Elsevier

Gynecologic Oncology

Volume 152, Issue 3, March 2019, Pages 465-471
Gynecologic Oncology

Pathways to a cancer-free future: A protocol for modelled evaluations to maximize the future impact of interventions on cervical cancer in Australia

https://doi.org/10.1016/j.ygyno.2018.12.019Get rights and content

Highlights

  • Pathways-Cervix is a comprehensive approach towards cervical cancer control from prevention to treatment/survivorship.

  • The program translates research into action through an implementation process engaging policy-makers and stakeholders.

  • Pathways-Cervix will generate the best-value investments or “best buys” in cervical cancer control.

  • Priority interventions evaluated were selected by a Scientific Advisory Committee in an Australian context.

  • The flexibility of the modelling platform can enable application of this program to other settings.

Abstract

Objective

Australia's HPV vaccination and HPV-based cervical screening programs are changing the landscape in cervical cancer prevention. We aim to identify areas which can make the biggest further impact on cervical cancer burden. This protocol describes the first stage of a program of work called Pathways-Cervix that aims to generate evidence from modelled evaluations of interventions across the cervical cancer spectrum.

Methods

Based on evidence from literature reviews and guidance from a multi-disciplinary Scientific Advisory Committee (SAC), the most relevant evaluations for prevention, diagnosis and treatment were identified.

Results

Priority evaluations agreed by the SAC included: increasing/decreasing and retaining vaccination uptake at the current level; vaccinating older women; increasing screening participation; methods for triaging HPV-positive women; improving the diagnosis of cervical intraepithelial neoplasia (CIN) and cancer; treating cervical abnormalities and cancer; and vaccinating women treated for CIN2/3 to prevent recurrence. Evaluations will be performed using a simulation model, Policy1-Cervix previously used to perform policy evaluations in Australia. Exploratory modelling of interventions using idealised scenarios will initially be conducted in single birth cohorts. If these have a significant impact on findings then evaluations with more realistic assumptions will be conducted. Promising strategies will be investigated further by multi-cohort simulations predicting health outcomes, resource use and cost outcomes.

Conclusions

Pathways-Cervix will assess the relative benefits of strategies and treatment options in a systematic and health economic framework, producing a list of ‘best buys’ for future decision-making in cervical cancer control.

Introduction

Cervical cancer typically arises after many years of persistent infection of cervical cells with oncogenic human papillomaviruses (HPV) [1]. In the pre-vaccination era, nearly all sexually active women were exposed to HPV infection but most infections are transient or controlled by the immune system. A fraction of women will develop overt, persistent oncogenic HPV infection, a high percentage of which will then progress to precancer [2,3]. A high-percentage of precancer will become invasive cancer if not detected and treated in a timely fashion [4]. Thus, a substantial number of women will develop cervical cancer if they do not receive primary (prophylactic HPV vaccination) and/or secondary (screening for and diagnosis and treatment of precancer) prevention.

In a changing landscape in cervical cancer prevention, diagnosis and treatment, focusing research efforts and resources in areas that can make the biggest impact on its outcomes is a challenge. In Australia, changes have occurred and are continuing to occur in vaccination and screening practices, as outlined below. It is in this context that “Pathways to a cancer-free future” (‘Pathways’) was conceived. Pathways is a multi-stage program of work that spans the cancer control spectrum, from prevention to treatment and survivorship. Its aims are to synthesise evidence from the literature and thereby generate evidence from targeted modelled evaluations of cancer control interventions that can guide and underpin future research investment and policy implementation. Pathways will initially be applied to five major cancers in Australia (cervical, lung, bowel, prostate, and breast cancer). The aim of the current article is to outline the design and objectives of Pathways-Cervix and summarise the protocol for modelled evaluations.

Section snippets

Cytology based screening

Australia has among the lowest reported cervical cancer age-standardised (world) incidence (5.5 cases per 100,000 women) and mortality rates (1.6 cases per 100,000 women) [5] due to prevention of cervical cancer through its National Cervical Screening Program (NCSP). The NCSP was established in 1991 and, prior to December 2017, recommended 2-yearly cervical screening with conventional cytology for sexually active women aged between 18 and 20 years and 69 years. The proportion of eligible women

Study design

Pathways has three stages, schematically presented in Fig. 1. Stage 1 is to identify possible further changes in prevention, diagnosis and treatment, and then to use modelling to evaluate the changes in health outcomes they might achieve and their potential cost-effectiveness from an Australian health services perspective. Stage 2 is a consultative phase, where national and international experts, organisations, government, and community representatives, will critically assess the findings of

Ethics and dissemination

The Pathways-Cervix protocol for modelled evaluations has been reviewed and approved by the SAC. No human subjects are involved in this protocol and therefore Human Research Ethics Committee was not required. No deviations from the protocol will be conducted without prior review and approval of the relevant working party leads from the SAC. The findings of the evaluations will be reported in a series of papers in peer-reviewed journals and presented at national and international scientific

Discussion

The interventions to be evaluated as part of Pathways-Cervix were identified by the SAC as priority interventions. The SAC identified two different evaluation types. The first type examines maximum impact in a particular area by examining a number of aspects in an idealised way which provides an early indication of the most important priority areas. The second type involve a more detailed cost-effectiveness analysis using data from other interventions as carried out in our previous work in

Conflict of interest statement

JMLB reports unrestricted investigator initiated grants from MSD (papillomatosis typing study) and Seqirus (cervical cancer typing study) outside the submitted work. IF reports income from the sale of the vaccines as inventor of the technology underlying the HPV vaccines referred to in the paper; this is paid to him as part of his salary from the University of Queensland. SMG reports grants from Merck Investigator initiated research grants [RRP, HPV antibody outcome YFHI], grants from

Author contribution

KC conceived the overall Pathways programme. SH, SY and HH conducted literature scoping under the guidance of KC and KB who manages the programme. KC, MAS, KTS, JBL, MH, JK and AK produced the initial list of potential modelled evaluations. BKA, MS, JMLB, RK, AB, LR, SH, JC, DB, IF, SMG, RG, IH, PEC, PG, MA and KC as members of the Scientific Advisory Committee selected the priority evaluations and provided guidance for further work. LSV drafted the manuscript with input from KC, MAS, KT and

Acknowledgement

This work was supported by Cancer Council NSW.

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