Cost-Utility Analysis of Human Papillomavirus Vaccination and Cervical Screening on Cervical Cancer Patient in Indonesia: Beyond the Abstract

The fact that cervical cancer is preventable disease induces a comprehensive recommendation in order to reduce the burden of cervical cancer worldwide. Human Papillomavirus (HPV) vaccination for younger population and cervical screening for sexually active women, as the primary and secondary prevention proposed by WHO, apparently showed promising results in preventing cervical cancer elsewhere.

Indonesia, as one of the third-highest of cervical cancer incidence and mortality, requires a comprehensive strategy on preventing cervical cancer. However, as developing countries, Indonesia encounter several issues, mainly cost-related, in order to provide the most effective prevention strategies for their people, for example, low budget for vaccination policy, low numbers of high-skilled health care provider and, of course, infrastructure. 

The pharmacoeconomic study, such as cost-utility analysis, helps decision maker in a country on allocating the limited budget into the most cost-effective strategy. With respect to the cervical cancer prevention strategies, consisting HPV vaccination and cervical screening, the pharmacoeconomic studies alongside clinical trial is not applicable due to the follow-up period of the outcomes is too long. Therefore, we performed model-based pharmacoeconomic studies in order to provide the clinical and economic outcomes from the implementation of Visual inspection using Acetic Acid (VIA) screening alone and the addition of HPV vaccination on top of it, in Indonesia. this study specifically examines the question: Is the addition of HPV vaccination, on top of current VIA screening program, a cost-effective strategy in Indonesia according to a threshold recommended by WHO. 

We basically developed a population-based static model so that the natural history of cervical cancer disease in the population can be described. The reference explains a cohort of 100.000 of the 12-years-old girl during their lifetime before Indonesian government implements any cervical cancer prevention policy. The implementation of VIA screening alone and or the combination of VIA screening and HPV vaccination will obviously change the story of cervical cancer in the population hereinafter the clinical and economic outcomes related cervical cancer.

The key findings of this study is that although several parameters, including discount rate, cervical cancer treatment cost, and Quality of Life as part of Quality Adjusted Life Years (QALYs), were considerably important for the outcome calculation, the combination of HPV vaccination and VIA screening for cervical cancer prevention in Indonesia is very cost effective (I$1,863/QALYs) according to the recommended threshold of 1x GDP (I$3,475). In addition, this combination strategy also provides the highest reduction of both cervical cancer incidence and mortality in Indonesia. 

Since the problems with the provision of cervical cancer prevention in Indonesia are not only budget allocation but also human resources and infrastructure, this analysis provides an initial insight about how this policy will generate a clinical and economic benefit for the society. Several implementation strategies, such as partial implementation according to the actual burden and the availability of the budget from each region, could be considered as an option. In addition, as the coverage of DTP vaccination for comparable target population is considerably high, it is considered as one of the important factors on the success of HPV vaccination policy.

Written by: Didik Setiawan

Read the Abstract