| 摘要: | 本研究以衛生政策觀點透過建構決策分析模型模擬台灣健康女性子宮頸癌疾病自然史、彙整流行病學參數、篩檢工具特性，以及相關成本進行電腦模擬分析，評估30 歲健康女性於例行性篩檢政策之下，加入輔助策略－針對36 歲以上超過6 年未參與過例行性篩檢之婦女實施人類乳突病毒DNA 自我採檢服務－與每年一次子宮頸細胞抹片及HPV DNA 檢測不同篩檢策略間之成本效益分析。
本研究使用已發表適用於台灣子宮頸癌篩檢策略之馬可夫模型，研究中主要的三項篩檢策略分別為(1)子宮頸細胞抹片、(2)HPV DNA 檢測，以抹片做追蹤檢查、(3)HPV DNA 自我採檢輔助於例行性抹片篩檢；每一項篩檢策略之年限皆為一年。本研究使用適用於台灣子宮頸癌流行病學之參數，並彙整篩檢工具之特性及相關成本，臨床測量結果包括，子宮頸癌發生率、死亡率、生命年限、生活品質調整後存活年數(QALYs)、及差異成本效果比(ICER)，而未來成本及存活年數將以3%折現率計算。最後，使用單維敏感度分析、機率敏感度分析、及情境敏感度分析對各參數之不確定性進行評估。
研究發現主要三項子宮頸癌篩檢策略於篩檢率和參與率達100%時與沒有篩檢策略比較之下，電腦模擬預測子宮頸癌發生個案數減少比例從71.5%-96.0%，死亡個案數則從72.3%-96.7%。子宮頸細胞抹片策略、HPV DNA 檢測，以抹片追蹤、及HPV DNA 自我採檢輔助於例行性抹片篩檢之策略，三項篩檢策略之總成本及總QALYs 分別為NT$368(25.6761QALYs)、NT$4,236 (25.6827QALYs)、NT$4,477(25.6830QALYs)、NT$7,533(25.6851QALYs)。三項篩檢策略與沒有篩檢策略比較下之ICER 值分別為NT$582,241/QALY、NT$596,562/QALY、NT$791,173/QALY。當台灣成本效益評估之閾值為三倍GDP(NT$1,800,000)時，各篩檢策略皆具成本效益；若與現行每年一次抹片篩檢策略比較，HPV DNA 自我採檢輔助於例行性抹片篩檢、及HPV DNA 檢測之策略，皆具成本效益。
評估台灣子宮頸癌篩檢政策，使用每年一次子宮頸抹片篩檢、HPV DNA 檢測、及HPV DNA自我採檢輔助於例行性抹片篩檢，與沒有篩檢策略比較之下，其差異成本效果比均低於世界衛生組織所建議之標準閾值。本研究結果顯示實施HPV DNA 自我採檢策略是具成本效益之子宮頸癌篩檢策略。
Objectives: This study adopts a perspective of Department of Health in cost-effectiveness analysis to compare a HPV DNA self-sampling supplemented to the annual Pap smear screening
strategy with no-screening strategy and two other different cervical cancer screening strategies. All screening strategies are targeted to women aged 30 or above. The HPV DNA self-sampling strategy is for women who failed to attend the routine regular cervical cancer screening program for previous 6 years. The study aimed to evaluate the long-term cost-effectiveness of cervical cancer screening supplemented with self-sampling for human papillomavirus DNA testing in Taiwan.
Methods: An earlier published decision analytic model of cervical cancer screening in Taiwan was used in this study. Three screening tools were taken into consideration: (1) Pap smear alone,(2) HPV DNA testing followed by Pap smear triage, and (3) self-sampling for HPV DNA testing followed by Pap smear triage. The interval of all cervical cancer screening strategies in this study is annual. The model parameters were collected from the published references and official statistical reports in Taiwan. Outcome measures included life expectancy, quality-adjusted life years (QALYs), lifetime costs, and incremental cost-effectiveness ratios (ICERs). Future costs and life-years were discounted at annual rate of 3%. One-way sensitivity analysis, probabilistic sensitivity analyses (PSAs) and scenario sensitivity analysis were conducted to assess parameter uncertainty.Results: The model predicted that three main screening strategies reduce the lifetime cervical cancer incidence from 71.5% to 96.0%, and lifetime mortality from 72.3% and 96.7%, if the screening and invitation rate of self-sampling were 100%. Total costs and QALYs for no screening, Pap smear alone, HPV DNA testing followed by Pap smear triage, and self-sampling for HPV DNA testing followed by Pap smear triage were NT$368(25.6761QALYs), NT$4,236(25.6827QALYs), NT$4,477(25.6830QALYs), and NT$7,533(25.6851QALYs) per women. Compared with no screening strategy, the incremental cost-effectiveness ratio were NT$582,241/QALY, NT$596,562/QALY, and NT$791,173, respectively. All three screening strategies were considered cost-effective compared with the no-screening strategy when three times GDP per capita is used as the decision threshold (NT$1,800,000). Compared with the primary screening (annual Pap smear), HPV DNA testing for self-sampling followed by Pap smear triage, and HPV DNA testing followed by Pap smear triage was a cost-effective strategy.
Conclusions: In comparison with no screening stategy, adding HPV DNA self-sampling supplemeted to the annual Pap smear screening stategy could be considerd cost-effective under
the threshold proposed by WHO in Taiwan. |
