Emily Annika Burger

• Silvestre, Jacopo Di; Salgado, M. Victoria; Jeon, Jihyoun; Mok, Yoonseo; Holford, Theodore R. & Vedøy, Tord Finne [Vis alle 9 forfattere av denne artikkelen] (2026). Age- and sex-specific smoking trends by birth cohort in Norway, 1978–2024: an analysis of cross-sectional survey data. The Lancet Regional Health - Europe. 71. doi: 10.1016/j.lanepe.2026.101886.
• Bekkevold, Terese; Laake, Ida; Feiring, Berit; Søreng, Kristiane; Presthus, Gro & Alfsen, Glenny Cecilie [Vis alle 14 forfattere av denne artikkelen] (2026). HPV Genotype Distribution in Cervical Cancer and High-Grade Lesions in Norway, and Early Vaccine Impact. International Journal of Cancer. ISSN 0020-7136. doi: 10.1002/ijc.70712.
• Wu, Yansi; Burger, Emily Annika; Holmboe, Fredrik; Bangum, Magnus; Oteiza, Francisco & Bugge, Christoffer [Vis alle 8 forfattere av denne artikkelen] (2026). Integrating Structured Expert Elicitation with External Evidence to Inform Earlier Reimbursement Decisions: A Norwegian Case Study of Selpercatinib for Non-Small Cell Lung Cancer. PharmacoEconomics - Open. ISSN 2509-4262. 10(4), s. 679–694. doi: 10.1007/s41669-026-00656-9. Fulltekst i vitenarkiv Vis sammendrag

  Background The Norwegian public–private partnership, CONNECT, identified the reimbursement submission case of selpercatinib—a first-line targeted therapy for RET fusion-positive non-small cell lung cancer (NSCLC)—as a unique opportunity to assess the role of structured expert elicitation (SEE) in conjunction with phase II evidence. Objective This study aims to compare the potential of using SEE and other sources of external evidence with phase III clinical trial results to explore the possibility of facilitating earlier (conditional) reimbursement decisions. Methods We conducted a series of cost-effectiveness analyses, grouping different sources of evidence (i.e., published clinical evidence and SEE) to estimate the long-term health and economic consequences of selpercatinib versus pembrolizumab plus pemetrexed and platinum-based chemotherapy for patients with advanced RET fusion-positive NSCLC in Norway. We developed a probabilistic partitioned survival model to estimate and compare costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs) associated with evidence potentially available early in the product lifecycle, including SEE, with those using phase III evidence. Results ICERs consistently ranged between $8257 and $19,819 per QALY gained when we used SEE, either alone or in combination with additional external evidence, or when we used the phase III randomized controlled trial (RCT) evidence. Conclusions The consistent cost-effectiveness results between pre-submission and post-submission phases support the potential of SEE to complement health technology assessment (HTA) and potentially inform earlier (conditional) reimbursement decisions for this single case study. However, future research should focus on refining SEE protocols for continued methodological development and validation to improve generalizability and applicability.

• Khalife, Ghida; Baldwin, David; Koivunen, Jussi; Hardardottir, Hronn; Stenger, Michael & Johansson, Mikael [Vis alle 11 forfattere av denne artikkelen] (2026). Lung cancer screening in transition: highlights from the 3rd Oslo Lung Cancer Symposium, 2025. European Clinical Respiratory Journal. 13(1). doi: 10.1080/20018525.2026.2674339. Fulltekst i vitenarkiv Vis sammendrag

  The 3rd Annual Lung Cancer Symposium (Oslo Cancer Cluster, 25 September 2025) gathered experts from all the Nordic countries, Norway, Finland, Iceland, Denmark, Sweden, as well as Germany, the UK and the USA to present new evidence and implementation experiences in low-dose chest tomography lung cancer screening, with cross-cutting attention to risk stratification, health economics, AI-enabled workflows, and equity. The symposium was organized by Oslo Cancer Cluster, Levanger Hospital and the Norwegian University of Science and Technology, as a continuation of previous years´ annual efforts to gather and showcase the experiences and the progress of the Nordic countries with lung cancer screening. Across settings, LDCT screening is associated with stage shift and potential mortality reduction, consistent with large trials (NLST, NELSON) and maturing real-world experience (HANSE pilot study, programs in Croatia, Taiwan, the UK, and the US). Emerging Nordic pilots demonstrate feasibility, early-stage detection, and high adherence, while European coordination (SOLACE) is accelerating guideline harmonization and implementation pilots. Key themes included: (1) superiority of multivariable risk models over categorical criteria; (2) the necessity of integrating smoking cessation; (3) program economics that are likely acceptable under Nordic decision thresholds; (4) capacity and downstream pathway planning; and (5) equity-by-design to avoid widening disparities. This report synthesizes country updates and implications for Nordic and European scale-up.

• Pedersen, Kine; Silvestre, Jacopo Di; Sy, Stephen; Portnoy, Allison; Castle, Philip E. & Kim, Jane J. [Vis alle 7 forfattere av denne artikkelen] (2026). Optimizing Cervical Cancer Screening by Age at Vaccination for Human Papillomavirus: Health and Resource Implications. Annals of Internal Medicine. ISSN 0003-4819. 179(4), s. 497–505. doi: 10.7326/ANNALS-25-03192. Fulltekst i vitenarkiv
• Burger, Emily A.; Laprise, Jean-François; Spencer, Jennifer C.; Sy, Stephen; Regan, Mary Caroline & Drolet, Melanie [Vis alle 9 forfattere av denne artikkelen] (2026). Single-dose HPV vaccination in the United States — a multi-modeling analysis. The Lancet Regional Health - Americas. 55, s. 101361–101361. doi: 10.1016/j.lana.2025.101361. Fulltekst i vitenarkiv Vis sammendrag

  Background: Evidence supporting the non-inferior efficacy of single-dose human papillomavirus (HPV) vaccination has prompted reconsideration of existing multi-dose HPV vaccination schedules. We evaluated the long-term health impact of adopting single-dose HPV vaccination in the United States to inform policy deliberations. Methods: We applied two validated individual-based simulation models of HPV transmission and cervical cancer to project the impact of switching from a two-dose to a single-dose HPV vaccination schedule in 2025 in the context of historical HPV vaccination uptake in the United States. Four scenarios were simulated: continuation of two-dose vaccination (or equivalent single-dose efficacy of 98%) and three alternative pessimistic single-dose strategies with lower vaccine efficacy (90%) and/or duration of protection (average of 25 years). Outcomes included age-standardized incidence rates of HPV-16 infection and cervical cancer from years 2005-2099. Additional analyses examined effects under lower vaccination coverage observed in select U.S. regions. Findings: Maintaining two doses or switching to a non-inferior single-dose HPV vaccination schedule was projected to nearly eliminate HPV-16 infections and reduce cervical cancer incidence by over 90% by the end of the century. Scenarios assuming a lower efficacy or waning protection showed increases in cervical cancer incidence of less than 2 percentage points decades after a switch to single-dose vaccination with no impact on the timeframe to cervical cancer elimination. Interpretation: Switching to a single-dose HPV vaccination schedule is projected to maintain reductions in cervical cancer, even under pessimistic efficacy and durability assumptions. Continued monitoring of single-dose HPV vaccine efficacy over time remains critical. Funding: PATH on behalf of the Single-Dose HPV Vaccine Evaluation Consortium; Bill and Melinda Gates Foundation (grant No. OPP48979), and the US National Institutes of Health/National Cancer Institute (Grant Number U01 CA253912).

• Groot, Carin A. Uyl-de; Xander, Nicolas S.H.; Belleman, Tom; Burger, Emily Annika; Doeswijk, Robin & Durand-Zaleski, Isabelle [Vis alle 23 forfattere av denne artikkelen] (2026). Bridging affordability and sustainability of health innovations via novel pricing, cost-effectiveness, and reimbursement models to improve patient access: The ASCERTAIN project. Health Policy and Technology. ISSN 2211-8837. 15(2). doi: 10.1016/j.hlpt.2026.101155. Fulltekst i vitenarkiv Vis sammendrag

  Objectives Disparities in access to potential innovative health technologies (pIHTs) persist across Europe due to differing healthcare budgets, pricing policies, and health technology assessment (HTA) practices. The ASCERTAIN project aims to reduce these inequalities by developing integrated pricing, cost-effectiveness, and reimbursement approaches that enhance affordability, long-term sustainability, and timely patient access. Methods The project applies a mixed-methods approach, including literature review, stakeholder surveys, interviews, and focus groups, to ensure relevance across diverse health systems. It integrates access-based pricing, value-driven HTA, and adaptable reimbursement models into a practical, open-access ACCESS2MEDS Toolbox. This includes access-based pricing frameworks, cost-effectiveness models, and budget impact and reimbursement analyses, all adaptable to country-specific conditions to reduce uncertainty and improve transparency. Tools are co-created with patients, developers, clinicians, and policymakers and will be tested and validated using three use cases representing high-impact areas of innovation: precision oncology medicines, cell and gene therapies, and next-generation sequencing tests. Results Outputs will include validated tools enabling improved evaluation of clinical benefit, cost-effectiveness, and financial sustainability, strengthening value-based decision-making across Europe. Innovative access- and outcome-based pricing strategies will support responsible innovation while encouraging fair reimbursement and improved budget control. Policy roadmaps will guide the adoption of equitable access models and support system-level implementation. Conclusions ASCERTAIN will provide a harmonized framework that balances cost control, innovation incentives, and patient-centered care. By facilitating consistent, evidence-based pricing and reimbursement decisions, the project supports fair and sustainable access to pIHTs across Europe, with continued multi-stakeholder collaboration driving its wider adoption and real-world impact.

• Burger, Emily A; Jansen, Erik E L; Bondt, Daniël de; Killen, James; Spencer, Jennifer C & Regan, Mary Caroline [Vis alle 12 forfattere av denne artikkelen] (2025). Disparities in cervical cancer elimination time frames in the United States: a comparative modeling study. Journal of the National Cancer Institute. ISSN 0027-8874. 117(7), s. 1502–1502. doi: 10.1093/jnci/djae319. Fulltekst i vitenarkiv Vis sammendrag

  Abstract Population-level estimates in time frames for reaching cervical cancer elimination (ie, <4 cases per 100 000 women) in the United States may mask potential disparities in achieving elimination among subpopulations. We used 3 independent Cancer Intervention and Surveillance Modeling Network models to estimate differences in the time to cervical cancer elimination across 7 strata of correlated screening and human papillomavirus vaccination uptake, based on national survey data. Compared with the average population, elimination was achieved at least 22 years earlier for the high-uptake strata and at least 27 years later for the most extreme low-uptake strata. Accounting for correlated uptake impacted the population average time frame by no more than 1 year. Consequently, national average elimination time frames mask substantial disparities in reaching elimination among subpopulations. Addressing inequalities in cervical cancer control could shorten elimination time frames and would ensure more equitable elimination across populations. Furthermore, country-level elimination monitoring could be supplemented by monitoring progress in subpopulations.

• Landy, Rebecca; Haber, Gregory W; Graubard, Barry I; Fakhry, Carole; Campos, Nicole G & Burger, Emily A [Vis alle 10 forfattere av denne artikkelen] (2025). Impact of screening for human papillomavirus-positive oropharyngeal cancers: a microsimulation-based modeling study. Journal of the National Cancer Institute. ISSN 0027-8874. 117(6), s. 1217–1217. doi: 10.1093/jnci/djaf033. Fulltekst i vitenarkiv Vis sammendrag

  Abstract Background We estimated the impact of screening on morbidity and mortality of human papillomavirus (HPV)16-positive oropharyngeal cancer among US men aged 45-79 years. Methods We developed an individual-level, state-transition natural history microsimulation model to estimate the impact of screening using oral HPV16 detection, HPV16-E6 antibody detection, and transcervical ultrasound of neck/oropharynx. We compared clinical detection to counterfactual screen detection for cancer stage, single- vs multiple-modality treatment, and survival. Screening scenarios encompassed 4 progression speeds across cancer stages (very slow, slow, fast, and very fast) and 4 screening frequencies. Results Among US men aged 45-79 years in 2021 (n = 54 881 311), 163 958 clinically diagnosed human papillomavirus (HPV)-positive oropharyngeal cancers and 32 009 deaths would occur through age 84 in the absence of screening. Assuming very-fast progression, 4%, 20%, 31%, and 60% of these cancers would be detected by one-off, 5-yearly, 3-yearly, and annual screening. Annual screening (very-fast progression) could reduce the number of cancers diagnosed at advanced stages (American Joint Committee on Cancer, 7th edition, stages III/IV: 90.0% with no screening vs 59.1%) and treated by multiple modalities (80.6% with no screening vs 50.6%). Cancer mortality would also be reduced by 36.2%, with a gain of 106 000 life-years. Annual screening would have a number needed to screen (NNS) of 561 per screen-detected cancer, 1118 per additional cancer treated by single modality, 4740 per death prevented, and 520 per life-year gained; such high NNS reflect potential inefficiency of population-level screening. Conclusions If proven efficacious in randomized trials and cost-effective, screening for HPV-positive oropharyngeal cancers could provide considerable population-level reductions in advanced stage cancers, treatment-related morbidities, and mortality.

• Nguyen, Cindy; Burger, Emily Annika; Aasdahl, Lene; Morgante, Niccolò; Fimland, Marius Steiro & Bjørnelv, Gudrun Maria Waaler (2025). A cost-utility analysis for return-to-work interventions comparing alternative methods for handling missing health-related quality of life data. Journal of Rehabilitation Medicine. ISSN 1650-1977. 57. doi: 10.2340/jrm.v57.42359. Fulltekst i vitenarkiv Vis sammendrag

  Objective: Perform a cost-utility analysis for return-to-work interventions with missing health-related quality-of-life (HRQoL) data while transparently demonstrating the impact of different methods of handling missing data on outcomes. Methods: The costs and quality-adjusted life-years over a 2-year period were estimated for 2 return-to-work interventions, inpatient multimodal occupational rehabilitation (I-MORE) and outpatient acceptance and commitment therapy (O-ACT), using a healthcare perspective and a limited societal perspective. Four methods were used to handle the missing HRQoL data: complete case analysis, single imputation, multiple imputation, and linear mixed models. The cost-effectiveness outcomes were expressed as incremental net monetary benefit. Results: The average incremental quality-adjusted life-years comparing I-MORE with O-ACT ranged between –0.001 and 0.330 depending on missingness method. From a healthcare perspective, I-MORE was consistently not cost-effective (incremental net monetary benefits ranged from –€7,094 to –€9,363) while from a limited societal perspective, I-MORE was consistently cost-effective (incremental net monetary benefits ranged from €1,293 to €16,277). Conclusion: While cost-effectiveness findings remained consistent within each analytical perspective, the choice of different missingness methods led to variations in incremental quality-adjusted life-years. Multiple imputation is recommended to handle missing HRQoL data as it is transparent and flexible. How-ever, a thorough investigation of the missing data mechanism should still be conducted.

• Wu, Yansi; Kunst, Natalia; Gyõrbiró, David M.; Kristiansen, Ivar Sønbø; Strand, Trond-Eirik & Nguyen, Olav Toai Duc [Vis alle 10 forfattere av denne artikkelen] (2025). Cost-effectiveness of low-dose CT lung cancer screening among individuals that have ever smoked in Norway: A model-based analysis using NELSON trial criteria and outcomes. International Journal of Cancer. ISSN 0020-7136. 158(9), s. 2452–2465. doi: 10.1002/ijc.70270. Fulltekst i vitenarkiv
• Burger, Emily A; Laprise, Jean-François; Portnoy, Allison; Spencer, Jennifer C; Sy, Stephen & Regan, Mary Caroline [Vis alle 10 forfattere av denne artikkelen] (2024). Population-level health impact of hypothetical waning 1-dose human papillomavirus vaccination and 2-dose mitigation strategies in a high cervical cancer burden setting. Journal of the National Cancer Institute. Monographs. ISSN 1052-6773. 2024(67), s. 386–386. doi: 10.1093/jncimonographs/lgae039. Fulltekst i vitenarkiv Vis sammendrag

  Abstract Background We simulated the impact of hypothetical waning scenarios of a 1-dose human papillomavirus (HPV) vaccination paired with switching to 2-dose mitigation strategies guided by empirical vaccine trial reporting timelines. Methods Using 2 independent mathematical models fitted to a high-burden setting, we projected the cumulative cervical cancer cases averted over 85 years for alternative HPV vaccination scenarios under 2 program adoption timelines: 1) de novo introduction of a 1-dose HPV vaccination and 2) a switch from an existing 2-dose HPV vaccination program to a 1-dose vaccination. We assumed 80% vaccination coverage with the bivalent vaccine and an average duration of a 1-dose HPV vaccine protection of either 30 or 25 years with 100% efficacy. We varied the eligible age group(s) at program introduction and the 2-dose mitigation (single-age cohort or multi-age cohort). If needed for mitigation, reintroduction of 2-dose vaccination was assumed to occur in 2036 (ie, 30 years after initiation of the Costa Rica Vaccine Trial). Results Under both vaccine adoption timelines, the models projected that countries could achieve the same level of health benefits by switching to 2 doses in 2036 using a multi-age cohort approach as with initiating a 2-dose or 1-dose vaccination program with no waning. With only a single-age cohort 2-dose mitigation approach, 98%-99% of cases would be prevented compared with the health benefits of 2 doses or a noninferior, durable 1 dose. Conclusions Countries hesitant to adopt a 1-dose HPV vaccination program may have opportunities to leverage the benefits and efficiency of a 1-dose schedule while awaiting longer-term reporting from 1-dose durability studies, including Costa Rica Vaccine Trial.

• Hansen, Bo Lars Thorvald Terning; Nygård, Mari Kiens; Castle, Phil E.; Burger, Emily Annika & Aasbø, Gunvor (2024). Sociodemographic characteristics associated with cervical cancer screening participation by send-to-all and opt-in HPV self-sampling: Who benefits? Results from a randomized controlled trial among long-term non-attending women in Norway. International Journal of Cancer. ISSN 0020-7136. 155(6), s. 1053–1067. doi: 10.1002/ijc.34989. Fulltekst i vitenarkiv
• Brisson, Marc; Laprise, Jean-François; Drolet, Mélanie; Chamberland, Éléonore; Bénard, Élodie & Burger, Emily Annika [Vis alle 11 forfattere av denne artikkelen] (2024). Population-level impact of switching to 1-dose human papillomavirus vaccination in high-income countries: examining uncertainties using mathematical modeling. Journal of the National Cancer Institute. Monographs. ISSN 1052-6773. 2024(67), s. 387–399. doi: 10.1093/jncimonographs/lgae038. Fulltekst i vitenarkiv
• 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. 44(4), s. 380–392. doi: 10.1177/0272989X241241339. Fulltekst i vitenarkiv Vis sammendrag

  Background Screening pregnant women for gestational diabetes mellitus (GDM) has recently been expanded in Norway, although screening eligibility criteria continue to be debated. We aimed to compare the cost-effectiveness of alternative GDM screening strategies and explored structural uncertainty and the value of future research in determining the most cost-effective eligibility criteria for GDM screening in Norway. Design We developed a probabilistic decision tree to estimate the total costs and health benefits (i.e., quality-adjusted life-years; QALYs) associated with 4 GDM screening strategies (universal, current guidelines, high-risk, and no screening). We identified the most cost-effective strategy as the strategy with the highest incremental cost-effectiveness ratio below a Norwegian benchmark for cost-effectiveness ($28,400/QALY). We excluded inconclusive evidence on the effects of screening on later maternal type 2 diabetes mellitus (T2DM) in the primary analysis but included this outcome in a secondary analysis using 2 different sources of evidence (i.e., Cochrane or US Preventive Services Task Force). To quantify decision uncertainty, we conducted scenario analysis and value-of-information analyses. Results Current screening recommendations were considered inefficient in all analyses, while universal screening was most cost-effective in our primary analysis ($26,014/QALY gained) and remained most cost-effective when we assumed a preventive effect of GDM treatment on T2DM. When we assumed no preventive effect, high-risk screening was preferred ($19,115/QALY gained). When we assumed GDM screening does not prevent perinatal death in scenario analysis, all strategies except no screening exceeded the cost-effectiveness benchmark. In most analyses, decision uncertainty was high. Conclusions The most cost-effective screening strategy, ranging from no screening to universal screening, depended on the source and inclusion of GDM treatment effects on perinatal death and T2DM. Further research on these long-term outcomes could reduce decision uncertainty.

• Michel, Yvonne Anne; Aas, Eline; Augestad, Liv Ariane; Burger, Emily Annika; Thoresen, Lisbeth & Bjørnelv, Gudrun Maria Waaler (2024). Healthcare use and costs in the last six months of life by level of care and cause of death. BMC Health Services Research. 24(1). doi: 10.1186/s12913-024-10877-5. Fulltekst i vitenarkiv Vis sammendrag

  Background: Existing knowledge on healthcare use and costs in the last months of life is often limited to one patient group (i.e., cancer patients) and one level of healthcare (i.e., secondary care). Consequently, decision-makers lack knowledge in order to make informed decisions about the allocation of healthcare resources for all patients. Our aim is to elaborate the understanding of resource use and costs in the last six months of life by describing healthcare use and costs for all causes of death and by all levels of formal care. Method: Using five national registers, we gained access to patient-level data for all individuals who died in Norway between 2009 and 2013. We described healthcare use and costs for all levels of formal care—namely primary, secondary, and home- and community-based care —in the last six months of life, both in total and differentiated across three time periods (6-4 months, 3-2 months, and 1-month before death). Our analysis covers all causes of death categorized in ten ICD-10 categories. Results: During their last six months of life, individuals used an average of healthcare resources equivalent to €46,000, ranging from €32,000 (Injuries) to €64,000 (Diseases of the nervous system and sense organs). In terms of care level, 63% of healthcare resources were used in home- and community-based care (i.e., in-home nursing, practical assistance, or nursing home care), 35% in secondary care (mostly hospital care), and 2% in primary care (i.e., general practitioners). The amount and level of care varied by cause of death and by time to death. The proportion of home- and community-based care which individuals received during their last six months of life varied from 38% for cancer patients to 92% for individuals dying with mental diseases. The shorter the time to death, the more resources were needed: nearly 40% of all end-of-life healthcare costs were expended in the last month of life across all causes of death. The composition of care also differed depending on age. Individuals aged 80 years and older used more home- and community-based care (77%) than individuals dying at younger ages (40%) and less secondary care (old: 21% versus young: 57%). Conclusions: Our analysis provides valuable evidence on how much healthcare individuals receive in their last six months of life and the associated costs, broken down by level of care and cause of death. Healthcare use and costs varied considerably by cause of death, but were generally higher the closer a person was to death. Our findings enable decision-makers to make more informed resource-allocation decisions and healthcare planners to better anticipate future healthcare needs.

• Sjule, Hanna Meidell; Vinter, Caroline Andrea; Dueland, Svein; Line, Pål Dag; Burger, Emily Annika & Bjørnelv, Gudrun Maria Waaler (2024). The Spillover Effects of Extending Liver Transplantation to Patients with Colorectal Liver Metastases: A Discrete Event Simulation Analysis. Medical decision making. ISSN 0272-989X. 44, s. 529–542. doi: 10.1177/0272989X241249154. Fulltekst i vitenarkiv Vis sammendrag

  Background: Liver transplantation is an alternative treatment for patients with nonresectable colorectal cancer liver-only metastases (CRLM); however, the potential effects on wait-list time and life expectancy to other patients on the transplant waiting list have not been considered. We explored the potential effects of expanding liver transplantation eligibility to include patients with CRLM on wait-list time and life expectancy in Norway. Methods: We developed a discrete event simulation model to reflect the Norwegian liver transplantation waiting list process and included 2 groups: 1) patients currently eligible for liver transplantation and 2) CRLM patients. Under 2 alternative CRLM-patient transplant eligibility criteria, we simulated 2 strategies: 1) inclusion of only currently eligible patients (CRLM patients received standard-of-care palliative chemotherapy) and 2) expanding waiting list eligibility to include CRLM patients under 2 eligibility criteria. Model outcomes included median waiting list time, life expectancy, and total life-years. Results: For every additional CRLM patient listed per year, the overall median wait-list time, initially 52 d, increased by 8% to 11%. Adding 2 additional CRLM patients under the most restrictive eligibility criteria increased the CRLM patients’ average life expectancy by 10.64 y and decreased the average life expectancy for currently eligible patients by 0.05 y. Under these assumptions, there was a net gain of 149.61 life-years over a 10-y programmatic period, which continued to increase under scenarios of adding 10 CRLM patients to the wait-list. Health gains were lower under less restrictive CRLM eligibility criteria. For example, adding 4 additional CRLM patients under the less restrictive eligibility criteria increased the CRLM patients’ average life expectancy by 5.64 y and decreased the average life expectancy for currently eligible patients by 0.12 y. Under these assumptions, there was a net gain of 96.36 life-years over a 10-y programmatic period, which continued to increase up to 7 CRLM patients. Conclusions: Our model-based analysis enabled the consideration of the potential effects of enlisting Norwegian CRLM patients for liver transplantation on wait-list time and life expectancy. Enlisting CRLM patients is expected to increase the total health effects, which supports the implementation of liver transplantation for CRLM patients in Norway. Highlights: • Given the Norwegian donor liver availability, adding patients with nonresectable colorectal cancer liver-only metastases (CRLM) to the liver transplantation waiting list had an overall modest, but varying, impact on total waiting list time. • Survival gains for selected CRLM patients treated with liver transplantation would likely outweigh the losses incurred to patients listed currently. • To improve the total life-years gained in the population, Norway should consider expanding the treatment options for CRLM patients to include liver transplantation. • Other countries may also have an opportunity to gain total life-years by extending the waiting list eligibility criteria; however, country-specific analyses are required.

• Burger, Emily Annika; Laprise, Jean-François; Portnoy, Allison; Spencer, Jennifer C.; Sy, Stephen & Regan, Mary Caroline [Vis alle 10 forfattere av denne artikkelen] (2024). Population-level health impact of hypothetical waning 1-dose human papillomavirus vaccination and 2-dose mitigation strategies in a high cervical cancer burden setting. Journal of the National Cancer Institute. Monographs. ISSN 1052-6773. 2024(67), s. 379–386. doi: 10.1093/jncimonographs/lgae039. Fulltekst i vitenarkiv
• Morgante, Niccolo; Bjørnelv, Gudrun Maria Waaler; Aasdahl, Lene; Nguyen, Cindy; Fimland, Marius Steiro & Kunst, Natalia [Vis alle 7 forfattere av denne artikkelen] (2024). Evaluating the Health and Economic Impacts of Return-to-Work Interventions: A Modeling Study. Value in Health. ISSN 1098-3015. doi: 10.1016/j.jval.2024.10.3850. Fulltekst i vitenarkiv
• Portnoy, Allison; Pedersen, Kine; Kim, Jane J. & Burger, Emily Annika (2024). Vaccination and screening strategies to accelerate cervical cancer elimination in Norway: a model-based analysis. British Journal of Cancer. ISSN 0007-0920. doi: 10.1038/s41416-024-02682-y. Fulltekst i vitenarkiv
• Trent, Pernille Kristina Bjerre; Eriksson, Ane Gerda Zahl; Staff, Anne Cathrine; Juul-Hansen, Knut Erling; Burger, Emily Annika & Wangen, Knut Reidar (2024). A cost-effectiveness analysis of sentinel lymph node biopsy compared with lymphadenectomy in intermediate- and high-risk endometrial carcinoma. International Journal of Gynecological Cancer. ISSN 1048-891X. 35(1). doi: 10.1136/ijgc-2024-005906. Fulltekst i vitenarkiv Vis sammendrag

  Background Sentinel lymph node biopsy (SLN) is increasingly used for surgical staging of endometrial carcinoma. Objective To estimate the effect and cost-effectiveness of the implementation of an SLN algorithm for surgical staging in patients with intermediate- and high-risk endometrial carcinoma compared with lymphadenectomy. Methods We performed a model-based, cost-effectiveness analysis using primary data from a tertiary referral hospital that included 829 patients with endometrial carcinoma undergoing surgical staging. We quantified the health and economic outcomes from two time periods, before and after implementation of the SLN algorithm by robotic surgery. Costs were measured directly from the hospital’s financial department, while long-term health outcomes were estimated using self-reported lymphedema and health-related quality-of-life among survivors. Sensitivity analyses were conducted to evaluate uncertainty. Results We projected that the SLN implementation period, predominately reflecting use of robotic SLN, simultaneously improved health outcomes (0.08 incremental quality-adjusted life-years) and lowered costs (US$1051) compared with the prior period involving robotic or open lymphadenectomy. SLN remained more beneficial and less costly across key sensitivity analyses—namely, varying the cost of the robotic platform, surgical equipment, number of yearly robotic procedures, percentage of robotic procedures versus percentage of laparotomies, length of stay, and lymphedema development. After 1000 simulations of the model, SLN implementation provided greater health benefits for lower costs (ie, cost saving) in 89% of simulations. Conclusion Implementation of an SLN algorithm in the staging of intermediate- and high-risk endometrial carcinoma improved health outcomes for lower costs compared with lymphadenectomy. Cost-effectiveness could further improve by continuing to increase the proportion of robotic procedures.

• 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. Fulltekst i vitenarkiv Vis sammendrag

  Objectives Model-based cost-effectiveness analyses can inform decisions about screening guidelines by quantifying consequences of alternative algorithms. Although actual screening adherence is imperfect, incorporating nonadherence into analyses that aim to determine optimal screening may affect the policy recommendations. We evaluated the impact of nonadherence assumptions on the optimal cervical cancer screening in Norway. Methods We used a microsimulation model of cervical carcinogenesis to project the long-term health and economic outcomes under alternative screening algorithms and adherence patterns. We compared 18 algorithms involving primary human papillomavirus testing (5-yearly) that varied follow-up management of different human papillomavirus results. We considered 12 adherence scenarios: perfect adherence, 8 high- and low-coverage “random-complier” scenarios, and 3 “systematic-complier” scenarios that reflect conditional screening behavior over a lifetime. We calculated incremental cost-effectiveness ratios and considered a strategy with the highest incremental cost-effectiveness ratio < 55 000 US dollars/quality-adjusted life-year as “optimal.” Results Under perfect adherence, the least intensive screening strategy was optimal; in contrast, assuming any nonadherence resulted in a more intensive optimal strategy. Accounting for lower adherence resulted in both lower costs and health benefits, which allowed for a more intensive strategy to be considered optimal, but more harms for women who screen according to guidelines (ie, up to 41% more colposcopies when comparing the optimal strategy in the lowest-adherence scenario with the optimal strategy under perfect adherence). Conclusions Assuming nonadherence in analyses designed to inform national guidelines may lead to a relatively more intensive recommendation. Designing guidelines for those who do not adhere to them may lead to over-screening of those who do.

• 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), s. 188–195. doi: 10.1093/jncimonographs/lgad015. Fulltekst i vitenarkiv
• 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. s. 1–9. doi: 10.1007/s40273-023-01341-z. Fulltekst i vitenarkiv
• Prem, Kiesha; Choi, Yoon Hong; Bénard, Élodie; Burger, Emily Annika; Hadley, Liza & Laprise, Jean-François [Vis alle 14 forfattere av denne artikkelen] (2023). Global impact and cost-effectiveness of one-dose versus two-dose human papillomavirus vaccination schedules: a comparative modelling analysis. BMC Medicine. 21(1). doi: 10.1186/s12916-023-02988-3. Fulltekst i vitenarkiv Vis sammendrag

  Background To eliminate cervical cancer as a public health problem, the World Health Organization had recommended routine vaccination of adolescent girls with two doses of the human papillomavirus (HPV) vaccine before sexual initiation. However, many countries have yet to implement HPV vaccination because of financial or logistical barriers to delivering two doses outside the infant immunisation programme. Methods Using three independent HPV transmission models, we estimated the long-term health benefits and cost-effectiveness of one-dose versus two-dose HPV vaccination, in 188 countries, under scenarios in which one dose of the vaccine gives either a shorter duration of full protection (20 or 30 years) or lifelong protection but lower vaccine efficacy (e.g. 80%) compared to two doses. We simulated routine vaccination with the 9-valent HPV vaccine in 10-year-old girls at 80% coverage for the years 2021–2120, with a 1-year catch-up campaign up to age 14 at 80% coverage in the first year of the programme. Results Over the years 2021–2120, one-dose vaccination at 80% coverage was projected to avert 115.2 million (range of medians: 85.1–130.4) and 146.8 million (114.1–161.6) cervical cancers assuming one dose of the vaccine confers 20 and 30 years of protection, respectively. Should one dose of the vaccine provide lifelong protection at 80% vaccine efficacy, 147.8 million (140.6–169.7) cervical cancer cases could be prevented. If protection wanes after 20 years, 65 to 889 additional girls would need to be vaccinated with the second dose to prevent one cervical cancer, depending on the epidemiological profiles of the country. Across all income groups, the threshold cost for the second dose was low: from 1.59 (0.14–3.82) USD in low-income countries to 44.83 (3.75–85.64) USD in high-income countries, assuming one dose confers 30-year protection. Conclusions Results were consistent across the three independent models and suggest that one-dose vaccination has similar health benefits to a two-dose programme while simplifying vaccine delivery, reducing costs, and alleviating vaccine supply constraints. The second dose may become cost-effective if there is a shorter duration of protection from one dose, cheaper vaccine and vaccination delivery strategies, and high burden of cervical cancer.

• Portnoy, Allison; Pedersen, Kine; Sy, Stephen; Tropé, Ameli Ellen Claesdotter; Engesæter, Birgit Øvstebø & Kim, Jane J. [Vis alle 7 forfattere av denne artikkelen] (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. Fulltekst i vitenarkiv Vis sammendrag

  Abstract As Norway considers revising triage approaches following their first adolescent cohort with human papillomavirus (HPV) vaccination entering the cervical cancer screening program, we analyzed the health impact and cost‐effectiveness of alternative primary HPV triage approaches for women initiating cervical cancer screening in 2023. We used a multimodeling approach that captured HPV transmission and cervical carcinogenesis to evaluate the health benefits, harms and cost‐effectiveness of alternative extended genotyping and age‐based triage strategies under five‐yearly primary HPV testing (including the status‐quo screening strategy in Norway) for women born in 1998 (ie, age 25 in 2023). We examined 35 strategies that varied alternative groupings of high‐risk HPV genotypes (“high‐risk” genotypes; “medium‐risk” genotypes or “intermediate‐risk” genotypes), number and types of HPV included in each group, management of HPV‐positive women to direct colposcopy or active surveillance, wait time for re‐testing and age at which the HPV triage algorithm switched from less to more intensive strategies. Given the range of benchmarks for severity‐specific cost‐effectiveness thresholds in Norway, we found that the preferred strategy for vaccinated women aged 25 years in 2023 involved an age‐based switch from a less to more intensive follow‐up algorithm at age 30 or 35 years with HPV‐16/18 genotypes in the “high‐risk” group. The two potentially cost‐effective strategies could reduce the number of colposcopies compared to current guidelines and simultaneously improve health benefits. Using age to guide primary HPV triage, paired with selective HPV genotype and follow‐up time for re‐testing, could improve both the cervical cancer program effectiveness and efficiency.

• Landy, Rebecca; Haber, Gregory; Graubard, Barry I.; Campos, Nicole G.; Sy, Stephen & Kim, Jane J. [Vis alle 11 forfattere av denne artikkelen] (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), s. 429–436. doi: 10.1093/jnci/djad009. Fulltekst i vitenarkiv
• Hertzberg, Silvia Nanjala Walekhwa; Jørstad, Øystein Kalsnes; Petrovski, Beata Eva; Bragadottir, Ragnheidur; Steffensen, Leif Arthur & Moe, Morten Carsten [Vis alle 8 forfattere av denne artikkelen] (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), s. 1–16. doi: 10.3390/ijerph191912603. Fulltekst i vitenarkiv Vis sammendrag

  Purpose: To describe the trends in hospital utilization and economic outcomes associated with the transition from laser to intravitreal injection (IVI) therapy for diabetic retinopathy (DR) at Oslo University Hospital (OUH), which provides the largest retina service in Norway. Methods: This descriptive study analyzed hospital administrative data and determined the average utilization and treatment proportions of laser therapy, IVIs and vitrectomy for each patient per year. The Chi-square test was used to compare resource use between treatment groups. From an extended healthcare perspective, the annual cost per patient was calculated using Norwegian tariff data from 2020 and the National Medication Price Registry for patients seen between 2010 and 2018. Bootstrapping was performed to generate 95% confidence intervals for the cost per patient per year. Results: Among the 1838 (41% female) patients treated for DR between 2005 and 2018, OUH provided on average 1.09 laser treatments per DR patient and 0.54 vitrectomies per DR patient in 2005, whose utilization declined to 0.54 and 0.05 treatments per DR patient, respectively, by 2018. Laser treatments declined from 64% to 10%, while vitrectomies declined from 32% to 1%. In contrast, IVI treatments increased from 4.5% to 89% of the total share, representing an average increase, from 0.08 injections per patient in 2005 to 4.73 injections per patient in 2018. Both the increasing number of DR patients and the shift in the type of treatment increased the economic costs of treating DR from a total of EUR 0.605 million (EUR 2935 per patient) in 2010 to EUR 2.240 million (EUR 3665 per patient) in 2018, with IVIs contributing considerably to these costs. Conclusions: Despite the decline in the use of vitrectomies, the transition from laser to IVI therapy for DR increased the healthcare resource utilization and economic costs of its treatment over the observed time. A main cost driver was the need for long-term IVIs, in addition to the drug cost itself. Trade-offs can be achieved through effective alternative IVI delivery or appropriate drug choice that balances patient needs with the economic burden of treating DR.

• Burger, Emily Annika; Laprise, Jean-François; Sy, Stephen; Regan, Mary Caroline; Prem, Kiesha & Jit, Mark [Vis alle 8 forfattere av denne artikkelen] (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. Fulltekst i vitenarkiv
• 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, s. 39–47. doi: 10.1016/j.ygyno.2022.10.027. Fulltekst i vitenarkiv
• 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), s. e1630–e1640. doi: 10.1111/aos.15151. Fulltekst i vitenarkiv Vis sammendrag

  Purpose The aim of this study was to estimate the 1-year costs associated with treating diabetic macular oedema (DME) patients using current intravitreal anti-vascular endothelial growth factor (anti-VEGF) biologics compared with the dexamethasone implant. Methods We conducted a descriptive cost-evaluation analysis using data from Oslo University Hospital and literature to compare three different intravitreal drugs for DME: bevacizumab, aflibercept and dexamethasone. Stratification of patients into ‘Naive’ or ‘Switch’ group was based on treatment history. We estimated the costs from healthcare and ‘extended’ healthcare perspectives. Sensitivity analysis evaluated the impact of various parameters. Results The average injections per patient per year for the Naive group (bevacizumab), Switch group (aflibercept) and dexamethasone were 9.5, 9.1 and 3.0 respectively. From a healthcare perspective, the 1-year costs for the Naive group were 15% lower (bevacizumab, €3619), and for the Switch group, 23% higher (aflibercept, €5226) compared with dexamethasone (€4252). The ‘extended’ healthcare perspective showed the cost per patient per year for bevacizumab remained nominally lower in the Naive group, while dexamethasone remained lower for the Switch group (€5116 for dexamethasone, compared to €4987 for bevacizumab and €6537 for aflibercept). Conclusions From a primary healthcare perspective, the dexamethasone as a first-line DME treatment may increase economic costs in settings where bevacizumab is used off-label. Treating resistant DMEwith dexamethasone may reduce the costs and treatment burden compared with switching to aflibercept.

• 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. 7(1). doi: 10.1177/23814683211071093. Fulltekst i vitenarkiv Vis sammendrag

  Introduction. Delayed implementation of evidence-driven interventions has consequences that can be formally evaluated. In Norway, programs to prevent cervical cancer (CC)—screening and treatment of precancerous lesions and prophylactic vaccination against human papillomavirus (HPV) infection—have been implemented, but each encountered delays in policy implementation. To examine the effect of these delays, we project the outcomes that would have been achieved with timely implementation of two policy changes compared with the de facto delays in implementation (in Norway). Methods. We used a multimodeling approach that combined HPV transmission and cervical carcinogenesis to estimate the health outcomes and timeline for CC elimination associated with the implementation of two CC prevention policy decisions: a multicohort vaccination program of women up to age 26 years with bivalent vaccine in 2009 compared with actual “delayed” implementation in 2016, and a switch from cytology to primary HPV-based testing in 2015 compared with “delayed” rollout in 2020. Results. Timely implementation of two policy changes compared with current Norwegian prevention policy timeline could have averted approximately 970 additional cases (range of top 10 sets: 830–1060) and accelerated the CC elimination timeline by around 4 years (from 2039 to 2035). Conclusions. If delaying implementation of effective and cost-effective interventions is being considered, the decision-making process should include quantitative analyses on the effects of delays.

• Burger, Emily Annika; Kok, Inge M. C. M. de; O'mahony, James F.; Rebolj, Matejka; Jansen, Erik E. L. & Bondt, Daniel D. de [Vis alle 13 forfattere av denne artikkelen] (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. 11. doi: 10.7554/eLife.81711. Fulltekst i vitenarkiv
• 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), s. 795–807. doi: 10.1177/0272989X221082683. Fulltekst i vitenarkiv
• Castanon, Alejandra; Rebolj, Matejka; Burger, Emily Annika; Kok, Inge de; Smith, Megan A & Hanley, Sharon [Vis alle 9 forfattere av denne artikkelen] (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. Fulltekst i vitenarkiv Vis sammendrag

  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.

• 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. Fulltekst i vitenarkiv Vis sammendrag

  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.

• Smith, Megan A; Burger, Emily Annika; Castanon, Alejandra; Kok, Inge de; Hanley, Sharon & Rebolj, Matejka [Vis alle 12 forfattere av denne artikkelen] (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. Fulltekst i vitenarkiv Vis sammendrag

  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 [Vis alle 8 forfattere av denne artikkelen] (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. doi: 10.1016/j.pmedr.2021.101452. Fulltekst i vitenarkiv Vis sammendrag

  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.

• Kim, Jane J.; Simms, Kate T.; Killen, James; Smith, Megan A; Burger, Emily & Sy, Stephen [Vis alle 8 forfattere av denne artikkelen] (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), s. 1–15. doi: 10.1371/JOURNAL.PMED.1003534. Fulltekst i vitenarkiv Vis sammendrag

  Background A nonavalent human papillomavirus (HPV) vaccine has been licensed for use in women and men up to age 45 years in the United States. The cost-effectiveness of HPV vaccination for women and men aged 30 to 45 years in the context of cervical cancer screening practice was evaluated to inform national guidelines. Methods and findings We utilized 2 independent HPV microsimulation models to evaluate the cost-effectiveness of extending the upper age limit of HPV vaccination in women (from age 26 years) and men (from age 21 years) up to age 30, 35, 40, or 45 years. The models were empirically calibrated to reflect the burden of HPV and related cancers in the US population and used standardized inputs regarding historical and future vaccination uptake, vaccine efficacy, cervical cancer screening, and costs. Disease outcomes included cervical, anal, oropharyngeal, vulvar, vaginal, and penile cancers, as well as genital warts. Both models projected higher costs and greater health benefits as the upper age limit of HPV vaccination increased. Strategies of vaccinating females and males up to ages 30, 35, and 40 years were found to be less cost-effective than vaccinating up to age 45 years, which had an incremental cost-effectiveness ratio (ICER) greater than a commonly accepted upper threshold of $200,000 per quality-adjusted life year (QALY) gained. When including all HPV-related outcomes, the ICER for vaccinating up to age 45 years ranged from $315,700 to $440,600 per QALY gained. Assumptions regarding cervical screening compliance, vaccine costs, and the natural history of noncervical HPV-related cancers had major impacts on the cost-effectiveness of the vaccination strategies. Key limitations of the study were related to uncertainties in the data used to inform the models, including the timing of vaccine impact on noncervical cancers and vaccine efficacy at older ages. Conclusions Our results from 2 independent models suggest that HPV vaccination for adult women and men aged 30 to 45 years is unlikely to represent good value for money in the US.

• Pedersen, Kine; Portnoy, Allison; Sy, Stephen; Hansen, Bo T.; Trope, Ameli & Kim, Jane J. [Vis alle 7 forfattere av denne artikkelen] (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. Fulltekst i vitenarkiv Vis sammendrag

  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.

• Burger, Emily Annika; Jansen, Erik EL; Killen, James; Kok, Inge de; Smith, Megan A & Sy, Stephen [Vis alle 13 forfattere av denne artikkelen] (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. Fulltekst i vitenarkiv Vis sammendrag

  Objectives To quantify the secondary impacts of the COVID-19 pandemic disruptions to cervical cancer screening in the United States, stratified by step in the screening process and primary test modality, on cervical cancer burden. Methods We conducted a comparative model-based analysis using three independent NCI Cancer Intervention and Surveillance Modeling Network cervical models to quantify the impact of eight alternative COVID-19-related screening disruption scenarios compared to a scenario of no disruptions. Scenarios varied by the duration of the disruption (6 or 24 months), steps in the screening process being disrupted (primary screening, surveillance, colposcopy, excisional treatment), and primary screening modality (cytology alone or cytology plus human papillomavirus “cotesting”). Results The models consistently showed that COVID-19-related disruptions yield small net increases in cervical cancer cases by 2027, which are greater for women previously screened with cytology compared with cotesting. When disruptions affected all four steps in the screening process under cytology-based screening, there were an additional 5–7 and 38–45 cases per one million screened for 6- and 24-month disruptions, respectively. In contrast, under cotesting, there were additional 4–5 and 35–45 cases per one million screened for 6- and 24-month disruptions, respectively. The majority (58–79%) of the projected increases in cases under cotesting were due to disruptions to surveillance, colposcopies, or excisional treatment, rather than to primary screening. Conclusions Women in need of surveillance, colposcopies, or excisional treatment, or whose last primary screen did not involve human papillomavirus testing, may comprise priority groups for reintroductions.

• Kim, Jane J; Simms, Kate T; Killen, James; Smith, Megan A; Burger, Emily & Sy, Stephen [Vis alle 8 forfattere av denne artikkelen] (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. Fulltekst i vitenarkiv
• Portnoy, Allison; Pedersen, Kine; Trogstad, Lill; Hansen, Bo Terning; Feiring, Berit & Laake, Ida [Vis alle 11 forfattere av denne artikkelen] (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. Fulltekst i vitenarkiv Vis sammendrag

  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.

• Fogelberg, Sara; Clements, Mark; Pedersen, Kine; Sy, Stephen; Sparén, Pär & Kim, Jane J. [Vis alle 7 forfattere av denne artikkelen] (2020). Cost-effectiveness of cervical cancer screening with primary HPV testing for unvaccinated women in Sweden. PLOS ONE. 15(9). doi: 10.1371/journal.pone.0239611. Fulltekst i vitenarkiv
• Burger, Emily; Smith, Megan A; Killen, James; Sy, Stephen; Simms, Kate T & Canfell, Karen [Vis alle 7 forfattere av denne artikkelen] (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. Fulltekst i vitenarkiv Vis sammendrag

  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.

• Simms, Kate T; Yuill, S; Killen, James; Smith, Megan A; Kulasingam, Shalini & Kok, Inge de [Vis alle 11 forfattere av denne artikkelen] (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. Fulltekst i vitenarkiv Vis sammendrag

  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.

• 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. Fulltekst i vitenarkiv Vis sammendrag

  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.

• Canfell, Karen; Kim, Jane J.; Brisson, M; Keane, Adam; Simms, Kate T & Caruana, Michael [Vis alle 23 forfattere av denne artikkelen] (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), s. 591–603. doi: 10.1016/S0140-6736(20)30157-4. Fulltekst i vitenarkiv
• Kok, Inge de; Burger, Emily; Naber, Steffie; Canfell, Karen; Killen, James & Simms, Kate [Vis alle 11 forfattere av denne artikkelen] (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. Fulltekst i vitenarkiv Vis sammendrag

  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.

• Brisson, Marc; Kim, Jane J; Canfell, Karen; Drolet, Melanie; Gingras, Guillaume & Burger, Emily [Vis alle 25 forfattere av denne artikkelen] (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. Fulltekst i vitenarkiv Vis sammendrag

  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.

• Aas, Eline; Burger, Emily & Pedersen, Kine (2019). Economic Evaluation of Medical Screening. I Hamilton, Jonathan H. (Red.), Oxford Research Encyclopedias: Economics and Finance. Oxford University Press. ISSN 9780190625979. doi: 10.1093/acrefore/9780190625979.013.377. Fulltekst i vitenarkiv Vis sammendrag

  Silicon pixel detectors are at the core of the current and planned upgrade of the ATLAS experiment at the LHC. Given their close proximity to the interaction point, these detectors will be exposed to an unprecedented amount of radiation over their lifetime. The current pixel detector will receive damage from non-ionizing radiation in excess of 1015 1 MeV neq/cm2, while the pixel detector designed for the high-luminosity LHC must cope with an order of magnitude larger fluence. This paper presents a digitization model incorporating effects of radiation damage to the pixel sensors. The model is described in detail and predictions for the charge collection efficiency and Lorentz angle are compared with collision data collected between 2015 and 2017 (≤ 1015 1 MeV neq/cm2).The objective of medical screening is to prevent future disease (secondary prevention) or to improve prognosis by detecting the disease at an earlier stage (early detection). This involves examination of individuals with no symptoms of disease. Introducing a screening program is resource demanding, therefore stakeholders emphasize the need for comprehensive evaluation, where costs and health outcomes are reasonably balanced, prior to population-based implementation. Economic evaluation of population-based screening programs involves quantifying health benefits (e.g., life-years gained) and monetary costs of all relevant screening strategies. The alternative strategies can vary by starting- and stopping-age, frequency of the screening and follow-up regimens after a positive test result. Following evaluation of all strategies, the efficiency frontier displays the efficient strategies and the country-specific cost-effectiveness threshold is used to determine the optimal, i.e., most cost-effective, screening strategy. Similar to other preventive interventions, the costs of screening are immediate, while the health benefits accumulate after several years. Hence, the effect of discounting can be substantial when estimating the net present value (NPV) of each strategy. Reporting both discounting and undiscounted results is recommended. In addition, intermediate outcome measures, such as number of positive tests, cases detected, and events prevented, can be valuable supplemental outcomes to report. Estimating the cost-effectiveness of alternative screening strategies is often based on decision-analytic models, synthesizing evidence from clinical trials, literature, guidelines, and registries. Decision-analytic modeling can include evidence from trials with intermediate or surrogate endpoints and extrapolate to long-term endpoints, such as incidence and mortality, by means of sophisticated calibration methods. Furthermore, decision-analytic models are unique, as a large number of screening alternatives can be evaluated simultaneously, which is not feasible in a randomized controlled trial (RCT). Still, evaluation of screening based on RCT data are valuable as both costs and health benefits are measured for the same individual, enabling more advanced analysis of the interaction of costs and health benefits. Evaluation of screening involves multiple stakeholders and other considerations besides cost-effectiveness, such as distributional concerns, severity of the disease, and capacity influence decision-making. Analysis of harm-benefit trade-offs is a useful tool to supplement cost-effectiveness analyses. Decision-analytic models are often based on 100% participation, which is rarely the case in practice. If those participating are different from those not choosing to participate, with regard to, for instance, risk of the disease or condition, this would result in selection bias, and the result in practice could deviate from the results based on 100% participation. The development of new diagnostics or preventive interventions requires re-evaluation of the cost-effectiveness of screening. For example, if treatment of a disease becomes more efficient, screening becomes less cost-effective. Similarly, the introduction of vaccines (e.g., HPV-vaccination for cervical cancer) may influence the cost-effectiveness of screening. With access to individual level data from registries, there is an opportunity to better represent heterogeneity and long-term consequences of screening on health behavior in the analysis.

• 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. 19(1). doi: 10.1186/s12885-019-5596-2. Fulltekst i vitenarkiv Vis sammendrag

  Background Public health efforts to prevent human papillomavirus (HPV)-related cancers include HPV vaccination and cervical cancer screening. We quantified the annual healthcare cost of six HPV-related cancers in order to provide inputs in cost-effectiveness analyses and quantify the potential economic savings from prevention of HPV-related cancers in Norway. Methods Using individual patient-level data from three unlinked population-based registries, we estimated the mean healthcare costs 1) annually across all phases of disease, 2) during the first 3 years of care following diagnosis, and 3) for the last 12 months of life for patients diagnosed with an HPV-related cancer. We included episodes of care related to primary care physicians, specialist care (private specialists and hospital-based care and prescriptions), and prescription drugs redeemed at pharmacies outside hospitals between 2012 and 2014. We valued costs (2014 €1.00 = NOK 8.357) based on diagnosis-related groups (DRG), patient copayments, reimbursement fees and pharmacy retail prices. Results In 2014, the total healthcare cost of HPV-related cancers amounted to €39.8 million, of which specialist care accounted for more than 99% of the total cost. The annual maximum economic burden potentially averted due to HPV vaccination will be lower for vulvar, penile and vaginal cancer (i.e., €984,620, €762,964 and €374,857, respectively) than for cervical, anal and oropharyngeal cancers (i.e., €17.2 million, €6.7 million and €4.6 million, respectively). Over the first three years of treatment following cancer diagnosis, patients diagnosed with oropharyngeal cancer incurred the highest total cost per patient (i.e. €49,774), while penile cancer had the lowest total cost per patient (i.e. €18,350). In general, costs were highest the first year following diagnosis and then declined; however, costs increased rapidly again towards end of life for patients who did not survive. Conclusion HPV-related cancers constitute a considerable economic burden to the Norwegian healthcare system. As the proportion of HPV-vaccinated individuals increase and secondary prevention approaches advance, this study highlights the potential economic burden avoided by preventing these cancers.

• Burger, Emily; Kok, Inge de; Groene, Emily; Killen, Jame; Canfell, Karen & Kulasingam, Shalini [Vis alle 16 forfattere av denne artikkelen] (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. Fulltekst i vitenarkiv Vis sammendrag

  The natural history of human papillomavirus (HPV)-induced cervical cancer (CC) is not directly observable, yet the age of HPV acquisition and duration of preclinical disease (dwell time) influences the effectiveness of alternative preventive policies. We performed a Cancer Intervention and Surveillance Modeling Network (CISNET) comparative modeling analysis to characterize the age of acquisition of cancer-causing HPV infections and implied dwell times for distinct phases of cervical carcinogenesis. Using four CISNET-cervical models with varying underlying structures but fit to common US epidemiological data, we estimated the age of acquisition of causal HPV infections and dwell times associated with three phases of cancer development: HPV, high-grade precancer, and cancer sojourn time. We stratified these estimates by HPV genotype under both natural history and CC screening scenarios, because screening prevents cancer development that affects the mix of detected cancers. The median time from HPV acquisition to cancer detection ranged from 17.5 to 26.0 years across the four models. Three models projected that 50% of unscreened women acquired their causal HPV infection between ages 19 and 23 years, whereas one model projected these infections occurred later (age 34 years). In the context of imperfect compliance with US screening guidelines, the median age of causal infection was 4.4–15.9 years later compared with model projections in the absence of screening. These validated CISNET-CC models, which reflect some uncertainty in the development of CC, elucidate important drivers of HPV vaccination and CC screening policies and emphasize the value of comparative modeling when evaluating public health policies.

• Portnoy, Allison; Campos, Nicole; Sy, Stephen; Burger, Emily; Cohen, Jamie & Regan, Catherine [Vis alle 7 forfattere av denne artikkelen] (2019). Impact and Cost-Effectiveness of Human Papillomavirus Vaccination Campaigns. Cancer Epidemiology, Biomarkers and Prevention. ISSN 1055-9965. 29(1), s. 22–30. doi: 10.1158/1055-9965.EPI-19-0767. Fulltekst i vitenarkiv
• Rodin, Danielle; Burger, Emily; Atun, Rifat; Barton, Michael; Gospodarowicz, Mary & Grover, Surbhi [Vis alle 12 forfattere av denne artikkelen] (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), s. 915–923. doi: 10.1016/S1470-2045(19)30308-0. Fulltekst i vitenarkiv
• 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, s. 177–179. doi: 10.1016/j.ypmed.2018.03.011. Fulltekst i vitenarkiv
• 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), s. 706–714. doi: 10.1001/jama.2017.19872. Fulltekst i vitenarkiv Vis sammendrag

  Importance: Evidence on the relative benefits and harms of primary high-risk human papillomavirus (hrHPV) testing is needed to inform guidelines. Objective: To inform the US Preventive Services Task Force by modeling the benefits and harms of various cervical cancer screening strategies. Design, Setting, and Participants: Microsimulation model of a hypothetical cohort of women initiating screening at age 21 years. Exposures: Screening with cytology, hrHPV testing, and cytology and hrHPV cotesting, varying age to switch from cytology to hrHPV testing or cotesting (25, 27, 30 years), rescreening interval (3, 5 years), and triage options for hrHPV-positive results (16/18 genotype, cytology testing). Current guidelines-based screening strategies comprised cytology alone every 3 years starting at age 21 years, with or without a switch to cytology and hrHPV cotesting every 5 years from ages 30 to 65 years. Complete adherence for all 19 strategies was assumed. Main Outcomes and Measures: Lifetime number of tests, colposcopies, disease detection, false-positive results, cancer cases and deaths, life-years, and efficiency ratios expressing the trade-off of harms (ie, colposcopies, tests) vs benefits (life-years gained, cancer cases averted). Efficient strategies were those that yielded more benefit and less harm than another strategy or a lower harm to benefit ratio than a strategy with less harms. Results: Compared with no screening, all modeled cervical cancer screening strategies were estimated to result in substantial reductions in cancer cases and deaths and gains in life-years. The effectiveness of screening across the different strategies was estimated to be similar, with primary hrHPV-based and alternative cotesting strategies having slightly higher effectiveness and greater harms than current guidelines-based cytology testing. For example, cervical cancer deaths associated with the guidelines-based strategies ranged from 0.30 to 0.76 deaths per 1000 women, whereas new strategies involving primary hrHPV testing or cotesting were associated with fewer cervical cancer deaths, ranging from 0.23 to 0.29 deaths per 1000 women. In all analyses, primary hrHPV testing strategies occurring at 5-year intervals were efficient. For example, 5-year primary hrHPV testing (cytology triage) based on switching from cytology to hrHPV screening at ages 30 years, 27 years, and 25 years had ratios per life-year gained of 73, 143, and 195 colposcopies, respectively. In contrast, strategies involving 3-year hrHPV testing had much higher ratios, ranging from 2188 to 3822 colposcopies per life-year gained. In most analyses, strategies involving cotesting were not efficient. Conclusions and Relevance: In this microsimulation modeling study, it was estimated that primary hrHPV screening may represent a reasonable balance of harms and benefits when performed every 5 years. Switching from cytology to hrHPV testing at age 30 years yielded the most efficient harm to benefit ratio when using colposcopy as a proxy for harms.

• Burger, Emily; Dyer, Michael; Sy, Stephen; Palefsky, Joel M.; Pokomandy, Alexandra de & Coutlee, François [Vis alle 8 forfattere av denne artikkelen] (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), s. 10–19. doi: 10.1097/QAI.0000000000001727. Fulltekst i vitenarkiv Vis sammendrag

  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 [Vis alle 9 forfattere av denne artikkelen] (2018). Impact of human papillomavirus vaccination on the clinical meaning of cervical screening results. Preventive Medicine. ISSN 0091-7435. 118, s. 44–50. doi: 10.1016/j.ypmed.2018.10.001. Fulltekst i vitenarkiv Vis sammendrag

  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.

• 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), s. 83–98. doi: 10.5617/njhe.4881. Fulltekst i vitenarkiv Vis sammendrag

  Abstract: Different sources of patient heterogeneity or personal characteristics may contribute to differential cost-effectiveness profiles of national screening programs for colorectal cancer (CRC). To motivate the use of subgroup analyses when individual level data are unavailable, we provide a stylized example of the potential economic value of capturing patient heterogeneity in CRC screening. We developed a Markov model to capture the impacts of patient heterogeneity on the cost-effectiveness of CRC screening involving once-only sigmoidoscopy compared to no screening. We simulated cohorts of Norwegian men, women, and six comorbidity subgroups that differentially influenced the relative treatment effect, the risks of developing CRC, dying from CRC, dying from background mortality or screening-related adverse events and baseline quality of life. We calculated the discounted (4%) incremental cost-effectiveness ratio (ICER), defined as the cost per quality-adjusted life year (QALY) gained, and the net monetary benefit (NMB) gained by stratification, from a societal perspective. Screening in men was cost-effective at any threshold value, while screening in women only provides good value for money from threshold values of €50,000 per QALY gained and above. Comorbidities unrelated to CRC development yielded generally less attractive cost-effectiveness ratios (i.e., increased the ICER), while related comorbidities improved the cost-effectiveness profiles of screening for CRC. A stratified policy that accounts for different screening outcomes between men and women could potentially improve the value of screening by €5.8 million annually. Accounting for patient heterogeneity in CRC screening will likely improve the value of screening strategies, as a single screening approach for the entire population can result in inefficient use of resources.Published: Online December 2018.

• 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), s. 4823–4829. doi: 10.1016/j.vaccine.2018.04.061. Fulltekst i vitenarkiv Vis sammendrag

  Background: Although guidelines for prophylactic human papillomavirus (HPV) vaccination recommend two doses for girls ages 9–14 years, several studies have demonstrated similar protection with one dose. Our objective was to evaluate the long-term health and economic impacts of routine one-dose HPV vaccination compared to (1) no vaccination and (2) two-dose HPV vaccination in a low-income country. Methods: We used a three-tiered hybrid modeling approach that captured HPV transmission, cervical carcinogenesis, and population demographics to project long-term health and economic outcomes associated with one-dose HPV vaccination (assuming 80% efficacy against HPV-16/18 infections under three waning scenarios) and two-dose HPV vaccination (assuming 100% efficacy over the lifetime) in Uganda. Costs included the vaccine program (dosage and delivery) costs over a 10-year period and cervical cancer costs over the lifetimes of the current population of Ugandan women. Health outcomes included number of cervical cancer cases and disability-adjusted life years (DALYs). Incremental cost-effectiveness ratios (i.e., cost per DALY averted) were calculated and compared against the Ugandan per-capita gross domestic product. Results: Routine one-dose HPV vaccination of 9-year-old girls required substantial upfront investment but was cost-saving compared to no vaccination when accounting for the cost-offsets from future cancers averted. Forty years after initiating routine vaccination and depending on assumptions of vaccine waning, one-dose HPV vaccination with equivalent coverage (70%) averted 15–16% of cervical cancer cases versus 21% with two-dose vaccination but required only half the upfront economic investment. Vaccination with two doses had an attractive cost-effectiveness profile except if one-dose vaccination enabled higher coverage (90% vs. 70%) and did not wane. Conclusions: One-dose HPV vaccination resulted in cost-savings compared to no vaccination and could be cost-effective compared to two-dose vaccination if protection is longstanding and higher coverage can be achieved.

• Pedersen, Kine; Fogelberg, Sara; Thamsborg, Lise H.; Clements, Mark; Nygård, Mari & Kristiansen, Ivar Sønbø [Vis alle 10 forfattere av denne artikkelen] (2018). An overview of cervical cancer epidemiology and prevention in Scandinavia. Acta Obstetricia et Gynecologica Scandinavica. ISSN 0001-6349. 97(7), s. 795–807. doi: 10.1111/aogs.13313. Fulltekst i vitenarkiv Vis sammendrag

  New technologies such as human papillomavirus (HPV) testing and vaccination necessitate comprehensive policy analyses to optimize cervical cancer prevention. To inform future Scandinavian‐specific policy analyses, we aimed to provide an overview of cervical cancer epidemiology and existing prevention efforts in Denmark, Norway and Sweden. We compiled and summarized data on current prevention strategies, population demography and epidemiology (for example, age‐specific HPV prevalence and cervical cancer incidence over time) for each Scandinavian country by reviewing published literature and official guidelines, performing registry‐based analyses using primary data and having discussions with experts in each country. In Scandinavia, opportunistic screening occurred as early as the 1950s and by 1996, all countries had implemented nationwide organized cytology‐based screening. Prior to implementation of widespread screening and during 1960–66, cervical cancer incidence was considerably higher in Denmark than in Norway and Sweden. Decades of cytology‐based screening later (i.e. 2010–2014), cervical cancer incidence has been considerably reduced and has converged across the countries since the 1960s, although it still remains lowest in Sweden. Generally, Scandinavian countries face similar cervical cancer burdens and utilize similar prevention approaches; however, important differences remain. Future policy analyses will need to evaluate whether these differences warrant differential prevention policies or whether efforts can be streamlined across Scandinavia.

• 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, s. 68–75. doi: 10.1016/j.ejca.2017.12.018. Fulltekst i vitenarkiv Vis sammendrag

  Background Several countries have implemented vaccination against human papillomavirus (HPV) for adolescent girls and must decide whether and how to adapt cervical cancer (CC) screening for these low-risk women. We aimed to identify the optimal screening strategies for women vaccinated against HPV infections and quantify the amount that could be spent to identify vaccination status among women and stratify CC screening guidelines accordingly. Methods We used a mathematical model reflecting HPV-induced CC in Norway to project the long-term health benefits, resources and costs associated with 74 candidate-screening strategies that varied by screening test, start age and frequency. Strategies were considered separately for women vaccinated with the bivalent/quadrivalent (2/4vHPV) and nonavalent (9vHPV) vaccines. We used a cost-effectiveness framework (i.e. incremental cost-effectiveness ratios and net monetary benefit) and a commonly-cited Norwegian willingness-to-pay threshold of €75,000 per quality-adjusted life-year gained. Results The most cost-effective screening strategy for 9vHPV- and 2/4vHPV-vaccinated women involved HPV testing once and twice per lifetime, respectively. The value of stratifying guidelines by vaccination status was €599 (2/4vHPV) and €725 (9vHPV) per vaccinated woman. Consequently, for the first birth cohort of ∼22,000 women who were vaccinated in adolescence in Norway, between €10.5–13.2 million over their lifetime could be spent on identifying individual vaccination status and stratify screening while remaining cost-effective. Conclusion Less intensive strategies are required for CC screening to remain cost-effective in HPV-vaccinated women. Moreover, screening can remain cost-effective even if large investments are made to identify individual vaccination status and stratify screening guidelines accordingly. Pedersen, Kine, et al. "Adapting cervical cancer screening for women vaccinated against human papillomavirus infections: The value of stratifying guidelines." European Journal of Cancer 91 (2018): 68-75. © 2018. This manuscript version is made available under the CC-BY-NC-ND 4.0 license.

• 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), s. 474–484. doi: 10.1111/1471-0528.14135. Fulltekst i vitenarkiv Vis sammendrag

  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.

• 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), s. 893–899. doi: 10.1093/cid/cix475. Fulltekst i vitenarkiv Vis sammendrag

  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; 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), s. 783–790. doi: 10.1038/bjc.2017.248. Fulltekst i vitenarkiv Vis sammendrag

  Background: Forthcoming cervical cancer screening strategies involving human papillomavirus (HPV) testing for women not vaccinated against HPV infections may increase colposcopy referral rates. We quantified health and resource trade-offs associated with alternative HPV-based algorithms to inform decision-makers when choosing between candidate algorithms. Methods: We used a mathematical simulation model of HPV-induced cervical carcinogenesis in Norway. We compared the current cytology-based strategy to alternative strategies that varied by the switching age to primary HPV testing (ages 25–34 years), the routine screening frequency (every 3–10 years), and management of HPV-positive, cytology-negative women. Model outcomes included reductions in lifetime cervical cancer risk, relative colposcopy rates, and colposcopy rates per cervical cancer prevented. Results: The age of switching to primary HPV testing and the screening frequency had the largest impacts on cancer risk reductions, which ranged from 90.9% to 96.3% compared to no screening. In contrast, increasing the follow-up intensity of HPV-positive, cytology-negative women provided only minor improvements in cancer benefits, but generally required considerably higher rates of colposcopy referrals compared to current levels, resulting in less efficient cervical cancer prevention. Conclusions: We found that in order to maximise cancer benefits HPV-based screening among unvaccinated women should not be delayed: rather, policy makers should utilise the triage mechanism to control colposcopy referrals.

• 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. Fulltekst i vitenarkiv Vis sammendrag

  Background: Attendance to routine cancer screening at repeated intervals is essential for reducing morbidity and mortality of targeted cancers, yet currently defined quality-assurance metrics evaluate coverage within a defined period of time (e.g. 3.5 years). Methods: We developed a longitudinal adherence metric that captures attendance to cancer screening at repeated intervals, and applied the metric to population-based data from the Cancer Registry of Norway that captures two decades of organised cervical cancer screening, including all screening tests and cervical cancer diagnoses for women living in Norway at any time during years 1992–2013 and eligible for at least two screening rounds (1 round = 3.5 years, N = 1 391 812). For each woman, we calculated the proportion of eligible screening rounds with at least one registered cytology test, and categorised women into one of five longitudinal adherence categories: never-screeners, severe under-screeners, moderate under-screeners, guidelines-based screeners and over-screeners. For each category, we evaluated cancer outcomes such as cancer stage at diagnosis. Results: Only 46% of screen-eligible women were consistently screened at least once every 3.5 years, and the majority of these were over-screened. In contrast, 29% were moderately under-screened, 17% were severely under-screened and 8% had never attended screening. Screening behaviour was associated with cancer outcomes; e.g., the proportion of cancers diagnosed at Stage I increased from 21% among never-screeners to 70% among over-screeners. Conclusion: The longitudinal adherence metric evaluates screening performance as a succession of screening episodes, reflecting both guidelines and the fundamental principles of screening, and may be a valuable addition to existing performance indicators. The final version of this research has been published by European Journal of Public Health. © Oxford University Press.

• Rutter, Carolyn; Kim, Jane J; Meester, RGS; Sprague, BL; Burger, Emily & Zauber, Ann G. [Vis alle 16 forfattere av denne artikkelen] (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. Fulltekst i vitenarkiv
• 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), s. 95–103. doi: 10.1158/1055-9965.EPI-16-0350. Fulltekst i vitenarkiv Vis sammendrag

  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.

• 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. Fulltekst i vitenarkiv
• Burger, Emily; Lee, Kyueun; Saraiya, Mona; Thompson, Trevor D.; Chesson, Harrell W. & Markowitz, Lauri E. [Vis alle 7 forfattere av denne artikkelen] (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), s. 2057–2066. doi: 10.1002/cncr.30007. Fulltekst i vitenarkiv Vis sammendrag

  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.

• 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), s. 326–333. doi: 10.1016/j.ygyno.2016.08.231. Fulltekst i vitenarkiv Vis sammendrag

  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.

• 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, s. 4–10. doi: 10.1016/j.ypmed.2015.04.024. Fulltekst i vitenarkiv Vis sammendrag

  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.

• Rochau, Ursula; Jahn, Beate; Qerimi, Vjollca; Burger, Emily; Kurzthaler, Christina & Kluibenschaedl, Martina [Vis alle 10 forfattere av denne artikkelen] (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), s. 164–178. doi: 10.1016/j.critrevonc.2014.12.017. Fulltekst i vitenarkiv
• 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. s. 62–71. doi: 10.4220/Sykepleienf.2015.53414. Fulltekst i vitenarkiv Vis sammendrag

  Bakgrunn: Forebygging står sentralt i norsk helsepolitikk, og observasjonsstudier tyder på at organisert screening har redusert forekomsten av livmorhalskreft i Norge. Samfunnets ressurser er imidlertid knappe. Hensikt: Vår hensikt var å estimere de årlige kostnadene av Masseundersøkelsen mot livmorhalskreft. Metode: Vi beregnet statens direkte utgifter og de årlige samfunnsøkonomiske kostnader av dagens screeningprogram for livmorhalskreft på grunnlag av opplysninger fra Kreftregisteret om antall utførte undersøkelser under Masseundersøkelsen for livmorhalskreft og enhetskostnadene for disse. De samfunnsøkonomiske enhetskostnadene er basert på ulike beregninger av faktiske kostnader, mens statens utgifter er basert på de ulike takstsystemer. Resultater: I 2011 ble det utført i alt 360 704 primærscreeningprøver, som med våre beregninger ville medføre 21 783 nye etterundersøkelser. Det ble innsendt biopsier for omtrent 9000 kvinner, og 3057 kvinner fikk utført konisering. De samlete samfunnsøkonomiske kostnader ved screeningprogrammet var 730 millioner kroner, hvorav 52 prosent utgjorde indirekte kostnader i form av reisekostnader og fravær fra arbeid. Statens direkte utgifter utgjorde 163 millioner kroner. Konklusjon: Det norske screeningprogrammet for livmorhalskreft har betydelige kostnader, der kvinnenes tids- og reisekostnader og legekonsultasjoner veier mest.

• 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), s. 1088–1097. doi: 10.1016/j.jval.2015.08.003. Fulltekst i vitenarkiv Vis sammendrag

  Background Decision makers often need to simultaneously consider multiple criteria or outcomes when deciding whether to adopt new health interventions. Objectives Using decision analysis within the context of cervical cancer screening in Norway, we aimed to aid decision makers in identifying a subset of relevant strategies that are simultaneously efficient, feasible, and optimal. Methods We developed an age-stratified probabilistic decision tree model following a cohort of women attending primary screening through one screening round. We enumerated detected precancers (i.e., cervical intraepithelial neoplasia of grade 2 or more severe (CIN2+)), colposcopies performed, and monetary costs associated with 10 alternative triage algorithms for women with abnormal cytology results. As efficiency metrics, we calculated incremental cost-effectiveness, and harm-benefit, ratios, defined as the additional costs, or the additional number of colposcopies, per additional CIN2+ detected. We estimated capacity requirements and uncertainty surrounding which strategy is optimal according to the decision rule, involving willingness to pay (monetary or resources consumed per added benefit). Results For ages 25 to 33 years, we eliminated four strategies that did not fall on either efficiency frontier, while one strategy was efficient with respect to both efficiency metrics. Compared with current practice in Norway, two strategies detected more precancers at lower monetary costs, but some required more colposcopies. Similar results were found for women aged 34 to 69 years. Conclusions Improving the effectiveness and efficiency of cervical cancer screening may necessitate additional resources. Although efficient and feasible, both society and individuals must specify their willingness to accept the additional resources and perceived harms required to increase effectiveness before a strategy can be considered optimal.

Se alle arbeider i NVA

• Aas, Eline; Kinge, Jonas Minet; Burger, Emily Annika; Pedersen, Kine; Iversen, Tor & Godager, Geir [Vis alle 14 forfattere av denne artikkelen] (2025). Feil tallgrunnlag kan koste liv i helsetjenesten. Fulltekst i vitenarkiv
• Burger, Emily Annika (2025). Dagens Medisin Vaksin Arena: Optimizing HPV Prevention: Vaccine Choice and Screening Design. [Internet]. Nationalteatre konferansesenter. Fulltekst i vitenarkiv
• Aas, Eline; Wu, Yansi; Burger, Emily Annika; Sæther, Erik Magnus; Bugge, Christoffer & Francisco, Oteiza [Vis alle 8 forfattere av denne artikkelen] (2024). Strukturert klinikerinnspill. Fulltekst i vitenarkiv
• Aas, Eline; Wu, Yansi; Burger, Emily Annika; Sæther, Erik Magnus; Bugge, Christoffer & Francisco, Oteiza [Vis alle 8 forfattere av denne artikkelen] (2023). Hvordan kan systematisk klinikerinnspill redusere usikkerhet og bidra til raskere innføring av nye behandlinger. Fulltekst i vitenarkiv
• Burger, Emily Annika; Baussano, Iacopo; Kim, Jane J.; Laprise, Jean-François; Berkhof, Johannes & Schiller, John T. [Vis alle 11 forfattere av denne artikkelen] (2023). Recent economic evaluation of 1-dose HPV vaccination uses unsupported assumptions. Vaccine. ISSN 0264-410X. 41(16), s. 2648–2649. doi: 10.1016/j.vaccine.2022.07.022. Fulltekst i vitenarkiv
• Bjørnelv, Gudrun Maria Waaler; Burger, Emily Annika & Aas, Eline (2023). Hvor ble det av prioriteringskriteriene for ABC-klinikken? Fulltekst i vitenarkiv Vis sammendrag

  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?

• Baasland, Ingrid; Berland, Jannicke Mohr; Burger, Emily Annika; Jonassen, Christine M; Lie, Kathrine & Opdahl, Signe (2023). Livmorhalsprogrammet forebygger livmorhals­kreft. Forskersonen.no. Fulltekst i vitenarkiv Vis sammendrag

  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.

• Nygård, Mari; Burger, Emily Annika; Nygård, Ståle; Tropé, Ameli; Falkenthal, Thea Eline Hetland & Berland, Jannicke Mohr [Vis alle 10 forfattere av denne artikkelen] (2023). Skal vi screene og konisere inn i evigheten – eller bytte HPV-vaksine? Fulltekst i vitenarkiv Vis sammendrag

  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.

• Aas, Eline & Burger, Emily Annika (2022). Økonomisk evaluering. Fulltekst i vitenarkiv
• Burger, Emily Annika (2022). Using decision-analytic modeling to help prioritize alternative HPV vaccination and cervical cancer screening strategies: Norwegian and global perspectives. Fulltekst i vitenarkiv
• 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. Fulltekst i vitenarkiv
• Portnoy, Allison; Pedersen, Kine; Trogstad, Lill; Hansen, Bo Terning; Feiring, Berit & Laake, Ida [Vis alle 11 forfattere av denne artikkelen] (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. Fulltekst i vitenarkiv
• 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. Fulltekst i vitenarkiv
• Kristiansen, Ivar Sønbø; Burger, Emily & Blasio, Birgitte Freiesleben De (2020). Covid-19: Simuleringsmodeller ved epidemier. 140(6), s. 1–6. doi: 10.4045/TIDSSKR.20.0225. Fulltekst i vitenarkiv
• Kristiansen, Ivar Sønbø; Burger, Emily & Blasio, Birgitte Freiesleben De (2020). Covid-19: Simuleringsmodeller ved epidemier. 140(6). doi: 10.4045/tidsskr.20.0225. Fulltekst i vitenarkiv
• Burger, Emily; Dyer, Michael; Palefsky, Joel M.; Sy, Stephen; Pokomandy, Alexandra de & Coutlee, François [Vis alle 8 forfattere av denne artikkelen] (2017). A Natural History Model of Anal Carcinogenesis for High-risk HIV-positive Men: Model Development and Calibration. Fulltekst i vitenarkiv
• 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. Fulltekst i vitenarkiv
• Burger, Emily; Pedersen, Kine; Sy, Stephen; Kristiansen, Ivar Sønbø & Kim, Jane J. (2017). Primary HPV-based Cervical Cancer Screening: Balancing Health Benefits Colposcopy Referrals. Fulltekst i vitenarkiv
• Castle, Philip E. & Burger, Emily (2016). Age of HPV vaccination? The Lancet Infectious Diseases. ISSN 1473-3099. 16(10), s. 1091–1093. doi: 10.1016/S1473-3099(16)30144-X. Fulltekst i vitenarkiv
• 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. Fulltekst i vitenarkiv
• 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. Fulltekst i vitenarkiv
• Pedersen, Kine; Burger, Emily; Campbell, Suzanne; Nygård, Mari & Lönnberg, Stefan (2015). Risk of cervical cancer by screening intensity: A registry-based analysis. Fulltekst i vitenarkiv
• 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. Fulltekst i vitenarkiv
• Groeneveld, linn; Engesæter, Birgit; Aasbø, Gunvor; Hansen, Mona; Christiansen, Irene Kraus & Berland, Jannicke [Vis alle 14 forfattere av denne artikkelen] (2021). Prosjektforslag hjemmetest: Implementering av hjemmeprøvetaking i Livmorhalsprogrammet. Kreftregisteret - Institutt for populasjonsbasert kreftforskning. Fulltekst i vitenarkiv Vis sammendrag

  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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