Emily Annika Burger

• Henkel, Pia Sofie; Burger, Emily Annika; Sletner, Line & Pedersen, Kine (2024). Exploring Structural Uncertainty in Cost-Effectiveness Modeling of Gestational Diabetes Screening: An Application Example from Norway. Medical decision making. ISSN 0272-989X. doi: 10.1177/0272989X241241339.
• Kunst, Natalia; Burger, Emily Annika; Coupé, Veerle M. H.; Kuntz, Karen M. & Aas, Eline (2023). A Guide to an Iterative Approach to Model-Based Decision Making in Health and Medicine: An Iterative Decision-Making Framework. PharmacoEconomics (Auckland). ISSN 1170-7690. p. 1–9. doi: 10.1007/s40273-023-01341-z.
• Portnoy, Allison; Pedersen, Kine; Sy, Stephen; Tropé, Ameli Ellen Claesdotter; Engesæter, Birgit Øvstebø & Kim, Jane J. [Show all 7 contributors for this article] (2023). Cost-effectiveness of primary human papillomavirus triage approaches among vaccinated women in Norway: A model-based analysis. International Journal of Cancer. ISSN 0020-7136. doi: 10.1002/ijc.34804. Full text in Research Archive
• Spencer, Jennifer C.; Burger, Emily Annika; Campos, Nicole G.; Regan, Mary Caroline; Sy, Stephen & Kim, Jane J. (2023). Adapting a model of cervical carcinogenesis to self-identified Black women to evaluate racial disparities in the United States. Journal of the National Cancer Institute. Monographs. ISSN 1052-6773. 2023(62), p. 188–195. doi: 10.1093/jncimonographs/lgad015.
• Prem, Kiesha; Choi, Yoon Hong; Bénard, Élodie; Burger, Emily Annika; Hadley, Liza & Laprise, Jean-François [Show all 14 contributors for this article] (2023). Global impact and cost-effectiveness of one-dose versus two-dose human papillomavirus vaccination schedules: a comparative modelling analysis. BMC Medicine. ISSN 1741-7015. 21(1). doi: 10.1186/s12916-023-02988-3.
• Landy, Rebecca; Haber, Gregory; Graubard, Barry I.; Campos, Nicole G.; Sy, Stephen & Kim, Jane J. [Show all 11 contributors for this article] (2023). Upper age limits for US male human papillomavirus vaccination for oropharyngeal cancer prevention: a microsimulation-based modeling study. Journal of the National Cancer Institute. ISSN 0027-8874. 115(4), p. 429–436. doi: 10.1093/jnci/djad009.
• Pedersen, Kine; Kristiansen, Ivar Sønbø; Sy, Stephen; Kim, Jane J. & Burger, Emily Annika (2023). Designing Guidelines for Those Who Do Not Follow Them: The Impact of Adherence Assumptions on Optimal Screening Guidelines. Value in Health. ISSN 1098-3015. doi: 10.1016/j.jval.2023.04.005. Full text in Research Archive
• Knauss, Tara; Hansen, Bo Lars Thorvald Terning; Pedersen, Kine; Aasbø, Gunvor; Kunst, Natalia & Burger, Emily Annika (2022). The cost-effectiveness of opt-in and send-to-all HPV self-sampling among long-term non-attenders to cervical cancer screening in Norway: The Equalscreen randomized controlled trial. Gynecologic Oncology. ISSN 0090-8258. 168, p. 39–47. doi: 10.1016/j.ygyno.2022.10.027.
• Burger, Emily Annika; de Kok, Inge M. C. M.; O'mahony, James F.; Rebolj, Matejka; Jansen, Erik E. L. & de Bondt, Daniel D. [Show all 13 contributors for this article] (2022). A model-based analysis of the health impacts of COVID-19 disruptions to primary cervical screening by time since last screen for current and future disruptions. eLIFE. ISSN 2050-084X. 11. doi: 10.7554/eLife.81711.
• Hertzberg, Silvia Nanjala Walekhwa; Jørstad, Øystein Kalsnes; Petrovski, Beata Eva; Bragadottir, Ragnheidur; Steffensen, Leif Arthur & Moe, Morten Carsten [Show all 8 contributors for this article] (2022). Transition from Laser to Intravitreal Injections for Diabetic Retinopathy: Hospital Utilization and Costs from an Extended Healthcare Perspective. International Journal of Environmental Research and Public Health (IJERPH). ISSN 1661-7827. 19(19), p. 1–16. doi: 10.3390/ijerph191912603. Full text in Research Archive
• Burger, Emily Annika; Laprise, Jean-François; Sy, Stephen; Regan, Mary Caroline; Prem, Kiesha & Jit, Mark [Show all 8 contributors for this article] (2022). Now or later: Health impacts of delaying single-dose HPV vaccine implementation in a high-burden setting. International Journal of Cancer. ISSN 0020-7136. doi: 10.1002/ijc.34054.
• Portnoy, Allison; Nygård, Mari; Trogstad, Lill; Kim, Jane J. & Burger, Emily Annika (2022). Impact of Delaying Effective and Cost-Effective Policy Decisions: An Example From Cervical Cancer Prevention in Norway. Medical Decision Making Policy & Practice. ISSN 2381-4683. 7(1). doi: 10.1177/23814683211071093. Full text in Research Archive
• Hertzberg, Silvia Nanjala Walekhwa; Moe, Morten Carstens; Jørstad, Øystein Kalsnes; Petrovski, Beata Eva; Burger, Emily Annika & Petrovski, Goran (2022). Healthcare expenditure of intravitreal anti-vascular endothelial growth factor inhibitors compared with dexamethasone implant for diabetic macular oedema. Acta Ophthalmologica. ISSN 1755-375X. 100(8), p. e1630–e1640. doi: 10.1111/aos.15151. Full text in Research Archive
• Portnoy, Allison; Pedersen, Kine; Nygård, Mari; Trogstad, Lill; Kim, Jane J. & Burger, Emily Annika (2022). Identifying a Single Optimal Integrated Cervical Cancer Prevention Policy in Norway: A Cost-Effectiveness Analysis. Medical decision making. ISSN 0272-989X. 42(6), p. 795–807. doi: 10.1177/0272989X221082683.
• Smith, Megan A; Burger, Emily Annika; Castanon, Alejandra; de Kok, Inge; Hanley, Sharon & Rebolj, Matejka [Show all 12 contributors for this article] (2021). Impact of disruptions and recovery for established cervical screening programs across a range of high-income country program designs, using COVID-19 as an example: A modelled analysis. Preventive Medicine. ISSN 0091-7435. doi: 10.1016/j.ypmed.2021.106623. Show summary

  COVID-19 has disrupted cervical screening in several countries, due to a range of policy-, health-service and participant-related factors. Using three well-established models of cervical cancer natural history adapted to simulate screening across four countries, we compared the impact of a range of standardised screening disruption scenarios in four countries that vary in their cervical cancer prevention programs. All scenarios assumed a 6- or 12-month disruption followed by a rapid catch-up of missed screens. Cervical screening disruptions could increase cervical cancer cases by up to 5-6%. In all settings, more than 60% of the excess cancer burden due to disruptions are likely to have occurred in women aged less than 50 years in 2020, including settings where women in their 30s have previously been offered HPV vaccination. Approximately 15-30% of cancers predicted to result from disruptions could be prevented by maintaining colposcopy and precancer treatment services during any disruption period. Disruptions to primary screening had greater adverse effects in situations where women due to attend for screening in 2020 had cytology (vs. HPV) as their previous primary test. Rapid catch-up would dramatically increase demand for HPV tests in 2021, which it may not be feasible to meet because of competing demands on the testing machines and reagents due to COVID tests. These findings can inform future prioritisation strategies for catch-up that balance potential constraints on resourcing with clinical need.

• Cyr, Pascale Renée; Pedersen, Kine; Iyer, Anita Lakshmi; Bundorf, Kate; Goldhaber-Fiebert, Jeremy & Gyrd-Hansen, Dorte [Show all 8 contributors for this article] (2021). Providing more balanced information on the harms and benefits of cervical cancer screening: A randomized survey among US and Norwegian women. Preventive Medicine Reports. ISSN 2211-3355. doi: 10.1016/j.pmedr.2021.101452. Full text in Research Archive Show summary

  We aimed to identify how additional information about benefits and harms of cervical cancer (CC) screening impacted intention to participate in screening, what type of information on harms women preferred receiving, from whom, and whether it differed between two national healthcare settings. We conducted a survey that randomized screen-eligible women in the United States (n = 1084) and Norway (n = 1060) into four groups according to the timing of introducing additional information. We found that additional information did not significantly impact stated intentions-to-participate in screening or follow-up testing in either country; however, the proportion of Norwegian women stating uncertainty about seeking precancer treatment increased from 7.9% to 14.3% (p = 0.012). Women reported strong system-specific preferences for sources of information: Norwegians (59%) preferred it come from a national public health agency while Americans (59%) preferred it come from a specialist care provider. Regression models revealed having a prior Pap-test was the most important predictor of intentions-to-participate in both countries, while having lower income reduced the probabilities of intentions-to-follow-up and seek precancer treatment among U.S. women. These results suggest that additional information on harms is unlikely to reduce participation in CC screening but could increase decision uncertainty to seek treatment. Providing unbiased information would improve on the ethical principle of respect for autonomy and self-determination. However, the clinical impact of additional information on women's understanding of the trade-offs involved with CC screening should be investigated. Future studies should also consider country-specific socioeconomic barriers to screening if communication re-design initiatives aim to improve CC screening participation.

• Jenny, Spencer; Campos, Nicole G.; Burger, Emily Annika; Sy, Stephen & Kim, Jane J (2021). Potential Effectiveness of a Therapeutic HPV Intervention Campaign in Uganda. International Journal of Cancer. ISSN 0020-7136. doi: 10.1002/ijc.33867. Show summary

  Cervical cancer is a major source of morbidity and mortality in Uganda. In addition to prophylactic HPV vaccination, secondary prevention strategies are needed to reduce cancer burden. We evaluated the potential cancer reductions associated with a hypothetical single-contact therapeutic HPV intervention- with 70% coverage and variable efficacy [30-100%]- using a three-stage HPV modeling framework reflecting HPV and cervical cancer burden in Uganda. In the reference case, we assumed prophylactic pre-adolescent HPV vaccination starting in 2020 with 70% coverage. A one-time therapeutic intervention targeting 35-year-old women in 2025 (not age-eligible for prophylactic vaccination) averted 1,801 cervical cancers per 100,000 women over their lifetime (100% efficacy) or 533 cancers per 100,000 (30% efficacy). Benefits were considerably smaller in birth cohorts eligible for prophylactic HPV vaccination (768 cases averted per 100,000 at 100% efficacy). Evaluating the population-level impact over 40 years, we found introduction of a therapeutic intervention in 2025 with 100% efficacy targeted annually to 30-year-old women averted 139,000 incident cervical cancers in Uganda. This benefit was greatly reduced if efficacy was lower (30% efficacy; 41,000 cases averted), introduction was delayed (2040 introduction; 72,000 cases averted) or both (22,000 cases averted). We demonstrate the potential benefits of a single-contact HPV therapeutic intervention in a low-income setting, but show the importance of high therapeutic efficacy and early introduction timing relative to existing prophylactic programs. Reduced benefits from a less efficacious intervention may be somewhat offset if available within a shorter time frame.

• Pedersen, Kine; Portnoy, Allison; Sy, Stephen; Hansen, Bo T.; Trope, Ameli & Kim, Jane J. [Show all 7 contributors for this article] (2021). Switching clinic-based cervical cancer screening programs to human papillomavirus self-sampling: A cost-effectiveness analysis of vaccinated and unvaccinated Norwegian women. International Journal of Cancer. ISSN 0020-7136. doi: 10.1002/ijc.33850. Full text in Research Archive Show summary

  Several countries have implemented primary human papillomavirus (HPV) testing for cervical cancer screening. HPV testing enables home-based, self-collected sampling (self-sampling), which provides similar diagnostic accuracy as clinician-collected samples. We evaluated the impact and cost-effectiveness of switching an entire organized screening program to primary HPV self-sampling among cohorts of HPV vaccinated and unvaccinated Norwegian women. We conducted a model-based analysis to project long-term health and economic outcomes for birth cohorts with different HPV vaccine exposure, that is, preadolescent vaccination (2000- and 2008-cohorts), multiage cohort vaccination (1991-cohort) or no vaccination (1985- cohort). We compared the cost-effectiveness of switching current guidelines with clinician-collected HPV testing to HPV self-sampling for these cohorts and considered an additional 44 strategies involving either HPV self-sampling or clinician-collected HPV testing at different screening frequencies for the 2000- and 2008-cohorts. Given Norwegian benchmarks for cost-effectiveness, we considered a strategy with an additional cost per quality-adjusted life-year below $55 000 as cost-effective. HPV selfsampling strategies considerably reduced screening costs (ie, by 24%-40% across cohorts and alternative strategies) and were more cost-effective than cliniciancollected HPV testing. For cohorts offered preadolescent vaccination, cost-effective strategies involved HPV self-sampling three times (2000-cohort) and twice (2008-cohort) per lifetime. In conclusion, we found that switching from cliniciancollected to self-collected HPV testing in cervical screening may be cost-effective among both highly vaccinated and unvaccinated cohorts of Norwegian women.

• Kim, Jane J.; Simms, Kate T.; Killen, James; Smith, Megan A; Burger, Emily & Sy, Stephen [Show all 8 contributors for this article] (2021). Human papillomavirus vaccination for adults aged 30 to 45 years in the United States: A cost-effectiveness analysis. Nature Methods. ISSN 1548-7091. 18(3), p. 1–15. doi: 10.1371/JOURNAL.PMED.1003534.
• Kim, Jane J; Simms, Kate T; Killen, James; Smith, Megan A; Burger, Emily & Sy, Stephen [Show all 8 contributors for this article] (2021). Mid-Adult Human Papillomavirus Vaccination in the United States: A Cost-Effectiveness Analysis. PLoS Medicine. ISSN 1549-1277. 18(3). doi: 10.1371/journal.pmed.1003534.
• Burger, Emily Annika; Jansen, Erik EL; Killen, James; de Kok, Inge; Smith, Megan A & Sy, Stephen [Show all 13 contributors for this article] (2021). Impact of COVID-19-related care disruptions on cervical cancer screening in the United States. Journal of Medical Screening. ISSN 0969-1413. doi: 10.1177/09691413211001097. Full text in Research Archive
• Portnoy, Allison; Pedersen, Kine; Trogstad, Lill; Hansen, Bo Terning; Feiring, Berit & Laake, Ida [Show all 11 contributors for this article] (2021). Impact and cost-effectiveness of strategies to accelerate cervical cancer elimination: A model-based analysis. Preventive Medicine. ISSN 0091-7435. 144. doi: 10.1016/j.ypmed.2020.106276. Full text in Research Archive Show summary

  Following the global call for action by the World Health Organization to eliminate cervical cancer (CC), we evaluated how each CC policy decision in Norway influenced the timing of CC elimination, and whether introducing nonavalent human papillomavirus (HPV) vaccine would accelerate elimination timing and be cost-effective. We used a multi-modeling approach that captured HPV transmission and cervical carcinogenesis to estimate the CC incidence associated with six past and future CC prevention policy decisions compared with a pre-vaccination scenario involving 3-yearly cytology-based screening. Scenarios examined the introduction of routine HPV vaccination of 12-year-old girls with quadrivalent vaccine in 2009, a temporary catch-up program for females aged up to 26 years in 2016–2018 with bivalent vaccine, the universal switch to bivalent vaccine in 2017, expansion to include 12-year-old boys in 2018, the switch from cytology- to HPV-based screening for women aged 34–69 in 2020, and the potential switch to nonavalent vaccine in 2021. Introducing routine female vaccination in 2009 enabled elimination to be achieved by 2056 and prevented 17,300 cases. Cumulatively, subsequent policy decisions accelerated elimination to 2039. According to our modeling assumptions, switching to the nonavalent vaccine would not be considered ‘good value for money’ at relevant cost-effectiveness thresholds in Norway unless the incremental cost was $19 per dose or less (range: $17–24) compared to the bivalent vaccine. CC control policies implemented over the last decade in Norway may have accelerated the timeframe to elimination by more than 17 years and prevented over 23,800 cases by 2110.

• Burger, Emily; Portnoy, Allison; Campos, Nicole G.; Sy, Stephen; Regan, Catherine & Kim, Jane J (2020). Choosing the optimal HPV vaccine: The health impact and economic value of the nonavalent and bivalent HPV vaccines in 48 Gavi‐eligible countries. International Journal of Cancer. ISSN 0020-7136. 148(4). doi: 10.1002/ijc.33233. Full text in Research Archive Show summary

  The human papillomavirus (HPV) vaccines may provide some level of cross‐protection against high‐risk HPV genotypes not directly targeted by the vaccines. We evaluated the long‐term health and economic impacts of routine HPV vaccination using either the nonavalent HPV vaccine or the bivalent HPV vaccine in the context of 48 Gavi‐eligible countries. We used a multi‐modeling approach to compare the bivalent with or without cross‐protection and the nonavalent HPV vaccine. The optimal, that is, most cost‐effective, vaccine was the vaccine with an incremental cost‐effectiveness ratio below the per‐capita gross domestic product (GDP) for each country. By 2100 and assuming 70% HPV vaccination coverage, a bivalent vaccine without cross‐protection, a bivalent vaccine with favorable cross‐protection and the nonavalent vaccine were projected to avert 14.9, 17.2 and 18.5 million cumulative cases of cervical cancer across all 48 Gavi‐eligible countries, respectively. The relative value of the bivalent vaccine compared to the nonavalent vaccine increased assuming a bivalent vaccine conferred high cross‐protection. For example, assuming a cost‐effectiveness threshold of per‐capita GDP, the nonavalent vaccine was optimal in 83% (n = 40) of countries if the bivalent vaccine did not confer cross‐protection; however, the proportion of countries decreased to 63% (n = 30) if the bivalent vaccine conferred high cross‐protection. For lower cost‐effectiveness thresholds, the bivalent vaccine was optimal in a greater proportion of countries, under both cross‐protection assumptions. Although the nonavalent vaccine is projected to avert more cases of cervical cancer, the bivalent vaccine with favorable cross‐protection can prevent a considerable number of cases and would be considered a high‐value vaccine for many Gavi‐eligible countries.

• Simms, Kate T; Yuill, S; Killen, James; Smith, Megan A; Kulasingam, Shalini & de Kok, Inge [Show all 11 contributors for this article] (2020). Historical and projected hysterectomy rates in the USA: Implications for future observed cervical cancer rates and evaluating prevention interventions. Gynecologic Oncology. ISSN 0090-8258. 158(3). doi: 10.1016/j.ygyno.2020.05.030. Show summary

  Background SEER-reported cervical cancer incidence rates reflect the total female population including women no longer at risk due to hysterectomy. Hysterectomy rates have been declining in the United States as alternative treatments have become available, which could result in an apparent increase in SEER-reported cervical cancer rates. We aimed to obtain nationally representative historical data on hysterectomy rates in USA, use trends analysis to project rates back to 1935 and forward to 2035, and then predict the impact of changing hysterectomy rates on SEER-reported cervical cancer rates. Methods We performed a systematic search of Medline, Embase, Premedline, Cochrane Central databases and extracted nationally-representative hysterectomy incidence data from 1965 to 2009, including data on the number of cervix-preserving (subtotal) procedures. We then projected rates back to 1935, and forward to 2035 based on trends from joinpoint regression. These rates were then used to estimate hysterectomy prevalence out to 2035, and then to predict the impact of changing hysterectomy rates on SEER-reported cervical cancer rates to 2035. We examined alternative assumptions regarding projected hysterectomy incidence rates out to 2035, including a scenario in which rates decline no further from 2009 rates, and a scenario where rates decline at twice the baseline rate. Results Estimated age-standardized hysterectomy incidence increased from 2.4 to 10.6 per 1000 women between 1935 and 1975. Thereafter, rates are predicted to fall to 3.9 per 1000 by 2035. Subtotal hysterectomy procedures declined from being the predominant method in 1935 to less than 12% of procedures from 1970 onwards. Consequently, holding all else constant, an increase in SEER-reported age-standardized cervical cancer incidence rates (ages 0–85+) of 9% is expected from 2009 to 2035. The predictions were minimally impacted by alternative scenarios for future hysterectomy rates. Conclusions Declining hysterectomy rates have implications for the interpretation of SEER-reported cervical cancer rates. A background increase in cervical cancer rates due to decreasing population hysterectomy exposure may partially offset expected decreases from recent cervical screening changes recommended by the US Preventive Services Task Force. Evaluations of new cervical cancer prevention opportunities should consider the background impact of historical and projected hysterectomy rates.

• de Kok, Inge; Burger, Emily; Naber, Steffie; Canfell, Karen; Killen, James & Simms, Kate [Show all 11 contributors for this article] (2020). The Impact of Different Screening Model Structures on Cervical Cancer Incidence and Mortality Predictions: The Maximum Clinical Incidence Reduction (MCLIR) Methodology. Medical decision making. ISSN 0272-989X. 4(40). doi: 10.1177/0272989X20924007. Show summary

  Background. To interpret cervical cancer screening model results, we need to understand the influence of model structure and assumptions on cancer incidence and mortality predictions. Cervical cancer cases and deaths following screening can be attributed to 1) (precancerous or cancerous) disease that occurred after screening, 2) disease that was present but not screen detected, or 3) disease that was screen detected but not successfully treated. We examined the relative contributions of each of these using 4 Cancer Intervention and Surveillance Modeling Network (CISNET) models. Methods. The maximum clinical incidence reduction (MCLIR) method compares changes in the number of clinically detected cervical cancers and mortality among 4 scenarios: 1) no screening, 2) one-time perfect screening at age 45 that detects all existing disease and delivers perfect (i.e., 100% effective) treatment of all screen-detected disease, 3) one-time realistic-sensitivity cytological screening and perfect treatment of all screen-detected disease, and 4) one-time realistic-sensitivity cytological screening and realistic-effectiveness treatment of all screen-detected disease. Results. Predicted incidence reductions ranged from 55% to 74%, and mortality reduction ranged from 56% to 62% within 15 years of follow-up for scenario 4 across models. The proportion of deaths due to disease not detected by screening differed across the models (21%–35%), as did the failure of treatment (8%–16%) and disease occurring after screening (from 1%–6%). Conclusions. The MCLIR approach aids in the interpretation of variability across model results. We showed that the reasons why screening failed to prevent cancers and deaths differed between the models. This likely reflects uncertainty about unobservable model inputs and structures; the impact of this uncertainty on policy conclusions should be examined via comparing findings from different well-calibrated and validated model platforms.

• Burger, Emily; Smith, Megan A; Killen, James; Sy, Stephen; Simms, Kate T & Canfell, Karen [Show all 7 contributors for this article] (2020). Projected time to elimination of cervical cancer in the USA: a comparative modelling study. The Lancet Public Health. ISSN 2468-2667. 5(4). doi: 10.1016/S2468-2667(20)30006-2. Show summary

  Summary Background In May, 2018, the Director-General of WHO issued a global call to eliminate cervical cancer as a public health problem, which will involve ambitious screening and vaccination coverage targets. We aimed to assess the potential for, and timing of, cervical cancer elimination in the USA and whether this could be expedited by adopting ambitious coverage targets, using two cervical cancer simulation models. Methods In this modelling study, we used two independently-developed cervical cancer microsimulation models—Harvard and Policy1-Cervix—to estimate changes in the incidence of human papillomavirus (HPV)-induced cervical cancer over time in the USA, including herd effects from vaccination. We compared nine alternative scenarios for prophylactic HPV vaccination and cervical screening scale-up with a status quo scenario that involved no additional interventions in the context of a threshold for cervical cancer elimination of four or fewer cases per 100 000 women-years. We also estimated the number of cervical cancer cases that could be averted between 2019 and 2100 associated with the adoption of ambitious goals for cervical cancer screening and vaccination coverage, and other potential strategies. Findings Under status quo assumptions, the Havard and Policy1-Cervix models projected that cervical cancer incidence would decrease to less than four or fewer new cases per 100 000 women-years by the 2038 and 2046, respectively. Scaling up screening coverage to 90% in 2020, was the most effective intervention to expedite time to elimination (10–13-year reduction), averting a mean of 1400–2088 additional cases annually between 2019 and 2100. Increasing HPV vaccination coverage to 90% or vaccinating adults aged 26–45 years had relatively little effect on cervical cancer incidence. Sensitivity analysis using different population structures resulted in differences in time to elimination (range −10 years to +27 years) compared with status quo predictions. Interpretation The USA is on track to eliminate cervical cancer as a public health problem in the next two to three decades. Time to elimination could be expedited by 10–13 years by achieving higher screening coverage. Targeting of underscreened and under-vaccinated women remains key to achieving cervical cancer elimination for all women. Funding US National Cancer Institute.

• Brisson, Marc; Kim, Jane J; Canfell, Karen; Drolet, Melanie; Gingras, Guillaume & Burger, Emily [Show all 25 contributors for this article] (2020). Impact of HPV vaccination and cervical screening on cervical cancer elimination: a comparative modelling analysis in 78 low-income and lower-middle-income countries. The Lancet. ISSN 0140-6736. 395(10224). doi: 10.1016/S0140-6736(20)30068-4. Show summary

  Summary Background The WHO Director-General has issued a call for action to eliminate cervical cancer as a public health problem. To help inform global efforts, we modelled potential human papillomavirus (HPV) vaccination and cervical screening scenarios in low-income and lower-middle-income countries (LMICs) to examine the feasibility and timing of elimination at different thresholds, and to estimate the number of cervical cancer cases averted on the path to elimination. Methods The WHO Cervical Cancer Elimination Modelling Consortium (CCEMC), which consists of three independent transmission-dynamic models identified by WHO according to predefined criteria, projected reductions in cervical cancer incidence over time in 78 LMICs for three standardised base-case scenarios: girls-only vaccination; girls-only vaccination and once-lifetime screening; and girls-only vaccination and twice-lifetime screening. Girls were vaccinated at age 9 years (with a catch-up to age 14 years), assuming 90% coverage and 100% lifetime protection against HPV types 16, 18, 31, 33, 45, 52, and 58. Cervical screening involved HPV testing once or twice per lifetime at ages 35 years and 45 years, with uptake increasing from 45% (2023) to 90% (2045 onwards). The elimination thresholds examined were an average age-standardised cervical cancer incidence of four or fewer cases per 100 000 women-years and ten or fewer cases per 100 000 women-years, and an 85% or greater reduction in incidence. Sensitivity analyses were done, varying vaccination and screening strategies and assumptions. We summarised results using the median (range) of model predictions. Findings Girls-only HPV vaccination was predicted to reduce the median age-standardised cervical cancer incidence in LMICs from 19·8 (range 19·4–19·8) to 2·1 (2·0–2·6) cases per 100 000 women-years over the next century (89·4% [86·2–90·1] reduction), and to avert 61·0 million (60·5–63·0) cases during this period. Adding twice-lifetime screening reduced the incidence to 0·7 (0·6–1·6) cases per 100 000 women-years (96·7% [91·3–96·7] reduction) and averted an extra 12·1 million (9·5–13·7) cases. Girls-only vaccination was predicted to result in elimination in 60% (58–65) of LMICs based on the threshold of four or fewer cases per 100 000 women-years, in 99% (89–100) of LMICs based on the threshold of ten or fewer cases per 100 000 women-years, and in 87% (37–99) of LMICs based on the 85% or greater reduction threshold. When adding twice-lifetime screening, 100% (71–100) of LMICs reached elimination for all three thresholds. In regions in which all countries can achieve cervical cancer elimination with girls-only vaccination, elimination could occur between 2059 and 2102, depending on the threshold and region. Introducing twice-lifetime screening accelerated elimination by 11–31 years. Long-term vaccine protection was required for elimination. Interpretation Predictions were consistent across our three models and suggest that high HPV vaccination coverage of girls can lead to cervical cancer elimination in most LMICs by the end of the century. Screening with high uptake will expedite reductions and will be necessary to eliminate cervical cancer in countries with the highest burden. Funding WHO, UNDP, UN Population Fund, UNICEF–WHO–World Bank Special Program of Research, Development and Research Training in Human Reproduction, Canadian Institute of Health Research, Fonds de recherche du Québec–Santé, Compute Canada, National Health and Medical Research Council Australia Centre for Research Excellence in Cervical Cancer Control.

• Canfell, Karen; Kim, Jane J.; Brisson, M; Keane, Adam; Simms, Kate T & Caruana, Michael [Show all 23 contributors for this article] (2020). Mortality impact of achieving WHO cervical cancer elimination targets: a comparative modelling analysis in 78 low-income and lower-middle-income countries. The Lancet. ISSN 0140-6736. 395(10224), p. 591–603. doi: 10.1016/S0140-6736(20)30157-4.
• Fogelberg, Sara; Clements, Mark; Pedersen, Kine; Sy, Stephen; Sparén, Pär & Kim, Jane J. [Show all 7 contributors for this article] (2020). Cost-effectiveness of cervical cancer screening with primary HPV testing for unvaccinated women in Sweden. PLOS ONE. ISSN 1932-6203. 15(9). doi: 10.1371/journal.pone.0239611.
• Hylin, Hannah Douglass; Thrane, Helene; Pedersen, Kine; Kristiansen, Ivar Sønbø & Burger, Emily (2019). The healthcare costs of treating human papillomavirus-related cancers in Norway. BMC Cancer. ISSN 1471-2407. 19(1). doi: 10.1186/s12885-019-5596-2. Full text in Research Archive
• Portnoy, Allison; Campos, Nicole; Sy, Stephen; Burger, Emily; Cohen, Jamie & Regan, Catherine [Show all 7 contributors for this article] (2019). Impact and Cost-Effectiveness of Human Papillomavirus Vaccination Campaigns. Cancer Epidemiology, Biomarkers and Prevention. ISSN 1055-9965. 29(1), p. 22–30. doi: 10.1158/1055-9965.EPI-19-0767.
• Burger, Emily; de Kok, Inge; Groene, Emily; Killen, Jame; Canfell, Karen & Kulasingam, Shalini [Show all 16 contributors for this article] (2019). Estimating the Natural History of Cervical Carcinogenesis Using Simulation Models: A CISNET Comparative Analysis. Journal of the National Cancer Institute. ISSN 0027-8874. doi: 10.1093/jnci/djz227. Full text in Research Archive
• Aas, Eline; Burger, Emily & Pedersen, Kine (2019). Economic Evaluation of Medical Screening. In Hamilton, Jonathan H. (Eds.), Oxford Research Encyclopedias: Economics and Finance. Oxford University Press. ISSN 9780190625979. doi: doi:%2010.1093/acrefore/9780190625979.013.377. Full text in Research Archive
• Rodin, Danielle; Burger, Emily; Atun, Rifat; Barton, Michael; Gospodarowicz, Mary & Grover, Surbhi [Show all 12 contributors for this article] (2019). Scale-up of radiotherapy for cervical cancer in the era of human papillomavirus vaccination in low-income and middle-income countries: a model-based analysis of need and economic impact. The Lancet Oncology. ISSN 1470-2045. 20(7), p. 915–923. doi: 10.1016/S1470-2045(19)30308-0.
• Vervaart, Mathyn; Burger, Emily & Aas, Eline (2018). Acknowledging patient heterogeneity in colorectal cancer screening: An example from Norway. Nordic Journal of Health Economics. ISSN 1892-9729. 6(1), p. 83–98. doi: 10.5617/njhe.4881. Full text in Research Archive
• Burger, Emily; Dyer, Michael; Sy, Stephen; Palefsky, Joel M.; de Pokomandy, Alexandra & Coutlee, François [Show all 8 contributors for this article] (2018). Development and Calibration of a Mathematical Model of Anal Carcinogenesis for High-Risk HIV-Infected Men. Journal of Acquired Immune Deficiency Syndromes. ISSN 1525-4135. 79(1), p. 10–19. doi: 10.1097/QAI.0000000000001727. Show summary

  OBJECTIVES: Men who have sex with men who are living with HIV are at highest risk for anal cancer. Our objective was to use empirical data to develop a comprehensive disease simulation model that reflects the most current understanding of anal carcinogenesis, which is uniquely positioned to evaluate future anal cancer screening strategies and provide insight on the unobservable course of the disease. SETTING: North America. METHODS: The individual-based simulation model was calibrated leveraging primary data from empirical studies, such as a longitudinal HIV-positive men who have sex with men cohort study [Human Immunodeficiency and Papilloma Virus Research Group (HIPVIRG); n = 247] and the North American AIDS Cohort Collaboration on Research and Design [(NA-ACCORD); n = 13,146]. We used the model to infer unobservable progression probabilities from high-grade precancer to invasive anal cancer by CD4 nadir and human papillomavirus (HPV) genotype. RESULTS: The calibrated model had good correspondence to data on genotype- and age-specific HPV prevalence; genotype frequency in precancer and cancer; and age- and nadir CD4-specific cancer incidence. The model-projected progression probabilities differed substantially by HPV genotype and nadir CD4 status. For example, among individuals with CD4 nadir <200, the median monthly progression probability from a high-grade lesion to invasive cancer was 0.054% (ie, 6.28% 10-year probability) and 0.004% (ie, 0.48% 10-year probability) for men with an HPV-16 infection versus without a detectable HPV infection, respectively. CONCLUSIONS: We synthesized existing evidence into a state-of-the-art anal cancer disease simulation model that will be used to quantify the tradeoffs of harms and benefits of alternative strategies, understand critical uncertainties, and inform national anal cancer prevention policy.

• Castle, Philip E.; Xie, X; Xue, X; Poitras, N; Lorey, T & Kinney, Walter [Show all 9 contributors for this article] (2018). Impact of human papillomavirus vaccination on the clinical meaning of cervical screening results. Preventive Medicine. ISSN 0091-7435. 118, p. 44–50. doi: 10.1016/j.ypmed.2018.10.001. Show summary

  Women previously vaccinated against human papillomavirus (HPV) type 16 and 18 are now reaching the age (21 years) at which cervical-cancer screening is recommended in the U.S. The impact of HPV vaccination on risks of cervical precancer following a positive and negative screen among women aged 21-24 years who just started routine cervical screening are not well described. Therefore, three-year absolute and relative (RR) cumulative risks of cervical intraepithelial neoplasia grade 2 or more severe diagnoses (≥CIN2) and grade 3 or more severe diagnoses (≥CIN3) were estimated for women undergoing cervical screening at Kaiser Permanente Northern California. Risks were estimated in women aged 21-24 years (n = 75,008) undergoing cervical screening since late 2006, 6 months after HPV vaccination became available; women were categorized vaccinated at ages <18, 18-20, and 21-24 years and compared to those who were unvaccinated. Three-year risks were estimated for normal, low-grade, and high-grade cytology results. Three-year risks of ≥CIN2 and ≥CIN3 for unvaccinated women following low-grade cytology were 10.89% for and 3.70%, respectively. By comparison, Three-year risks of ≥CIN2 and ≥CIN3 were 5.26% (RR = 0.48, 95%CI = 0.24-0.99) and 0.99% (RR = 0.27, 95%CI = 0.06-1.13), respectively, for women vaccinated under the age of 18 years. Three-year ≥CIN2 and ≥CIN3 risks were lower for those HPV vaccinated at younger age for any screening result (ptrend ≤ 0.01 for all comparisons). These data support initiating cervical screening at an older age or changing the management of a low-grade cytology result in women aged 21-24 years who were vaccinated against HPV younger than age of 18 years.

• Kim, Jane J; Burger, Emily; Regan, Catherine & Sy, Stephen (2018). Screening for cervical cancer in primary care a decision analysis for the us preventive services task force. Journal of the American Medical Association (JAMA). ISSN 0098-7484. 320(7), p. 706–714. doi: 10.1001/jama.2017.19872. Full text in Research Archive
• Burger, Emily; Campos, Nicole G.; Sy, Stephen; Catherine, Regan & Kim, Jane J (2018). Health and economic benefits of single-dose HPV vaccination in a Gavi-eligible country. Vaccine. ISSN 0264-410X. 36(32), p. 4823–4829. doi: 10.1016/j.vaccine.2018.04.061. Full text in Research Archive
• Pedersen, Kine; Fogelberg, Sara; Thamsborg, Lise H.; Clements, Mark; Nygård, Mari & Kristiansen, Ivar Sønbø [Show all 10 contributors for this article] (2018). An overview of cervical cancer epidemiology and prevention in Scandinavia. Acta Obstetricia et Gynecologica Scandinavica. ISSN 0001-6349. 97(7), p. 795–807. doi: 10.1111/aogs.13313. Full text in Research Archive
• Pedersen, Kine; Burger, Emily; Nygård, Mari; Kristiansen, Ivar Sønbø & Kim, Jane J. (2018). Adapting cervical cancer screening for women vaccinated against human papillomavirus infections: The value of stratifying guidelines. European Journal of Cancer. ISSN 0959-8049. 91, p. 68–75. doi: 10.1016/j.ejca.2017.12.018. Full text in Research Archive
• Rutter, Carolyn; Kim, Jane J; Meester, RGS; Sprague, BL; Burger, Emily & Zauber, Ann G. [Show all 16 contributors for this article] (2017). Effect of Time to Diagnostic Testing for Breast, Cervical, and Colorectal Cancer Screening Abnormalities on Screening Efficacy: A Modeling Study. Cancer Epidemiology, Biomarkers and Prevention. ISSN 1055-9965. doi: 10.1158/1055-9965.EPI-17-0378.
• Kim, Jane J; Burger, Emily; Sy, Stephen & Campos, Nicole G. (2017). Optimal cervical cancer screening in women vaccinated against human papillomavirus. Journal of the National Cancer Institute. ISSN 0027-8874. 109(2). doi: 10.1093/jnci/djw216.
• Burger, Emily; Pedersen, Kine; Sy, Stephen; Kristiansen, Ivar Sønbø & Kim, Jane J (2017). Choosing wisely: a model-based analysis evaluating the trade-offs in cancer benefit and diagnostic referrals among alternative HPV testing strategies in Norway. British Journal of Cancer. ISSN 0007-0920. 117(6), p. 783–790. doi: 10.1038/bjc.2017.248. Full text in Research Archive
• Pedersen, Kine; Burger, Emily; Campbell, Suzanne; Nygård, Mari; Aas, Eline & Lönnberg, Stefan (2017). Advancing the evaluation of cervical cancer screening: development and application of a longitudinal adherence metric. European Journal of Public Health. ISSN 1101-1262. doi: 10.1093/eurpub/ckx073. Full text in Research Archive
• Burger, Emily; Kim, Jane J.; Sy, Stephen & Castle, Philip E. (2017). Age of acquiring causal human papillomavirus (HPV) infections: Leveraging simulation models to explore the natural history of HPV-induced cervical cancer. Clinical Infectious Diseases. ISSN 1058-4838. 65(6), p. 893–899. doi: 10.1093/cid/cix475. Show summary

  Background. Although new human papillomavirus (HPV) infections can occur at all ages, the age at which women acquire their “causal” HPV infection that develops into cervical cancer is poorly understood and practically unobservable. We aimed to estimate the age distribution at which individuals acquired their causal HPV infection in the absence of HPV vaccination or screening to help guide the optimal use of both. Methods. Using an empirically calibrated mathematical model that simulates the natural history of cervical cancer, we estimated the cumulative number of causal HPV infections by age, stratified by HPV genotype (HPV16 vs. other HPV genotypes), and the direct age-specific reduction in cancer incidence for alternative vaccination initiation scenarios (i.e., age 9-45 years). Results. Our model projected that among all cervical cancers, 50% and 75% of women acquired their causal HPV infection by ages 20.6 (range: 20.1-21.1) and 30.6 (range: 29.6-31.6) years, respectively. HPV16 infections were acquired at an earlier age. Assuming 95% efficacy against HPV16 and HPV18 infections, the direct reduction in lifetime risk of cervical cancer varied from 58% (range: 56-59%) among women vaccinated at age 9 years to 6% (range: 5-8%) among women vaccinated at age 45 years. Similar patterns were observed for the second-generation vaccine. Conclusions. Although new HPV infections and precancers can occur throughout a woman’s lifetime, only a small proportion are acquired in mid-adult women and are vaccine-preventable. Our simulations highlight the potential limitations of using surrogate endpoints for vaccine efficacy studies of mid-adult women to guide policy decisions for implementation.

• Burger, Emily; Sy, Stephen; Nygård, Mari & Kim, Jane J (2017). The cost-effectiveness of cervical self-sampling to improve routine cervical cancer screening: The importance of respondent screening history and compliance. Cancer Epidemiology, Biomarkers and Prevention. ISSN 1055-9965. 26(1), p. 95–103. doi: 10.1158/1055-9965.EPI-16-0350. Show summary

  Background: Human papillomavirus (HPV) testing allows women to self-collect cervico-vaginal cells at home (i.e., self-sampling). Using primary data from a randomized pilot study, we evaluated the long-term consequences and cost-effectiveness of using self-sampling to improve participation to routine cervical cancer screening in Norway. Methods: We compared a strategy reflecting screening participation (using reminder letters) to strategies that involved mailing self-sampling device kits to women non-compliant to screening within a 5-year or 10-year period under two scenarios: A) self-sampling respondents had moderate under-screening histories, or B) respondents to self-sampling had moderate and severe under-screening histories. Model outcomes included quality-adjusted life-years (QALY) and lifetime costs. The 'most cost-effective' strategy was identified as the strategy just below $100,000 per QALY gained. Results: Mailing self-sampling device kits to all women non-compliant to screening within a 5-year or 10-year period can be more effective and less costly than the current reminder letter policy; however, the optimal self-sampling strategy was dependent on the profile of self-sampling respondents. For example, '10-yearly self-sampling' is preferred ($95,500 per QALY gained) if '5-yearly self-sampling' could only attract moderate under-screeners; however, '5-yearly self-sampling' is preferred if this strategy could additionally attract severe under-screeners. Conclusions: Targeted self-sampling of non-compliers likely represents good value-for-money; however, the preferred strategy is contingent on the screening histories and compliance of respondents. Impact: The magnitude of the health benefit and optimal self-sampling strategy is dependent on the profile and behavior of respondents. Health authorities should understand these factors prior to selecting and implementing a self-sampling policy.

• Pedersen, Kine; Sørbye, Sveinung Wergeland; Kristiansen, Ivar Sønbø & Burger, Emily (2017). Using novel biomarkers to triage young adult women with minor cervical lesions: a cost-effectiveness analysis. BJOG: An International Journal of Obstetrics and Gynaecology. ISSN 1470-0328. 124(3), p. 474–484. doi: 10.1111/1471-0528.14135. Show summary

  Objective To evaluate the short-term consequences and cost-effectiveness associated with the use of novel biomarkers to triage young adult women with minor cervical cytological lesions. Design Model-based economic evaluation using primary epidemiological data from Norway, supplemented with data from European and American clinical trials. Setting Organised cervical cancer screening in Norway. Population Women aged 25–33 years with minor cervical cytological lesions detected at their primary screening test. Methods We expanded an existing simulation model to compare 12 triage strategies involving alternative biomarkers (i.e. reflex human papillomavirus (HPV) DNA/mRNA testing, genotyping, and dual staining) with the current Norwegian triage guidelines. Main outcome measures The number of high-grade precancers detected and resource use (e.g. monetary costs and colposcopy referrals) for a single screening round (3 years) for each triage strategy. Cost-efficiency, defined as the additional cost per additional precancer detected of each strategy compared with the next most costly strategy. Results Five strategies were identified as cost-efficient, and are projected to increase the precancer detection rate between 18 and 57%, compared with current guidelines; however, the strategies did not uniformly require additional resources. Strategies involving HPV mRNA testing required fewer resources, whereas HPV DNA-based strategies detected >50% more precancers, but were more costly and required twice as many colposcopy referrals compared with the current guidelines. Conclusion Strategies involving biomarkers to triage younger women with minor cervical cytological lesions have the potential to detect additional precancers, yet the optimal strategy depends on the resources available as well as decision-makers' and women's acceptance of additional screening procedures.

• Pedersen, Kine; Burger, Emily; Sy, Stephen; Kristiansen, Ivar Sønbø & Kim, Jane J. (2016). Cost-effective management of women with minor cervical lesions: Revisiting the application of HPV DNA testing. Gynecologic Oncology. ISSN 0090-8258. 143(2), p. 326–333. doi: 10.1016/j.ygyno.2016.08.231. Full text in Research Archive Show summary

  Background Lack of consensus in management guidelines for women with minor cervical lesions, coupled with novel screening approaches, such as human papillomavirus (HPV) genotyping, necessitate revisiting prevention policies. We evaluated the cost-effectiveness and resource trade-offs of alternative triage strategies to inform cervical cancer prevention in Norway. Methods We used a decision-analytic model to compare the lifetime health and economic consequences associated with ten novel candidate approaches to triage women with minor cervical lesions. Candidate strategies varied by: 1) the triage test(s): HPV testing in combination with cytology, HPV testing alone with or without genotyping for HPV-16 and -18, and immediate colposcopy, and 2) the length of time between index and triage testing (i.e., 6, 12 or 18 months). Model outcomes included quality-adjusted life-years (QALYs), lifetime societal costs, and resource use (e.g., colposcopy referrals). Results The current Norwegian guidelines were less effective and more costly than candidate strategies. Given a commonly-cited willingness-to-pay threshold in Norway of $100,000 per QALY gained, the preferred strategy involved HPV genotyping with immediate colposcopy referral for HPV-16 or -18 positive and repeat HPV testing at 12 months for non-HPV-16 or -18 positive ($78,010 per QALY gained). Differences in health benefits among candidate strategies were small, while resource use varied substantially. More effective strategies required a moderate increase in colposcopy referrals (e.g., a 9% increase for the preferred strategy) compared with current levels. Conclusion New applications of HPV testing may improve management of women with minor cervical lesions, yet are accompanied by a trade-off of increased follow-up procedures.

• Burger, Emily; Lee, Kyueun; Saraiya, Mona; Thompson, Trevor D.; Chesson, Harrell W. & Markowitz, Lauri E. [Show all 7 contributors for this article] (2016). Racial and ethnic disparities in human papillomavirus-associated cancer burden with first-generation and second-generation human papillomavirus vaccines. Cancer. ISSN 0008-543X. 122(13), p. 2057–2066. doi: 10.1002/cncr.30007. Show summary

  BACKGROUND: In the United States, the burden of human papillomavirus (HPV)-associated cancers varies by racial/ethnic group. HPV vaccination may provide opportunities for primary prevention of these cancers. Herein, the authors projected changes in HPV-associated cancer burden among racial/ethnic groups under various coverage assumptions with the available first-generation and second-generation HPV vaccines to evaluate changes in racial/ethnic disparities. METHODS: Cancer-specific mathematical models simulated the burden of 6 HPV-associated cancers. Model parameters, informed using national registries and epidemiological studies, reflected sex-specific, age-specific, and racial/ethnic-specific heterogeneities in HPV type distribution, cancer incidence, stage of disease at detection, and mortality. Model outcomes included the cumulative lifetime risks of developing and dying of 6 HPV-associated cancers. The level of racial/ethnic disparities was evaluated under each alternative HPV vaccine scenario using several metrics of social group disparity. RESULTS: HPV vaccination is expected to reduce the risks of developing and dying of HPV-associated cancers in all racial/ethnic groups as well as reduce the absolute degree of disparities. However, alternative metrics suggested that relative disparities would persist and in some scenarios worsen. For example, when assuming high uptake with the second-generation HPV vaccine, the lifetime risk of dying of an HPV-associated cancer for males decreased by approximately 60%, yet the relative disparity increased from 3.0 to 3.9. CONCLUSIONS: HPV vaccines are expected to reduce the overall burden of HPV-associated cancers for all racial/ethnic groups and to reduce the absolute disparity gap. However, even with the second-generation vaccine, relative disparities will likely still exist and may widen if the underlying causes of these disparities remain unaddressed. Cancer 2016;122:2057-66.

• Hansen, Bo Terning; Campbell, Suzanne; Burger, Emily & Nygård, Mari (2015). Correlates of HPV vaccine uptake in school-based routine vaccination of preadolescent girls in Norway: A register-based study of 90,000 girls and their parents. Preventive Medicine. ISSN 0091-7435. 77, p. 4–10. doi: 10.1016/j.ypmed.2015.04.024. Show summary

  Objective To assess demographic, socioeconomic and behavioural correlates of HPV vaccination of preadolescent girls in a publicly funded, school-based vaccination programme. Methods Data for all Norwegian girls born 1997–1999, eligible for routine school-based HPV vaccination in 2009–2011 (n = 90,842), and their registered mother and father, were merged from national registries. Correlates of girl vaccination status were analysed by unadjusted and multivariable logistic regression. Results In total, 78.2% of the girls received the first dose of the HPV vaccine, 74.6% received three doses, and 94.8% received the MMR vaccine. Correlates associated with initiation of HPV vaccination included parental age, income and education, maternal occupational status and cervical screening attendance, and girl receipt of the MMR vaccine. Rates of completion of HPV vaccination among initiators were high, and disparities in completion were negligible. Maternal and paternal correlates of daughter HPV vaccination status were similar. Conclusions Routine school-based vaccination generally provides equitable delivery, yet some disparities exist. Information campaigns designed to reach the sub-groups with relatively low vaccine uptake could reduce disparities. In none of the sub-groups investigated did uptake of the HPV vaccine approach that of the MMR vaccine, further demonstrating a general potential for improvement in HPV vaccine uptake.

• Kim, J.J.; Campos, Nicole G.; Sy, Stephen; Burger, Emily; Cuzick, Jack & Castle, P [Show all 9 contributors for this article] (2015). Inefficiencies and High-Value Improvements in U.S. Cervical Cancer Screening Practice: A Cost-Effectiveness Analysis. Annals of Internal Medicine. ISSN 0003-4819. 163(8), p. 589–597. doi: 10.7326/M15-0420. Show summary

  BACKGROUND: Studies suggest that cervical cancer screening practice in the United States is inefficient. The cost and health implications of nonadherence in the screening process compared with recommended guidelines are uncertain. OBJECTIVE: To estimate the benefits, costs, and cost-effectiveness of current cervical cancer screening practice and assess the value of screening improvements. DESIGN: Model-based cost-effectiveness analysis. DATA SOURCES: New Mexico HPV Pap Registry; medical literature. TARGET POPULATION:Cohort of women eligible for routine screening. TIME HORIZON:Lifetime. PERSPECTIVE:Societal. INTERVENTION: Current cervical cancer screening practice; improved adherence to guidelines-based screening interval, triage testing, diagnostic referrals, and precancer treatment referrals. OUTCOME MEASURES: Reductions in lifetime cervical cancer risk, quality-adjusted life-years (QALYs), lifetime costs, incremental cost-effectiveness ratios, and incremental net monetary benefits (INMBs). RESULTS OF BASE-CASE ANALYSIS:Current screening practice was associated with lower health benefit and was not cost-effective relative to guidelines-based strategies. Improvements in the screening process were associated with higher QALYs and small changes in costs. Perfect adherence to screening every 3 years with cytologic testing and adherence to colposcopy/biopsy referrals were associated with the highest INMBs ($759 and $741, respectively, at a willingness-to-pay threshold of $100 000 per QALY gained); together, the INMB increased to $1645. RESULTS OF SENSITIVITY ANALYSIS: Current screening practice was inefficient in 100% of simulations. The rank ordering of screening improvements according to INMBs was stable over a range of screening inputs and willingness-to-pay thresholds. LIMITATION: The effect of human papillomavirus vaccination was not considered. CONCLUSIONS: The added health benefit of improving adherence to guidelines, especially the 3-year interval for cytologic screening and diagnostic follow-up, may justify additional investments in interventions to improve U.S. cervical cancer screening practice.

• Pedersen, Kine; Sørbye, Sveinung Wergeland; Burger, Emily; Lönnberg, Stefan & Kristiansen, Ivar Sønbø (2015). Using decision-analytic modeling to isolate interventions that are feasible, efficient and optimal: an application from the Norwegian Cervical Cancer Screening Program. Value in Health. ISSN 1098-3015. 18(8), p. 1088–1097. doi: 10.1016/j.jval.2015.08.003. Full text in Research Archive
• Rochau, Ursula; Jahn, Beate; Qerimi, Vjollca; Burger, Emily; Kurzthaler, Christina & Kluibenschaedl, Martina [Show all 10 contributors for this article] (2015). Decision-analytic modeling studies: An overview for clinicians using multiple myeloma as an example. Critical Reviews in Oncology/Hematology. ISSN 1040-8428. 94(2), p. 164–178. doi: 10.1016/j.critrevonc.2014.12.017.
• Pedersen, Kine; Lönnberg, Stefan; Skare, Gry Baadstrand; Sørbye, Sveinung Wergeland; Burger, Emily & Kristiansen, Ivar Sønbø (2015). Kostnader ved Masseundersøkelsen mot livmorhalskreft. Sykepleien Forskning. ISSN 1890-2936. p. 62–71. doi: 10.4220/Sykepleienf.2015.53414. Full text in Research Archive
• Burger, Emily; Sy, Stephen; Nygård, Mari; Kristiansen, Ivar Sønbø & Kim, Jane J (2015). Too late to vaccinate? The incremental benefits and cost-effectiveness of a delayed catch-up program using the 4-valent human papillomavirus vaccine in Norway. Journal of Infectious Diseases. ISSN 0022-1899. 211(2), p. 206–215. doi: 10.1093/infdis/jiu413. Show summary

  Background: Human papillomavirus (HPV) vaccines are ideally administered prior to HPV exposure; therefore catch-up programs for girls past adolescence have not been readily funded. We evaluated the benefits and cost-effectiveness of a delayed, 1-year female catch-up vaccination program in Norway. Methods: We calibrated a dynamic HPV transmission model to Norwegian data and projected the costs and benefits associated with eight HPV-related conditions while varying the upper vaccination age limit to 20, 22, 24 or 26 years. We explored the impact of vaccine protection in women with prior vaccine-targeted HPV infections, vaccine cost, coverage, and natural- and vaccine-induced immunity. Results: The incremental benefits and cost-effectiveness decreased as the upper age limit for catch-up increased. Assuming a vaccine cost of $150/dose, vaccination up to age 20 remained below Norway’s willingness-to-pay threshold (≈$83,000/ quality-adjusted life year gained); extension to age 22 was cost-effective at a lower cost-per-dose ($50-$75). At high levels of vaccine protection in women with prior HPV exposure, vaccinating up to age 26 was cost-effective. Results were stable with lower coverage. Conclusions: HPV vaccination catch-up programs may be warranted five years after routine implementation; however, even at low vaccine cost per dose, the cost-effectiveness of vaccinating beyond age 22 remains uncertain.

• Campos, Nicole G.; Burger, Emily; Sy, Stephen; Sharma, Monisha; Schiffman, Mark & Rodriguez, Ana Cecilia [Show all 9 contributors for this article] (2014). An updated natural history model of cervical cancer: Derivation of model parameters. American Journal of Epidemiology. ISSN 0002-9262. 180(5), p. 545–555. doi: 10.1093/aje/kwu159. Show summary

  Mathematical models of cervical cancer have been widely used to evaluate the comparative effectiveness and cost-effectiveness of preventive strategies. Major advances in the understanding of cervical carcinogenesis motivate the creation of a new disease paradigm in such models. To keep pace with the most recent evidence, we updated a previously developed microsimulation model of human papillomavirus (HPV) infection and cervical cancer to reflect 1) a shift towards health states based on HPV rather than poorly reproducible histological diagnoses and 2) HPV clearance and progression to precancer as a function of infection duration and genotype, as derived from the control arm of the Costa Rica Vaccine Trial (2004–2010). The model was calibrated leveraging empirical data from the New Mexico Surveillance, Epidemiology, and End Results Registry (1980–1999) and a state-of-the-art cervical cancer screening registry in New Mexico (2007–2009). The calibrated model had good correspondence with data on genotype- and age-specific HPV prevalence, genotype frequency in precancer and cancer, and age-specific cancer incidence. We present this model in response to a call for new natural history models of cervical cancer intended for decision analysis and economic evaluation at a time when global cervical cancer prevention policy continues to evolve and evidence of the long-term health effects of cervical interventions remains critical.

• Burger, Emily; Nygård, Mari; Gyrd-Hansen, Dorte; Moger, Tron Anders & Kristiansen, Ivar Sønbø (2014). Does the primary screening test influence women's anxiety and intention to screen for cervical cancer? A randomized survey of Norwegian women. BMC Public Health. ISSN 1471-2458. 14:360. doi: 10.1186/1471-2458-14-360. Full text in Research Archive
• Burger, Emily & Kim, Jane J (2014). The value of improving failures within a cervical cancer screening program: An example from Norway. International Journal of Cancer. ISSN 0020-7136. 135(8), p. 1931–1939. doi: 10.1002/ijc.28838. Show summary

  Failures in cervical cancer (CC) screening include nonparticipation, underscreening and loss to follow-up of abnormal results. We estimated the long-term health benefits from and maximum investments in interventions targeted to improving compliance to guidelines while remaining cost-effective. We used a mathematical model empirically calibrated to simulate the natural history of CC in Norway. A baseline scenario reflecting current practice using cytology-based screening was compared to scenarios that target different sources of noncompliance: (i) failure to follow-up women with abnormal results, (ii) screening less frequently than recommended (i.e., underscreening) and (iii) absence of screening. A secondary analysis included human papillomavirus (HPV)-based screening as the primary test. Model outcomes included reductions in lifetime cancer risk and incremental net monetary benefit (INMB) resulting from improvements with compliance. Compared to the status quo, improving all sources of noncompliance leads to important health gains and produced positive INMBs across a range of developed-country willingness-to-pay (WTP) thresholds. For example, a 2% increase in compliance could reduce lifetime cancer risk by 1–3%, depending on the targeted source of noncompliance and primary screening method. Assuming a WTP threshold of $83,000 per year of life saved and cytology-based screening, interventions that increase follow-up of abnormal results yielded the highest INMB per 2% increase in coverage [$19 ($10–21)]. With HPV-based screening, recruiting nonscreeners resulted in the largest INMB [$23 ($18–32)]. Considerable funds could be allocated toward policies that improve compliance with screening under the current cytology-based program or toward adoption of primary HPV-based screening while remaining cost-effective.

• Burger, Emily; Sy, Stephen; Nygård, Mari; Kristiansen, Ivar Sønbø & Kim, Jane J (2014). Prevention of HPV-Related Cancers in Norway: Cost-Effectiveness of Expanding the HPV Vaccination Program to Include Pre-Adolescent Boys. PLOS ONE. ISSN 1932-6203. 9(3). doi: 10.1371/journal.pone.0089974. Full text in Research Archive Show summary

  Background: Increasingly, countries have introduced female vaccination against human papillomavirus (HPV), causally linked to several cancers and genital warts, but few have recommended vaccination of boys. Declining vaccine prices and strong evidence of vaccine impact on reducing HPV-related conditions in both women and men prompt countries to reevaluate whether HPV vaccination of boys is warranted. Methods: A previously-published dynamic model of HPV transmission was empirically calibrated to Norway. Reductions in the incidence of HPV, including both direct and indirect benefits, were applied to a natural history model of cervical cancer, and to incidence-based models for other non-cervical HPV-related diseases. We calculated the health outcomes and costs of the different HPV-related conditions under a gender-neutral vaccination program compared to a female-only program. Results: Vaccine price had a decisive impact on results. For example, assuming 71% coverage, high vaccine efficacy and a reasonable vaccine tender price of $75 per dose, we found vaccinating both girls and boys fell below a commonly cited cost-effectiveness threshold in Norway ($83,000/quality-adjusted life year (QALY) gained) when including vaccine benefit for all HPV-related diseases. However, at the current market price, including boys would not be considered ‘good value for money.’ For settings with a lower cost-effectiveness threshold ($30,000/QALY), it would not be considered cost-effective to expand the current program to include boys, unless the vaccine price was less than $36/dose. Increasing vaccination coverage to 90% among girls was more effective and less costly than the benefits achieved by vaccinating both genders with 71% coverage. Conclusions: At the anticipated tender price, expanding the HPV vaccination program to boys may be cost-effective and may warrant a change in the current female-only vaccination policy in Norway. However, increasing coverage in girls is uniformly more effective and cost-effective than expanding vaccination coverage to boys and should be considered a priority.

• Burger, Emily; Ortendahl, J D; Sy, S; Kristiansen, Ivar Sønbø & Kim, J.J. (2012). Cost-effectiveness of cervical cancer screening with primary human papillomavirus testing in Norway. British Journal of Cancer. ISSN 0007-0920. 106(9), p. 1571–1578. doi: 10.1038/bjc.2012.94.
• Burger, Emily; Kornør, Hege; Klemp, Marianne ; Lauvrak, Vigdis & Kristiansen, Ivar Sønbø (2011). HPV mRNA tests for the detection of cervical intraepithelial neoplasia: A systematic review. Gynecologic Oncology. ISSN 0090-8258. 120(3), p. 430–438. doi: 10.1016/j.ygyno.2010.11.013. Show summary

  Objective. Perform a systematic review to determine the test performance of HPV mRNA testing compared to DNA testing using CIN2+ as the target condition. Methods. We searched bibliographic databases (MEDLINE, EMBASE and Cochrane Library) from January 1996 through August 2010 using a predefined search strategy. The reference standard used to diagnose precancerous lesions was histologically confirmed cervical intraepithelial neoplasia 2+ (CIN2+). Two reviewers independently assessed study eligibility, extracted data, and assessed risk of bias. Sensitivity, specificity, positive and negative likelihood ratios and diagnostic odds ratios were calculated for each study. In addition, we fitted a series of summary receiver operating characteristics (SROC) curves. A subgroup analysis was performed according to specific inclusion covariates. Results. Out of 3179 potentially relevant citations, 12 publications (11 studies) met our inclusion criteria. The included studies were of varying methodological quality, and were predominately performed in a secondary screening setting. Eight studies investigated the performance of the PreTect Proofer/NucliSENS EasyQ, two studies investigated the performance of the APTIMA assay and one study investigated both mRNA tests on the same patient samples. Due to few studies and considerable clinical heterogeneity, pooling of data was not possible. Instead, we compiled a ‘best evidence synthesis’ for E6/E7 mRNA HPV testing. Sensitivities ranged from 0.41 to 0.86 and from 0.90 to 0.95 for the PreTect Proofer/Easy Q and APTIMA assay, respectively. Specificities ranged from 0.63 to 0.97 and from 0.42 to 0.61 for the PreTect Proofer/Easy Q and APTIMA assay, respectively. The SROC curves for both mRNA tests were to the left of the diagonal and the APTIMA assay performed closest to the DNA tests. Conclusion. The review suggests that mRNA tests have diagnostic relevance, but additional studies and economic evaluations must be conducted in order to make a solid conclusion regarding the clinical applicability of HPV mRNA testing.

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• Burger, Emily Annika; Baussano, Iacopo; Kim, Jane J.; Laprise, Jean-François; Berkhof, Johannes & Schiller, John T. [Show all 11 contributors for this article] (2023). Recent economic evaluation of 1-dose HPV vaccination uses unsupported assumptions. Vaccine. ISSN 0264-410X. 41(16), p. 2648–2649. doi: 10.1016/j.vaccine.2022.07.022.
• Baasland, Ingrid; Berland, Jannicke Mohr; Burger, Emily Annika; Jonassen, Christine M; Lie, Kathrine & Opdahl, Signe (2023). Livmorhalsprogrammet forebygger livmorhals­kreft. Forskersonen.no. Show summary

  Masseundersøkelser – eller screening – handler om å undersøke personer uten sykdomstegn for å oppdage tidlig sykdom. Hensikten med livmorhalsscreening er å oppdage og behandle celleforandringer før kreft utvikles.

• Bjørnelv, Gudrun Maria Waaler; Burger, Emily Annika & Aas, Eline (2023). Hvor ble det av prioriteringskriteriene for ABC-klinikken? dagensmedisin.no. Show summary

  ABC-klinikken ved Ullevål skal legges ned i mars. Argumentene for nedleggelsen er økonomisk motivert. Men hvilke økonomiske argumenter skal egentlig telle ved prioritering i Norge – og hvordan påvirker disse tilliten som befolkningen har til ulike beslutninger?

• Nygård, Mari; Burger, Emily Annika; Nygård, Ståle; Tropé, Ameli; Falkenthal, Thea Eline Hetland & Mohr Berland, Jannicke [Show all 10 contributors for this article] (2023). Skal vi screene og konisere inn i evigheten – eller bytte HPV-vaksine? dagensmedisin.no. Show summary

  Norge blir ikke det første landet som eliminerer livmorhalskreft – til det er vi ikke ambisiøse nok, tidlig nok. Men vi kan fortsatt innrette oss bedre for å forebygge enda mer – og mer kostnadseffektivt.

• Burger, Emily Annika (2022). Using decision-analytic modeling to help prioritize alternative HPV vaccination and cervical cancer screening strategies: Norwegian and global perspectives.
• Aas, Eline & Burger, Emily Annika (2022). Økonomisk evaluering .
• Vervaart, Mathyn Adrianus Marinus; Aas, Eline; Asphaug, Lars; Bjørnelv, Gudrun Maria Waaler; Burger, Emily Annika & Wisløff, Torbjørn (2021). Undervurdering av en kompleks problemstilling. Dagens medisin. ISSN 1501-4290.
• Vervaart, Mathyn Adrianus Marinus; Aas, Eline; Asphaug, Lars; Bjørnelv, Gudrun Maria Waaler; Burger, Emily Annika & Wisløff, Torbjørn (2021). I strid med etablert kunnskap. Dagens medisin. ISSN 1501-4290.
• Portnoy, Allison; Pedersen, Kine; Trogstad, Lill; Hansen, Bo Terning; Feiring, Berit & Laake, Ida [Show all 11 contributors for this article] (2021). Cost-effectiveness of nonavalent HPV vaccine in Norway considering current empirical data and validation. Preventive Medicine. ISSN 0091-7435. doi: 10.1016/j.ypmed.2021.106688.
• Castanon, Alejandra; Rebolj, Matejka; Burger, Emily Annika; de Kok, Inge; Smith, Megan A & Hanley, Sharon [Show all 9 contributors for this article] (2021). Cervical screening during the COVID-19 pandemic: optimising recovery strategies. The Lancet Public Health. ISSN 2468-2667. doi: 10.1016/S2468-2667(21)00078-5. Full text in Research Archive Show summary

  Disruptions to cancer screening services have been experienced in most settings as a consequence of the COVID-19 pandemic. Ideally, programmes would resolve backlogs by temporarily expanding capacity; however, in practice, this is often not possible. We aim to inform the deliberations of decision makers in high-income settings regarding their cervical cancer screening policy response. We caution against performance measures that rely solely on restoring testing volumes to pre-pandemic levels because they will be less effective at mitigating excess cancer diagnoses than will targeted measures. These measures might exacerbate pre-existing inequalities in accessing cervical screening by disregarding the risk profile of the individuals attending. Modelling of cervical screening outcomes before and during the pandemic supports risk-based strategies as the most effective way for screening services to recover. The degree to which screening is organised will determine the feasibility of deploying some risk-based strategies, but implementation of age-based risk stratification should be universally feasible.

• Kristiansen, Ivar Sønbø; Burger, Emily & De Blasio, Birgitte Freiesleben (2020). Covid-19: Simulation models for epidemics. Tidsskrift for Den norske legeforening. ISSN 0029-2001. 140(6). doi: 10.4045/tidsskr.20.0225.
• Kristiansen, Ivar Sønbø; Burger, Emily & De Blasio, Birgitte Freiesleben (2020). Covid-19: Simuleringsmodeller ved epidemier. Tidsskrift for Den norske legeforening. ISSN 0029-2001. 140(6), p. 1–6. doi: 10.4045/TIDSSKR.20.0225.
• Castle, Philip E.; Wheeler, Cosette M.; Campos, Nicole G.; Sy, Stephen; Burger, Emily & Kim, Jane J. (2018). Inefficiencies of over-screening and under-screening for cervical cancer prevention in the U.S. Preventive Medicine. ISSN 0091-7435. 111, p. 177–179. doi: 10.1016/j.ypmed.2018.03.011.
• Burger, Emily; Pedersen, Kine; Sy, Stephen; Kristiansen, Ivar Sønbø & Kim, Jane J. (2017). Primary HPV-based Cervical Cancer Screening: Balancing Health Benefits Colposcopy Referrals.
• Burger, Emily; Dyer, Michael; Palefsky, Joel M.; Sy, Stephen; de Pokomandy, Alexandra & Coutlee, François [Show all 8 contributors for this article] (2017). A Natural History Model of Anal Carcinogenesis for High-risk HIV-positive Men: Model Development and Calibration.
• Burger, Emily; Kim, Jane J.; Sy, Stephen & Castle, Philip E. (2017). Exposing the Insulting Infection: Leveraging Models to Explore the Natural History of HPV Infections.
• Castle, Philip E. & Burger, Emily (2016). Age of HPV vaccination? The Lancet Infectious Diseases. ISSN 1473-3099. 16(10), p. 1091–1093. doi: 10.1016/S1473-3099(16)30144-X.
• Pedersen, Kine; Burger, Emily; Sy, Stephen; Kristiansen, Ivar Sønbø & Kim, Jane J. (2016). Cost-effective management of women with minor cervical lesions: Revisiting the application of HPV DNA testing.
• Sørbye, Sveinung Wergeland; Sæterdal, Ingvil Von Mehren; Hansen, Bo Terning; Nygård, Mari & Burger, Emily (2015). Vurderer på nytt å hpv-vaksinere gutter. [Internet]. Sykepleien. Show summary

  Spørsmålet om å gi hpv-vaksinen til gutter er ikke avgjort. Samtidig øker tilfellene av hpv-kreft blant både menn og kvinner. Sannsynligvis ikke kostnadseffektivt, var konklusjonen da Kunnskapssenteret for helsetjenesten gjorde en økonomisk evaluering av hpv-vaksine til gutter. – Men rapporten så først og fremst på gevinsten ved mindre hpv-kreft hos jenter, i mindre grad på forekomst av hpv-kreft blant gutter, påpeker Sveinung Wergeland Sørbye, overlege i klinisk patologi ved Universitetssykehuset i Nord-Norge.

• Burger, Emily; Lee, Kyueun & Kim, Jane J. (2015). Racial and Ethnic Disparities in HPV-related Cancer Incidence and Mortality with First- and Second-generation HPV Vaccines in the United States.
• Burger, Emily; Castle, P & Kim, Jane J (2015). The Optimal Age for Vaccinated Women to Initiate Cervical Cancer Screening in the United States.
• Pedersen, Kine; Sørbye, Sveinung Wergeland; Kristiansen, Ivar Sønbø & Burger, Emily (2015). Novel Biomarkers to Triage Women with Minor Cervical Lesions: Quantifying the Cost-Effectiveness Tradeoffs to Ensure Feasible Implementation.
• Pedersen, Kine; Burger, Emily; Campbell, Suzanne; Nygård, Mari & Lönnberg, Stefan (2015). Risk of cervical cancer by screening intensity: A registry-based analysis.
• Pedersen, Kine; Sørbye, Sveinung Wergeland; Burger, Emily; Lönnberg, Stefan & Kristiansen, Ivar Sønbø (2015). Quantifying benefits and harms in cervical cancer screening: A decision analytic approach.
• Pedersen, Kine; Sørbye, Sveinung Wergeland; Lönnberg, Stefan; Burger, Emily & Kristiansen, Ivar Sønbø (2014). Trade-offs in cervial cancer screening - Balancing detected cancer precursors and resource use. Show summary

  Reflex HPV-testing allows for improvements in both effectiveness and cost-effectiveness of the current screening algorithm. Candidate strategies can detect a larger number of precancers while using fewer resources compared to current practice; however, the optimal strategy depends on society’s willingness to pay costs and accept harms. Ultimately, the down-stream effectiveness of the alternative algorithms will depend on the extent to which precancers regress or progress into cancer.

• Sørbye, Sveinung Wergeland; Burger, Emily; Eide, Maj Liv; Iversen, Ole-Erik & Jørstad, Rolf Gunnar (2014). Feiltolkninger koster tjue liv i året. [Newspaper]. Avisa Nordland. Show summary

  Hvert år får 300 kvinner livmorhalskreft. Én av tre dør av sykdommen. Overlege i patologi, Sveinung W. Sørbye, tror liv kunne vært spart dersom den norske screeningmetoden hadde blitt byttet ut. – I Norge dør det årlig 10-20 kvinner som følge av feiltolkede celleprøver. Han mener tiden er moden for å innføre HPV-testing i screeningprogrammet, for å få ned antall dødsfall.

• Groeneveld, linn; Engesæter, Birgit; Aasbø, Gunvor; Hansen, Mona; Christiansen, Irene Kraus & Berland, Jannicke [Show all 14 contributors for this article] (2021). Prosjektforslag hjemmetest: Implementering av hjemmeprøvetaking i Livmorhalsprogrammet. Kreftregisteret - Institutt for populasjonsbasert kreftforskning. Full text in Research Archive Show summary

  Effektiv forebygging av livmorhalskreft fordrer at kvinner deltar i Livmorhalsprogrammet som anbefalt. I dag er deltakelsen på 71%, mens anbefalt deltakelse er minimum 80% ifølge internasjonale retningslinjer. Over halvparten av livmorhalskrefttilfellene diagnostisert i Norge er blant kvinner som ikke har tatt livmorhalsprøver som anbefalt. I tillegg får de som aldri eller sjelden screener seg, oftere påvist livmorhalskreft på et høyere stadium enn de som screener seg som anbefalt. En ny norsk studie viser at tilbud om hjemmetest til denne gruppen avdekker et betydelig antall forstadier til kreft og kreft som ikke ville blitt avdekket ved ordinær påminnelse om å ta screeningprøve hos lege. Både internasjonale og norske studier har vist at man på en kostnadseffektiv måte kan oppnå en betydelig forbedret deltakelse i screeningprogrammet blant kvinner dersom de får tilbud om hjemme-prøvetaking (= hjemmetest). Helsedirektoratet har bedt Kreftregisteret om å utrede hjemmetest som et tiltak for å øke deltakelsen i Livmorhalsprogrammet blant kvinner som ikke har møtt til screening på mer enn ti år. Forslaget skulle også inkludere bruk av hjemmetest for kvinner som ikke har tatt livmorhalsprøve på grunn av covid-19 pandemien, og eventuelle andre grupper. Denne rapporten skisserer hvordan hjemmetest kan innføres i Livmorhalsprogrammet. Anbefalt strategi er å gi tilbud om hjemmetest til tre grupper. Den første gruppen er kvinner med betydelig økt risiko for alvorlige celleforandringer i livmorhalsen på grunn av manglende deltakelse over lengre tid. Spesifikt anbefales det at kvinner uten registrert livmorhalsprøve i løpet av ti år eller mer får hjemmetest tilsendt i posten (opt-out). Den andre gruppen er kvinner uten registrert livmorhalsprøve de siste åtte eller ni år, denne gruppen anbefales å få mulighet til å bestille hjemmetest (opt-in). Den siste gruppen er kvinner som av fysiske eller psykiske årsaker vegrer seg for å ta en livmorhalsprøve hos legen. Det planlegges at disse kvinnene får tilbud om hjemmetest via lege. Hjemmetesting er enda mer aktuelt nå på grunn av covid-19 pandemien. Normalt registrerer Livmorhalsprogrammet cirka 450 000 prøver per år. Grove estimater viser at det ble registrert 50 000 færre livmorhalsprøver enn forventet i 2020. En ny smittebølge av covid-19 i november 2020, som førte til en ny sosial nedstenging av samfunnet i Oslo-regionen i januar 2021, ser også ut til å ha påvirket antall registrerte prøver i januar 2021. Hjemmetest i seg selv er et mer kostnadseffektivt alternativ enn legetatt prøve, ettersom helsepersonell ikke involveres i selve prøvetakingen. De helseøkonomiske modellene inkludert i rapporten viser at tilbud om hjemmetest gir en helsegevinst ved at andelen kvinner som deltar i screeningprogrammet vil øke, og dermed reduseres deres livstidsrisiko for å utvikle livmorhalskreft. Økt deltakelse vil imidlertid medføre en økt kostnad for screeningvirksomheten, men for samfunnet som en helhet vil det være lønnsomt. Dette tilbudet vil resultere i samfunnsmessige besparelser fordi færre kvinner vil måtte behandles for livmorhalskreft. Kvinner som rammes av livmorhalskreft får økte kvalitetsjusterte leveår (på engelsk: quality-adjusted life years -QALYs). I vår forenklede modell-baserte analyse ble det estimert at opt-out hjemmetesting, sammenlignet med påminnelsesbrev, kunne gi mer enn 1 365 ekstra (diskontert) QALYs blant de 217 000 kvinnene som kvalifiserer til hjemmetest i løpet av fem år. Dette er langt flere QALYs enn de 155 som behøves for å være kostnadseffektiv, gitt at myndighetenes betalingsvillighet for et ekstra leveår er 385 000 kroner. Samlet viser også beregningsmodellene som er gjennomført, at kostnaden per tilfelle av alvorlige celleforandringer som oppdages, er lavere ved hjemmetest sammenlignet med vanlig påminnelse og prøvetaking hos lege.

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