Cervical cancer is a common form of malignancy and a leading cause of cancer-related mortality in females (1). It is also an important contributor to disease burden in Sub-Saharan Africa, with an estimated 75 000 new cases documented each year, as well as approximately 50 000 new deaths annually (2). The highest incidence of cervical cancer in the world is reported in Eswatini, with 6.5% of women developing the disease before the age of 75(3). Countries in Western, Middle, and Southern Africa are hardest hit by cervical cancer-related deaths, with world age standardised mortality rates (ASMR) of 23.0%, 21.1.%, and 20.0%, respectively (3). The economic burden of cervical cancer is also substantial. For example, Wu et al (2020) reported that, in the Henan province of China, costs associated with cervical cancer, from diagnosis to one year after discharge, ranged from $8,066 to$22,888 per patient (4).
Cervical cancer is caused by infection with high-risk serotypes of the Human Papilloma Virus (HPV) (5). Infection can lead to the development of pre-cancerous lesions and malignancy if left untreated (6). Since neoplastic transformation can take years or even decades to develop, early detection and treatment of pre-cancerous lesions provides an important opportunity for therapeutic intervention (7). Indeed, the World Health Organization (WHO) has identified cervical cancer as a potentially eliminable form of cancer (7). That being said, cervical cancer remains under-diagnosed in clinical settings, particularly for developing countries (8). Evidence however indicates that adequate screening is associated with reduction in cervical cancer-related deaths (9). The WHO estimates that prevention through vaccination, screening and early treatment, applying the 90-70-90 targets, could reduce median cervical cancer incidence rate by 10% by 2030 (10).
Several approaches have been developed to assist clinicians in screening for cervical cancer. These include unaided visual inspection with acetic acid (VIA) as well as assisted cytological (e.g. Papanicolaou (PAP) smear) and molecular (e.g. HPV DNA testing methods) (11)(12). A Pap test is a liquid cytology-based test in which cervix cells are analysed (13). Unaided VIA is carried out by observing cervix cell colour changes in response to acetic acid exposure(14). These screening methods differ in terms of their diagnostic value, accuracy, and associated costs to the user and healthcare system (15).
Health economic evaluations (16) can help inform the clinical application and financing of appropriate screening methods for cervical cancer. Health economics research could ensure that the potential positive impact of health interventions are weighed against their use of limited resources particularly in lower- to middle-income healthcare settings (17). Economic evaluations might thus provide a possible framework to assist decision makers in providing much needed interventions based on available clinical evidence leveraged against the cost to the healthcare sector (18).
Several economic evaluations have examined the financial aspects of cervical cancer screening in resource-limited healthcare environments. Studies conducted in developing countries including India (19) and South Africa (20) suggest that the cost-effectiveness of individual modalities might differ based on setting. Findings from other studies conducted in developed nations such as Portugal (21) also support combining different screening methods depending on individual factors (21). This approach might however not be applicable in settings where health resources including access to molecular testing are already limited.
Health economic evaluations focused on cervical cancer screening are however limited by the use of different methodologies, and generalization across prior studies is often not possible. This highlights the need for a methodical approach to exploring systematic difference across various such economic evaluations conducted to date. At least three prior systematic reviews(22) have provided evidence supporting the cost-effectiveness of cervical cancer screening. However, Nahvijou et al (2014) limited their systematic review to cost-effectiveness analyses of cervical cancer screening methods (23). In 2015, Mendes et al (24) published a review whose aim was to identify mathematical models used to evaluate the impact of cervical cancer screening strategies. Though critical insights were gleaned from this review, restricting the study type to mathematical modelling resulted in the exclusion of primary-based economic evaluations. In their more recent review, Mezei et al. (2017) also limited their review to cost-effectiveness analyses, with a focus on lower- to middle-income countries. Furthermore, the authors selected only model-based economic evaluations (25). A large body of economic evaluation evidence is founded on randomized controlled trials and primary cost-effectiveness studies. Authors did not carry out an appraisal of the methodological quality of studies, which reduced the validity of the results. Lastly, authors focus on the cost-effectiveness of screening methods. This review builds on findings by Nahvijou et al (2014), Mendes et al (2015) and Mezei et al (2017), by reviewing all full economic evaluation methods including cost-utility, cost-benefit, cost-minimization, and cost-consequence analysis.
The aim of the present systematic review was to appraise the evidence on full economic evaluations of cervical cancer screening methods for improving pre-cancerous lesion detection in women from the payer and/ societal perspectives.