CERVICAL CANCER SCREENING IN THE PHILIPPINE SETTING- A COST-EFFECTIVENESS ANALYSIS

OBJECTIVE: Cervical cancer is preventable. However in the Philippines, cervical cancer incidence remain significant with an overall survival rate of 44% in 5 years and about 10/100,000 women dying after 5 years. Limited resources, insufficient screening infrastructure and inadequate treatment services have all led to an inability of less-developed countries like the Philippines to implement an extensive cytology-based cervical cancer screening program. Our objective is to identify and recommend a cost-effective approach towards early detection of precursor lesions and early stage cervical cancer for the Philippines. METHODS: This economic evaluation investigated four screening methods namely: acetic acid evaluation (AA), magnified acetic acid visualization (MAA), Pap smear using spatula+cotton swab (SS) and Pap smear using a cervix brush (CB). It was undertaken concurrently with a standard criterion study involving a nationwide sample of 9 secondary and tertiary hospitals, 5 community health centers and their catchment areas. Cost per woman screened, cost per precursor/early cancer lesion detected, and cost per life saved in 5 years were calculated using a societal perspective, 8% discount rate and 1998 as base year. RESULTS: Cost per woman screened is highest for CB and lowest for AA, at both hospital (CB=631.61PHP/15.44USD; SS=607.52PHP/14.86USD; MAA=478.80PHP/11.71USD; AA=476.31PHP/11.65USD) and health center settings (CB=425.34PHP/10.40USD; SS=401.24PHP/9.81USD; MAA=271.52/6.64USD; AA=270.05PHP/6.60USD). Cost per precursor/early cancer lesion detected among 100,000 women screened is highest for SS and lowest for MAA (SS=1,641,945.90PHP/40,152.25USD; CB=1,289,000PHP/31,521.29USD; AA=149,783.02PHP/3,662.80USD; MAA=116,515.82PHP/2,849.28USD). Cost per life saved is lowest for MAA and highest for SS (MAA=6,191.88PHP/151.42USD; AA=6,561.65PHP/160.46USD; CB=7,685.69PHP/187.95USD; SS=8,921.00PHP/218.15USD). Variations in incidence of precursor/early cervix cancer lesions, sensitivity of different screening methods, target population coverage and discount rate did not change the results of cost per life saved due to cervical screening. CONCLUSION: Acetic acid visualization of the cervix (with or without magnification) is the cervical cancer screen method of choice for the Philippines.