1.00
1.00
1.00
1.00
656.63
539.88
26.45
32.93
32.93
22.13
123.50
100%
100%
100%
22.00
6.00
6.00
724.46
132.75
741.00
9,528.34
-
1
2
3
every stage of treatment and considers only the first year of palliative therapy.
Sources:
263
1. National Comprehensive Cancer Network (NCCN), Guías de Práctica Oncológica – v.1 2005; Modificación a la
Norma Oficial Mexicana NOM-014-SSA2-1994, Para la Prevención, Detección, diagnóstico, tratamiento, control y
vigilancia epidemiológica del cáncer cérvico uterino.
2. Expert opinion (Interview with one expert in charge of the NCNN).
3. Marmolejo-Saucedo, Costos del diagnostico y tratamiento de las enfermedades relacionadas con el virus del
papiloma humano en el Instituto Nacional de Cancerologia, Mexico.
264
Peru
Unit cost
(International $,
2005)
% used1
Screening tests
Pap smear
3.42
90%
VPH DNA-based test
12.50
5%
0.80
3%
1.96
2%
Follow-up
2.77
80%
Nurse visit
0.84
100%
13.88
20%
Diagnosis – CIN 1
Colposcopy
27.70
80%
Biopsy – sample
20.70
80%
38.67
0%
Treatment – CIN 1
Blood typing
3.15
0%
Complete blood test
2.50
100%
Prothrombin time
2.50
100%
Blood glucose
2.50
100%
Creatinine
2.50
100%
Complete urine test
2.50
100%
Urine culture
2.50
100%
114.17
0%
Cryotherapy
38.67
10%
LEEP
48.22
10%
315.27
0%
Observation ward
71.35
0%
Regular ward
190.50
100%
ECG
8.59
0%
Follow-up – CIN 1
2.77
0%
Nurse visit
0.84
100%
13.88
100%
Colposcopy
27.70
100%
Biopsy - sample
20.70
100%
Biopsy - histopathology study
38.67
0%
Pap smear
3.42
100%
52.40
10%
IV antibiotics
27.51
10%
Blood transfusion
8.44
0%
Regular ward
190.50
10%
Diagnosis – CIN 2
Colposcopy
27.70
100%
Biopsy – sample
20.70
100%
(International
$, 2005)3
1.00
1.00
1.00
1.00
3.08
0.63
0.02
0.04
2.00
2.00
2.00
4.43
1.68
5.55
15.43
2.00
2.00
-
44.32
33.12
-
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
-
2.50
2.50
2.50
2.50
2.50
2.50
3.87
4.82
190.50
-
1.00
4.00
4.00
4.00
2.00
0.84
55.52
110.80
82.80
6.84
1.00
1.00
2.00
5.24
2.75
38.10
594.52
2.00
2.00
55.40
41.40
265
38.67
0%
Treatment – CIN 2
Blood typing
3.15
100%
Complete blood test
2.50
100%
Prothrombin time
2.50
100%
Blood glucose
2.50
100%
Creatinine
2.50
100%
Complete urine test
2.50
100%
Urine culture
2.50
100%
0%
Cryotherapy
38.67
5%
LEEP
48.22
80%
315.27
5%
Simple hysterectomy
1,053.93
10%
58.68
0%
190.50
40%
ECG
8.59
0%
Follow-up – CIN 2
2.77
0%
Nurse visit
0.84
0%
13.88
100%
Colposcopy
27.70
100%
Biopsy – sample
20.70
100%
38.67
0%
Pap smear
3.42
100%
20.38
10%
IV antibiotics
17.90
10%
Blood transfusion
8.44
0%
Regular ward
190.50
0%
Average cost per event - CIN 2
396.80
100%
Colposcopy
27.70
100%
Biopsy - sample
20.70
80%
Biopsy - histopathology study
38.67
0%
32.86
0%
58.85
70%
ECG
7.64
0%
Cystoscopy
60.80
70%
Proctoscopy
68.99
70%
Cone biopsy
474.40
20%
126.25
0%
21.20
100%
Bone scan
114.26
0%
117.97
0%
Pelvis MRI
178.33
70%
33.02
0%
Rectosigmoidoscopy
52.62
70%
Urography
15.45
0%
Complete hemogram
2.50
100%
Complete urine test
2.50
100%
-
-
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
2.25
-
3.15
2.50
2.50
2.50
2.50
2.50
2.50
1.93
38.58
15.76
105.39
171.45
-
5.00
4.00
4.00
4.00
69.40
110.80
82.80
13.68
1.00
1.00
-
2.04
1.79
728.57
2.00
2.00
2.00
2.00
1.00
1.00
1.00
1.00
1.00
1.00
5.00
1.00
793.60
55.40
33.12
82.39
42.56
48.29
94.88
21.20
124.83
36.83
12.50
2.50
266
Urine culture
2.50
Electrolyte
2.50
Serum creatinine
2.50
Prothrombin time
2.50
Glycemia
2.50
Ionogram
6.94
HIV test
33.94
ALT serum
2.47
AST (TGO)
2.47
Ureic nitrogen
3.35
Nurse visit
0.84
13.88
Surgery – IA1
133.75
Simple hysterectomy
1,053.93
2,037.58
999.53
Trachelectomy
574.07
58.68
135.10
360.62
care ward)
362.42
13.88
Pelvic teletherapy
869.60
829.69
428.69
care ward)
411.57
596.67
Palliative surgery
681.38
Palliative medicine
67.96
395.32
Follow-up – IA1
13.88
Pap smear
3.42
117.57
Surgery – IA2
Simple hysterectomy
1,053.93
2,037.58
999.53
Trachelectomy
574.07
58.68
135.10
360.62
care ward)
362.42
13.88
100%
100%
100%
100%
100%
0%
0%
0%
0%
0%
100%
100%
1.00
6.00
1.00
1.00
1.00
1.00
4.00
2.50
15.00
2.50
2.50
2.50
0.84
55.52
30%
70%
0%
0%
0%
0%
0%
100%
1.00
1.00
2.00
40.13
737.75
721.24
0%
100%
2.00
27.76
0%
0%
0%
-
-
0%
-
-
0%
0%
100%
100%
1.00
1.00
67.96
395.32
100%
100%
100%
6.00
2.00
2.00
83.28
6.84
235.14
3,744.88
0%
100%
100%
0%
0%
0%
100%
1.00
1.00
2.00
2,037.58
999.53
721.24
0%
100%
1.00
13.88
267
Pelvic teletherapy
care ward)
Palliative surgery
Palliative medicine
Follow-up – IA2
Pap smear
Surgery – IB1
Simple hysterectomy
Trachelectomy
care ward)
Pelvic teletherapy
care ward)
Palliative surgery
Palliative medicine
Follow-up – IB1
Pap smear
Surgery – IB2
Simple hysterectomy
Trachelectomy
care ward)
869.60
829.69
428.69
100%
100%
50%
1.00
1.00
1.00
869.60
829.69
214.35
411.57
0%
-
-
596.67
681.38
67.96
395.32
0%
0%
25%
5%
1.00
1.00
16.99
19.77
13.88
3.42
117.57
100%
98%
70%
6.00
2.00
2.00
83.28
6.70
164.60
7,406.67
1,053.93
2,037.58
999.53
574.07
58.68
135.10
360.62
0%
100%
100%
0%
0%
0%
100%
1.00
1.00
2.00
2,037.58
999.53
721.24
362.42
13.88
0%
100%
2.00
27.76
869.60
829.69
428.69
100%
100%
50%
1.00
1.00
1.00
869.60
829.69
214.35
411.57
0%
-
-
596.67
681.38
67.96
395.32
0%
0%
100%
100%
1.00
1.00
67.96
395.32
13.88
3.42
117.57
100%
100%
100%
6.00
2.00
2.00
83.28
6.84
235.14
7,917.75
1,053.93
2,037.58
999.53
574.07
58.68
135.10
360.62
0%
100%
100%
0%
0%
0%
100%
1.00
1.00
2.00
2,037.58
999.53
721.24
362.42
13.88
0%
100%
2.00
27.76
268
Pelvic teletherapy
care ward)
Palliative surgery
Palliative medicine
Follow-up – IB2
Pap smear
Surgery – IIA
Simple hysterectomy
Trachelectomy
care ward)
Pelvic teletherapy
care ward)
Palliative surgery
Palliative medicine
Follow-up – IIA
Pap smear
Surgery – IIB
Simple hysterectomy
Trachelectomy
care ward)
869.60
829.69
428.69
100%
100%
50%
1.00
1.00
1.00
869.60
829.69
214.35
411.57
0%
-
-
596.67
681.38
67.96
395.32
0%
0%
50%
50%
1.00
1.00
33.98
197.66
13.88
3.42
117.57
100%
60%
60%
22.00
3.00
3.00
305.36
6.16
211.63
7,884.00
1,053.93
2,037.58
999.53
574.07
58.68
135.10
360.62
0%
100%
100%
0%
0%
0%
100%
1.00
1.00
2.00
2,037.58
999.53
721.24
362.42
13.88
0%
0%
-
-
869.60
829.69
428.69
100%
100%
50%
1.00
1.00
1.00
869.60
829.69
214.35
411.57
50%
1.00
205.79
596.67
681.38
67.96
395.32
0%
0%
50%
50%
1.00
1.00
33.98
197.66
13.88
3.42
117.57
100%
100%
100%
22.00
2.00
2.00
305.36
6.84
235.14
8,086.22
1,053.93
2,037.58
999.53
574.07
58.68
135.10
360.62
0%
0%
0%
0%
0%
0%
0%
-
-
362.42
0%
-
-
-
269
Pelvic teletherapy
care ward)
Chemotherapy - IIB
Palliative surgery
Palliative medicine
Follow-up – IIB
Pap smear
Simple hysterectomy
Trachelectomy
care ward)
Pelvic teletherapy
care ward)
Palliative surgery
Palliative medicine
Pap smear
Surgery – IVA
Simple hysterectomy
Trachelectomy
care ward)
13.88
0%
-
-
869.60
829.69
428.69
100%
100%
100%
1.00
1.00
4.00
869.60
829.69
1,714.76
411.57
100%
1.00
411.57
596.67
681.38
67.96
395.32
60%
70%
100%
100%
1.00
1.00
3.00
3.00
358.00
476.97
203.88
1,185.96
13.88
3.42
117.57
100%
100%
100%
22.00
3.00
3.00
305.36
10.26
352.71
8,148.23
1,053.93
2,037.58
999.53
574.07
58.68
135.10
360.62
0%
0%
0%
0%
0%
0%
0%
-
-
362.42
13.88
0%
0%
-
-
869.60
829.69
428.69
100%
100%
100%
1.00
1.00
5.00
869.60
829.69
2,143.45
411.57
100%
1.00
411.57
596.67
681.38
67.96
395.32
85%
85%
100%
100%
1.00
1.00
2.00
2.00
507.17
579.17
135.92
790.64
13.88
3.42
117.57
100%
100%
100%
22.00
4.00
4.00
305.36
13.68
470.28
8,486.00
1,053.93
2,037.58
999.53
574.07
58.68
135.10
360.62
0%
0%
0%
0%
0%
0%
0%
-
-
-
-
270
Pelvic teletherapy
care ward)
Palliative surgery
Palliative medicine
Follow-up – IVA
Pap smear
Surgery – IVB
Simple hysterectomy
Trachelectomy
care ward)
Pelvic teletherapy
care ward)
Palliative surgery
Palliative medicine
Follow-up – IVB
Pap smear
362.42
13.88
0%
0%
-
-
869.60
829.69
428.69
100%
100%
100%
1.00
1.00
5.00
869.60
829.69
2,143.45
411.57
100%
1.00
411.57
596.67
681.38
67.96
395.32
90%
90%
100%
100%
1.00
1.00
2.00
2.00
537.00
613.24
135.92
790.64
13.88
3.42
117.57
100%
100%
100%
22.00
4.00
4.00
305.36
13.68
470.28
8,549.90
1,053.93
2,037.58
999.53
574.07
58.68
135.10
360.62
0%
0%
0%
0%
0%
0%
0%
-
-
362.42
13.88
0%
0%
-
-
869.60
829.69
428.69
100%
100%
100%
1.00
1.00
5.00
869.60
829.69
2,143.45
411.57
100%
1.00
411.57
596.67
681.38
67.96
395.32
85%
75%
100%
100%
1.00
1.00
2.00
2.00
507.17
511.04
135.92
790.64
13.88
3.42
117.57
100%
100%
100%
22.00
6.00
6.00
305.36
20.52
705.42
8,659.84
-
1
2
days; an average of 2 pap smears are performed in patients).
3
year 2005). Costs are based on the first year of treatment and includes follow up care (e.g. ambulatory visits,
any special circumstances (pregnancy, menstruation, PID, or HIV). Palliative care is assumed to be given at every
stage of treatment and only considers the first year of palliative therapy.
Sources:
271
1. Tobar A. Costo y desempeño de las pruebas de tamizaje costos del tratamiento del cancer cervicouterino en la
region de San Martín (Perú), OPS/DPC/NC, 2005.
2. Extrapolation based on unit cost estimates from 7 countries (Argentina, Brazil, Chile, Colombia, DR, Honduras and
Mexico) - population weighted average.
3. Expert opinion (Interview with one OBGYN physician).
272
Appendix I. Costs of transportation and lost work time associated with precervical cancer and invasive cervical cancer by
stage and country
Costs in International $ for 2005
Argentina
Brazil
Chile
Colombia
Dominican
Republic
Honduras
Jamaica
Mexico
Peru
(Internation
2005)
Transp.
P
costsq
Transp.
costsa
Patient
time
lossb
Transp.
Costsc
Patient
time
lossd
Transp.
costse
Patient
time
lossf
Transp.
costsg
Patient
time
lossh
Transp.
costsi
Patient
time
lossj
Transp.
costsk
Patient
time
lossl
Transp.
costsm
Patient
time
lossn
Transp.
costso
Patient
time
lossp
6.76
69.60
6.40
30.68
5.48
168.80
5.20
28.00
4.40
56.80
3.96
42.40
5.16
66.20
2.02
74.40
5.16
23.66
243.60
12.80
61.36
19.18
590.80
13.00
70.00
6.60
85.20
11.88
127.20
10.32
132.40
12.12
446.40
20.64
20.28
208.80
12.80
61.36
32.88
1,012.80
18.85
101.50
11.00
142.00
13.86
148.40
20.64
264.80
16.16
595.20
18.71
27.04
278.40
51.20
245.45
68.50
2,110.00
54.60
294.00
15.40
198.80
19.80
212.00
20.64
264.80
22.22
818.40
36.12
Average cost
per event (IA2)
33.80
348.00
48.00
230.11
68.50
2,110.00
57.20
308.00
19.80
255.60
21.78
233.20
23.22
297.90
19.19
706.80
38.70
Average cost
per event (IB1)
33.80
348.00
48.00
230.11
60.28
1,856.80
36.40
196.00
19.80
255.60
19.80
212.00
25.80
331.00
15.15
558.00
38.70
Average cost
per event (IB2)
47.32
487.20
102.40
490.91
87.68
2,700.80
91.00
490.00
63.80
823.60
55.44
593.60
69.66
893.69
19.19
706.80
74.82
Average cost
per event (IIA)
43.94
452.40
99.20
475.57
112.34
3,460.40
75.40
406.00
59.40
766.80
55.44
593.60
72.24
926.79
60.60
2,232.00
74.82
Average cost
per event (IIB)
50.70
522.00
89.60
429.55
93.16
2,869.60
80.60
434.00
61.60
795.20
55.44
593.60
74.82
959.89
60.60
2,232.00
77.40
Average cost
per event
(IIIA–IIIB)
91.26
939.60
89.60
429.55
82.20
2,532.00
80.60
434.00
61.60
795.20
55.44
593.60
74.82
959.89
60.60
2,232.00
79.98
Average cost
per event (IVA)
91.26
939.60
86.40
414.20
93.16
2,869.60
80.60
434.00
61.60
795.20
53.46
572.40
74.82
959.89
60.60
2,232.00
79.98
Average cost
per event (IVB)
94.64
974.40
89.60
429.55
93.16
2,869.60
83.20
448.00
61.60
795.20
55.44
593.60
74.82
959.89
60.60
2,232.00
79.98
Average cost
per screening
Average cost
per event
(CIN 1)
Average cost
per event
(CIN 2)
Average cost
per event (IA1)
273
66
26
23
46
49
49
95
95
99
1,
1,
1,
a
Transportation costs were based on assumptions made about the number of trips to and from the doctor’s office and/or clinic or hospital and the cost of each trip during the first
year. The number of trips to and from the doctor’s office and/or clinic or hospital was based on the number of outpatient visits and hospital admissions reported by physicians
in Buenos Aires. The cost of each trip was derived from the Asociacion Nacional de Empresas de Transportes Urbanos, 2005.
b
Care time costs were based on the number of days off work (one outpatient consultation or one day in the hospital was assumed to be the same
as one day off work), assuming an average 2005 average monthly salary in Argentina of Int. $765.60 (Direccion Central de Estudios y Formulacion de Politicas de Empleo, en
base a la EPH, INDEC, 2005) and 22 days of work per month.
c
in São Paulo. The cost of each trip was derived from the Associação Nacional das Empresas de Transportes Urbanos, 2005.
d
as one day off work), assuming an average 2005 monthly salary in Brazil of Int. $1,083.58 (BCB, 2005) and 22 days of work per month.
e
in Santiago. The cost of each trip was derived from the Asociacion Nacional de Empresas de Transportes Urbanos, 2005.
f
as one day off work), assuming an average 2005 monthly salary in Chile of Int. $1856.80 (Estadisticas del Trabajo y Prevision, 2005) and 22 days of work per month.
g
in Cartagena de Indias. The cost of each trip was derived from personal communication (Nelson Alvis).
h
as one day off work), assuming an average 2005 monthly salary in Colombia of Int. $308.00 (personal communication, Nelson Alvis) and 22 days of work per month.
i
in Santo Domingo. The cost of each trip was derived from personal communication (Elizabeth Gomez).
j
as one day off work), assuming an average 2005 monthly salary in Dominican Republic of Int. $624.80 (personal communication, Nelson Alvis) and 22 days of work per month.
k
in Tegucigalpa. The cost of each trip was derived from personal communication.
l
as one day off work), assuming an average 2005 monthly salary in Dominican Republic of Int. $466.40 (personal communication) and 22 days of work per month.
m
Transportation costs were based on the number of trips to and from the doctor’s office and/or clinic or hospital from eight countries and the population weighted average cost of
each trip during the first year. The number of trips to and from the doctor’s office and/or clinic or hospital was based on the number of outpatient visits and hospital admissions
extrapolated from eight countries.
n
as one day off work), assuming a population weighted average 2005 monthly salary of Int. $728.19 and 22 days of work per month.
274
o
year. The number of trips to and from the doctor’s office and/or clinic or hospital was based on the amount of outpatient visits and hospital admissions reported by physicians
in Mexico City. The cost of each trip was derived from personal communication.
p
as one day off work), assuming an average 2005 monthly salary in Dominican Republic of Int. $1,636.80 (personal communication) and 22 days of work per month.
q
Transportation costs were based on the number of trips to and from the doctor’s office and/or clinic or hospital from eight countries and the population weighted average cost of
each trip during the first year. The number of trips to and from the doctor’s office and/or clinic or hospital was based on the number of outpatient visits and hospital admissions
extrapolated from eight countries.
r
Care giver time costs were based on the number of days off work (one outpatient consultation or one day in the hospital was assumed to be the same
as one day off work), assuming a population weighted average 2005 monthly salary of Int. $728.19 and 22 days of work per month.
275
Appendix J. Vaccination cost per vaccinated girl and components of cost, expressed in different currencies by country
Cost per fully immunized girl in local currency units
Argentina
Brazil
Chile
25.00
60.08
53.15
12,516.41
International $
Peso
Real
Peso
Currency Unit
Vaccine cost*
15.00
43.55
36.52
8,401.35
Vaccine wastage*
2.25
6.53
5.48
1,260.20
Vaccine supplies (including wastage and
freight)*
1.31
3.80
3.19
733.72
Administration**
1.50
1.44
1.86
494.05
Vaccine Support**
4.94
4.75
6.11
1,627.08
Monitoring, Programmatic, Cold chain,
Injection safety, Operational costs
2.94
2.83
3.64
968.34
Incremental cost of adolescent
vaccination program
2.00
1.92
2.47
658.74
Vaccine cost per dose
5.00
14.52
12.17
2800.45
276
Currency Unit
Vaccine cost*
Vaccine wastage*
freight)*
Administration**
Vaccine Support**
Monitoring, programmatic, cold chain,
injection safety, operational costs
vaccination program
277
Cost per fully immunized girl in local currency units
Colombia
Mexico
25.00
48,563.25
250.93
International $
Peso
Peso
15.00
8401.35
163.47
2.25
1,260.20
24.52
Peru
71.15
Nuevo Sol
49.44
7.42
1.31
1.50
4.94
733.72
494.05
4,210.18
14.28
11.33
37.33
4.32
2.32
7.65
2.94
2505.65
22.22
4.55
2.00
5.00
1704.53
11,604.17
15.11
54.49
3.10
16.48
Currency Unit
Vaccine cost*
Vaccine wastage*
freight)*
Administration**
Vaccine Support**
vaccination program
278
Cost per fully immunized girl in U.S. dollars
Argentina
Brazil
25.00
20.78
21.21
International $
U.S. Dollars
U.S. Dollars
15.00
15.00
15.00
2.25
2.25
2.25
Chile
18.57
U.S. Dollars
15.00
2.25
1.31
1.50
4.94
1.31
0.52
1.70
1.31
0.62
2.03
1.31
0.0027
0.01
2.94
1.01
1.21
0.01
2.00
5.00
0.69
5.00
0.82
5.00
0.0036
5.00
Currency Unit
Vaccine cost*
Vaccine wastage*
freight)*
Administration*
Vaccine Support**
vaccination program
Cost per fully immunized girl in U.S. dollars
Colombia
Mexico
25.00
18.56
19.15
International $
U.S. Dollars
U.S. Dollars
15.00
15.00
15.00
2.25
2.25
2.25
Peru
20.51
U.S. Dollars
15.00
2.25
1.31
1.50
4.94
1.31
0.0006
0.0021
1.31
0.14
0.45
1.31
0.46
1.50
2.94
0.0013
0.27
0.89
2.00
5.00
0.0009
5.00
0.18
5.00
0.61
5.00
*Vaccine, wastage, and supplies are considered tradeable goods. Whether expressed in local currency units or in U.S. dollars, they are converted by using U.S. dollar to local currency
unit exchange rates. For tradeable goods, one U.S. dollar equals one International dollar; thus, when International dollars are expressed as U.S. dollars, those costs stay the same.
**Administration and vaccine support are considered local, nontradeable goods. When these costs are expressed in local currency units, they are converted from International dollars
using PPP exchange rates. When these costs are expressed in U.S. dollars, the local currency units are converted by using U.S. dollar exchange rates.
279

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