Reducing unnecessary referrals for colposcopy in hrHPV-positive women within the Dutch cervical cancer screening programme: A modelling study

Sylvia Kaljouw, Erik Jansen, Clare Aitken, Lotte Harrijvan, Steffie Naber, Inge Driesprong - de Kok

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Abstract

Background: With the implementation of primary high-risk human papillomavirus (hrHPV) screening in the Netherlands, an increase was observed in the number of unnecessary referrals (≤Cervical Intraepithelial Neoplasia (CIN) 1) to colposcopy. We aimed to investigate which alternative triage strategies safely reduce unnecessary referrals in HPV-based cervical cancer screening programmes. Methods: Microsimulation model MISCAN was used to simulate an unvaccinated cohort of ten million 30-year old Dutch women. We calculated unnecessary referrals, cervical cancer incidence, mortality, costs and QALYs for 24 triage strategies. Condition for direct referral (atypical squamous cells of undetermined significance (ASC-US), low-grade squamous intraepithelial lesions (LSIL), high-grade squamous intraepithelial lesions (HSIL), conditional on HPV-genotype 16/18/other high risk (OHR)), type of triage test (cytology alone or combined with hrHPV) and time to triage test (6 or 12 months) was varied. Results: The 24 triage strategies had varying effects on the number of unnecessary referrals ranging from −72% to +35%. Adjusting conditions for referral to ‘HPV16/18+ and ASC-US+’ and ‘HPVOHR+ and HSIL+’ and extending the interval between tests to 12 months resulted in a reduction in unnecessary referrals of 40% (incidence +0%, mortality −1%). Reduction in unnecessary referrals without genotyping was achieved by adjusting conditions for direct referral to LSIL (12 months to repeat test) (unnecessary referrals −37%, incidence +2%, mortality +0%). Conclusions: To reduce the number of unnecessary referrals without increasing incidence and mortality by more than 2% in the Dutch cervical cancer screening programme, genotyping for HPV16 or HPV16/18 should be implemented with 12 months to repeat testing.

Original languageEnglish
Pages (from-to)713-720
Number of pages8
JournalGynecologic Oncology
Volume160
Issue number3
DOIs
Publication statusPublished - 1 Mar 2021

Bibliographical note

Funding Information:
This study was funded by the Dutch National Institute for Public Health and the Environment (Rijksinstituut voor Volksgezondheid en Milieu). The funder assisted with selection of the strategies to be modelled. The funder played no further role in the data collection, analysis, interpretation; or writing of the report. The funding source (a government organisation) had no involvement in the study design, data collection, data analysis, interpretation of the data, writing of the report, or the decision to submit the paper for publication.

Publisher Copyright:
© 2021 The Authors

Research programs

  • EMC OR-01

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