06_cost-effectiveness study of hpv vaccination in the prevention of cervical cancer
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COST-EFFECTIVENESS OF HPV VACCINATION IN
PREVENTION OF CERVICAL CANCER
IN MALAYSIA
Dr. Sharifa Ezat Wan Puteh
Department of Community Health
Faculty of MedicineUKMMC
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Researchers
Researchers
Prof Dato Syed Aljunid
Sharifa Ezat Wan Puteh
Fuad Ismail
Aniza Ismail
Seri Suniza Ahmad Zailani Hatta
Sharifah Noor Akmal
Nurismah Md Isa
Paul Ng
Murali Ganesalingam
Vicknesh Visvalingam Mymoon Alias
Majdah Mohd
Rushdan Mohd Noor
Institutions
UKMMC
Hospital Kuala Lumpur
Hospital Sultanah Bahiyah AlorStar Kedah
Hospital Kuantan, Pahang Hospital Kangar, Perlis
Hospital Seremban, NegeriSembilan
Ministry of Health Malaysia
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Cervical Cancer Serious health problem
9 mil. women develop disease each year world wide.
Developing countries with no preexisting screening orpoor coverage.
Much higher compared to developed countries with
established screening programs (UK 11.5/100000)
2nd most commonest cancer in Malaysia after breast
cancer.
Strong relationship with the Human Papilloma virus
(HPV) 16, 18.
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Cervical Cancer Incidence By Age, Peninsular Malaysia
(Per 100,000)
ETHNICITY % of Cervical
Cancer Cases
CHINESE 56.4
MALAYS 32.8
INDIANS 10.8
Total Nos. of Cases Per Year = 1,557(NCR 2003)
Incidence of CC by Age
010
20
30
40
50
60
70
80
Age 0-9 10-19 20-29 30-39 40-49 50-59 60-69 70+
CR
2003 2006
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HPV Vaccine
Two types
1. Quadrivalent Vaccine
HPV Types 6, 11, 16, 18
Cervical, Vulva, Vagina Cancer and Genital Warts
2. Bivalent Vaccine
HPV Types 16,18
Cervical Cancer Only
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Objectives
SPECIFIC OBJECTIVES
To determine the cost of treatment and womens
quality of life according to age and disease progression.
To compare the CEA 3 programs i.e. Pap smear
program, HPV vaccination program and thecombined strategy (HPV vaccination with screeningprogram).
Robustness of the economic model using sensitivity analysis.
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STUDY HYPOTHESIS
Burden of Cervical Cancer is substantial to the Malaysian
economy.
Cost of treatment of cervical cancer patients will increasewith age and severity.
Combined strategy (HPV vaccination combined Pap
smear program) is the most cost-effective option.
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Cost-Effectiveness Model
Costs
Cost of Vaccination Program
Cost of Pap Smear Program
Cost of Managing Positive Pap Smear
Cost of Adverse Events of Vaccination
Outcomes
Quality Adjusted Life Years (QALYS)
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Cost-Effectiveness Ratio
(Cost/QALYs)
Negative: Cost Saving
Less than 1 GDP : Highly Cost Effective Between 1 to 3 GDP : Cost Effective
More than 3 GDP : Not Cost Effective
Per capita GDP 2006: RM 20,911 (WHO)
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METHODOLOGY
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Study Design
Economic Evaluation Design
Tools
1. Quality Of Life from SF-36 questionnaires. Physical composite summary scores (PCS)
Mental composite summary scores (MCS)
Quality Adjusted Life Years saved(QALYs)= QOL x lifeexpectancy (years) saved
2. Costing Data (patients & providers).
Duration: 2006-2008.
Respondents= 502 patients
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Costing Data
1. Expert group discussion, develop treatment algorithms, management costfor cervical cancers by severity pathways.
- Activity Based Costing.
2. Step down costing for the Providers Cost
Using case mix UKMMC cost per day admission and cost per day ofoutpatient.
Programs Cost-2 data and published literatures.
3. Micro costing questionnaire for Patients cost.
direct interview with respondents with cervical cancers. Modelling of vaccinated women, using QOL (secondary data Azman et
al 2004) and normal life expectancy of women (Statistics Dept 2006).
Patients sampled universally- inclusion and exclusion criteria.
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RESULTSSocio demographic dataand QOL
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Prevalence by Disease Stage
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Stage 4Stage 3Stage 2Stage 1ASCUSCIN 3CIN 2CIN 1
Disease by Stages
30
20
10
0
Percent
4.58%7.17%
28.29%30.88%
4.98%7.57%6.97%
9.56%
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Age and Ethnicity
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Mean age=53.0 (SD 11.23) years
OthersIndiansChineseMalay
Etnicity
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
Percent
1.79%
15.14%
37.25%
45.82%
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Respondents Income
Patients Income
Median RM 525 (IQR 300-1000)
/month.
Partners incomeMedian RM 500 (IQR 0-1150).
16
RM 3000
and above
RM 2500-
2999
RM 2000-
2499
RM 1500-
1999
RM 1000-
1499
RM 500-
999
Income
RM0-499
Patients' Income
70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
Percent
1.99%0.4%2.59%
2.79%
9.96%
20.32%
61.95%
RM 3000 and
above
RM 2500-
2999
RM 2000-
2499
RM 1500-
1999
RM 1000-
1499
RM 500-999Partners
Income RM0-
499
Range of Partners Income
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
Percent
6.18%
1.79%6.37%7.17%
11.35%
18.53%
48.61%
Household Income/ month: RM 800 (IQR 400-1525).
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Healthcare Expenditure
(Percentage Spent on Health)
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50-59%40-49%30-39%20-29%10-19%% spent onhealth care
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Preinvasive
Diseases
Stage 1A1 Stage 1A2 Stage 1B-2A Stage 2B-4A Stage 4B Total
33.98
27.72
24.23
26.5925.59
26.25
28.36
20.54
14.25
10.98
13.5112.65
11.48
15.18
Life Expectancy by Disease Severity
Life Expectancy Vaccinated Women Life Expectancy Cervical Cancers
Difference p
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QUALITY OF LIFE
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0102030405060708090
PhysicalFun
ctioning
(PF)
Rolelimitation-p
hysical
(REP)
BodilyPain(BP)
Generalhealth(GH)
Vitality(VT)
SocialFunctio
ning(SF)
Rolelim
itation-
emotional(REE)
MentalHea
lth(MH)
QOL between Cervical Cancers & Normal Women
Cervical Cancers
Normal Women
Population
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QOL by Disease Severity
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0.00
10.00
20.0030.00
40.00
50.00
60.00
PCS
MCS
PCS difference significant p
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QOL by Age
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0.00
5.00
10.00
15.00
20.00
25.00
30.00
35.00
40.00
45.00
50.00
Lessthan25
y
ears
old
2
5-34years
35-44years
45-54years
55-64years
65years
and
above
Total
PCS
MCS
PCS difference significant p
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Clinical Pathways Cost
Less than
25 years
old
25-34
years
35-44
years
45-54
years
55-64
years
65 years
and above
Total
1,7433,260
17,333
20,741
25,222 25,561
21,250
Cost/Case/Year by Age
Mean cost difference significant p
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Comparison of Costs by Activities
ActivitiesUK (
Million) %
Malaysia
(RM Million) %
Cost of Screening 104.3 56.2 22.0 9
Cost of Managing
Pre-invasiveDisease
34.5 18.6 1.4 1
Cost of managing
new invasive
cancer cases
33.3 17.9 167 68
Cost of managingexisting cases 13.5 7.3 55 22
Total 185.6 100 245.4 100
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Brown RE, Breugelmans JG, Theodoratou D, Benard S. Costs of Detection and Treatment of Cervical Cancer, Cervical Dysplasia
and Genital Warts in the UK. Current Medical Research and Options. 2006; 22 (4):663.Sharifa Ezat et al. 2008.Economic Burden of Cervical Cancer in Malaysia. Medical Journal of Indonesia. 17(4):272-280.
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COSTING and CEA
Three program strategies-
1. Pap smear2. HPV Vaccinations
3. Combined (Vaccination & Pap smear)
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Parameters in CE Model
Quadrivalent Vaccine Sensitivity Analysis Cost/dose
RM 300-RM 400
No booster required i.e. Vaccine
efficacy sustained
Side effects not serious
Pap smear population coverage
40, 70 and 80%
Mandatory Vaccinations
Administered at 15 years old
Plus catch up period from 9-26 years
old.
Coverage 70% only.
Cost and outcomes were
discounted 3% for 10 years.
Incidence Cx Cancer based on
19.7/100,000 female
population (year 2003).
Female population based on
Msia population statistics year
2006.
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Scenarios for Cost Effectiveness
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Scenario Pap Smear
Coverage
Price of
Vaccine/dose
Base Case 40% RM 300
Best Case 70% RM 300
Worst Case 40% RM 400
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CEA of Three Programs
Cost (RM)/
QALYs
Pap Smear
Only
HPV
Vaccination
only
Combined
Base Case 1,215 35,347 11,290
Best Case 1,100 35,347 7,713
Worst Case 1,215 46,530 14,590
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Incremental Cost Effectiveness Ratio (ICER)
Strategy Cost (RM) Effectivenes(QALYs)
Incremental Incremen-tal
Effectiveness
(QALYs)
ICER(per
QALYs
avoided)
RM
Cost (RM)
Pap smearprogram
40%
coverage
91,930,890 109,850 _ _ _
Pap smear
program
70%Coverage
211,462,910 192,237 77,999,691 82,387 947
Combined
Strategy
Best Case
1,837,478,053 238,240 1,626,015,143 46,002
35,347
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Budget Impact Assessment
0
2,000
4,000
6,000
8,000
10,000
12,000
14,000
16,000
Cost per year Cost per 5 years Cost per 10
years
Cost per 20
years
Cost per 50
years
Millions
RM (Cost) Projected Cost if Reduced Incidence
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Conclusions Loss of life to years is substantial in cervical cancer patients.
Cost gets higher with increase severity and age.
QOL lowest at
older age group
higher severity of disease.
Physical functions more affected than Mental functions.
Combined strategy is Highly Cost Effective
HPV Vaccine Alone is still cost-effective at all level of Sensitivity in preventingCervical Cancers in Malaysia
More cost effective at higher Pap smear coverage and if vaccine cost is
cheaper.
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THANK YOU
[email protected][email protected]
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