Impact of Patient Adherence and Test Performance on the Cost-Effectiveness of Cervical Cancer Screening in Developing Countries : The Case of Honduras

ObjectiveWe examined the impact of patient adherence and screening test performance on the cost-effectiveness of visual inspection with acetic acid (VIA) and Pap smears when used with colposcopy for diagnosis.Materials and MethodsCost-effectiveness analysis was performed using computer modeling. The primary outcome was cancer prevalence in the 10 years after screening. Three hypothetical populations of 35-year-old women were compared: never-screened women, women screened with VIA, and women screened with Pap smears. We used community-based data from our screening program in Honduras to estimate screening test sensitivity and specificity, adherence to follow-up, and costs of screening and colposcopy services. Published data were used to model disease outcomes.ResultsVIA was more sensitive than Pap smears (70% vs. 4%), less expensive (U.S. $0.23 vs. $3.17), and the 2-vist VIA system had a higher rate of adherence to follow-up than the 3-visit Pap smear system (84% vs. 38%). VIA had a higher false-positive rate than Pap smears resulting in higher colposcopy referral rates, but more dysplasia was detected and treated. Cost-effectiveness analysis revealed that screening with VIA would cost U.S. $3,198 per cancer case avoided and reduce cancer cases by 42%, versus U.S. $36,802 and 2% for Pap screening. Although Pap smear quality was low in Honduras, sensitivity analysis showed that VIA was more cost-effective than Pap smears, even when test accuracy was equivalent.ConclusionIn developing countries, systems barriers can limit the cost-effectiveness of Pap smears. VIA may be a cost-effective alternative for some resource-poor settings, although systems barriers, quality control, and feasibility issues must be considered.