Cost-effectiveness of artificial intelligence-assisted liquid-based cytology testing for cervical cancer screening in China

Mingwang Shen; Zhuoru Zou; Heling Bao; Christopher K Fairley; Karen Canfell; Jason J Ong; Jane Hocking; Eric P F Chow; Guihua Zhuang; Linhong Wang; Lei Zhang

doi:10.1016/j.lanwpc.2023.100726

Cost-effectiveness of artificial intelligence-assisted liquid-based cytology testing for cervical cancer screening in China

Lancet Reg Health West Pac. 2023 Mar 3:34:100726. doi: 10.1016/j.lanwpc.2023.100726. eCollection 2023 May.

Authors

Mingwang Shen^{1

2}, Zhuoru Zou¹, Heling Bao^{3

4}, Christopher K Fairley^{1

5

6}, Karen Canfell^{7

8

9}, Jason J Ong^{1

5

6}, Jane Hocking^{1

10}, Eric P F Chow^{5

6

10}, Guihua Zhuang^{1

2}, Linhong Wang⁴, Lei Zhang^{1

5

6}

Affiliations

¹ China-Australia Joint Research Center for Infectious Diseases, School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, Shaanxi 710061, China.
² Key Laboratory for Disease Prevention and Control and Health Promotion of Shaanxi Province, Xi'an, Shaanxi 710061, China.
³ Institute of Medical Information, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China.
⁴ National Center for Chronic and Non-communicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China.
⁵ Melbourne Sexual Health Centre, Alfred Health, Melbourne, VIC, Australia.
⁶ Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia.
⁷ Cancer Research Division, Cancer Council NSW, 153 Dowling Street, Woolloomooloo, Sydney, NSW 2011, Australia.
⁸ Prince of Wales Clinical School, The University of New South Wales, Sydney, NSW, Australia.
⁹ School of Public Health, University of Sydney, Sydney, NSW, Australia.
¹⁰ Sexual Health Unit, Faculty of Medicine, Dentistry and Health Sciences, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, VIC, Australia.

Abstract

Background: The 2021 World Health Organization (WHO) guidelines for cervical cancer screening recommend human papillomavirus (HPV) DNA or mRNA testing. Artificial intelligence (AI)-assisted liquid-based cytology (LBC) systems also have the potential to facilitate rapid scale-up of cervical cancer screening. We aimed to evaluate the cost-effectiveness of AI-assisted LBC testing, compared with the manual LBC and HPV-DNA testing, for primary cervical cancer screening in China.

Methods: We developed a Markov model for a cohort of 100,000 women aged 30 years over a lifetime to simulate the natural history of cervical cancer progression. We evaluated the incremental cost-effectiveness ratios (ICER) of 18 screening strategies (a combination of the three screening methods with six screening frequencies) from a healthcare provider's perspective. The willingness-to-pay threshold (US$30,828) was chosen as three times the Chinese per-capita gross domestic product in 2019. Univariate and probabilistic sensitivity analyses were performed to examine the robustness of the results.

Findings: Compared with no screening, all 18 screening strategies were cost-effective, with an ICER of $622-24,482 per quality-adjusted life-year (QALY) gained. If HPV testing after scaling up to population level screening costs $10.80 or more, screening once every 5 years using AI-assisted LBC would be the most cost-effective strategy with an ICER of $8790/QALY gained compared with the lower-cost non-dominated strategy on the cost-effectiveness frontier. Its probability of being cost-effective was higher (55.4%) than other strategies. Sensitivity analyses showed that the most cost-effective strategy would become AI-assisted LBC testing once every 3 years if the sensitivity (74.1%) and specificity (95.6%) of this method were both reduced by ≥10%. The most cost-effective strategy would become HPV-DNA testing once every 5 years if the cost of AI-assisted LBC was more expensive than manual LBC or if the HPV-DNA test cost is slightly reduced (from $10.8 to <$9.4).

Interpretation: AI-assisted LBC screening once every 5 years could be more cost-effective than manually-read LBC. Using AI-assisted LBC could have comparable cost-effectiveness to HPV DNA screening, but the relative pricing of HPV DNA testing is critical in this result.

Funding: National Natural Science Foundation of China, National Key R&D Program of China.

Keywords: AI-assisted LBC; Cervical cancer screening; Cost-effectiveness; HPV DNA testing; Manual LBC.