Screening for Anal Cancer Among Men Who Have Sex With Men With HIV: Benefits, Harms, and Cost-Effectiveness Analyses
Ashish A. Deshmukh, Haluk Damgacioglu, Keith Sigel, Joel M. Palefsky, Megan A. Clarke, Nicolas Wentzensen, Alan G. Nyitray, Ana P. Ortíz, Yueh-Yun Lin, Elizabeth Y. Chiao, Elizabeth A. Stier, Naomi Jay, Michael Gaisa, Yuxin Liu, Eric G. Meissner, Gweneth B. Lazenby, Anna R. Giuliano, Stephen E. Goldstone, Gary M. Clifford, Kalyani Sonawane, Jagpreet Chhatwal
Abstract
BACKGROUND: Following the success of the ANCHOR (Anal Cancer-HSIL Outcomes Research) trial, the U.S. Department of Health and Human Services recommends anal cancer screening for high-risk persons, particularly men who have sex with men (MSM) with HIV. OBJECTIVE: To quantify the cost-effectiveness and benefits versus harms of different anal cancer screening strategies. DESIGN: Microsimulation model. DATA SOURCES: The ANCHOR trial and published literature. TARGET POPULATION: MSM with HIV. TIME HORIZON: Lifetime. PERSPECTIVE: Health care sector. INTERVENTION: Cytology alone and human papillomavirus (HPV) testing (high-risk HPV [hrHPV], HPV16/18, and HPV16), co-testing, and triage options; ages at which to begin screening (≥35, ≥40, or ≥45 years); screening interval (annual, biennial, triennial, or quadrennial). OUTCOME MEASURES: Incremental cost-effectiveness ratios (ICERs) of dollars per quality-adjusted life-year (QALY) and the tradeoff of harms (high-resolution anoscopies [HRAs]) versus benefits (cancer cases averted and life-years gained). RESULTS OF BASE-CASE ANALYSIS: Screening initiation at age 35 years or older using cytology dominated initiation at ages 40 and 45 years or older, with ICERs ranging from $87 731 for a quadrennial interval to $350 100 for an annual interval. In the comparative analysis, the following unique strategies were on the cost-effectiveness frontier: quadrennial HPV16, quadrennial HPV16/18, triennial HPV16/18, triennial hrHPV, biennial HPV16/18, biennial hrHPV, annual cytology with hrHPV triage, and annual hrHPV; ICERs ranged from $81 341 to $2 510 847. In the harm-to-benefit analysis, triage options offered the most efficient HRA use. RESULTS OF SENSITIVITY ANALYSIS: ICERs decreased for newly eligible persons. For 35-year-old newly eligible MSM with HIV, ICERs for cytology ranged from $70 750 (quadrennial) to $223 895 (annual). LIMITATION: Findings are not generalizable to other high-risk populations. CONCLUSION: Anal cancer screening among MSM with HIV aged 35 years or older is cost-effective, but value-based prioritization of strategies is needed to optimize screening use. PRIMARY FUNDING SOURCE: National Cancer Institute.