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Decision-analytic modeling to evaluate benefits and harms of medical tests—uses and limitations. Med Decis Making. For example, our model inevitably requires assumptions about the costs of interventions and procedures, the effectiveness of VIA screening and vaccination, and about cervical cancer incidence and HPV prevalence data. As the quality of the results is only as good as the quality of the assumptions and synthesized data, the most reliable information from Morocco was included in the model 43 Griebsch I.

Economic evaluation in health care: merging theory with practice. New York : Oxford University Press ; Subsequently, to ensure the credibility of the results, model predictions on cervical cancer incidence were calibrated to real empirical data from Morocco. In addition, sensitivity analyses were performed which can help appreciate the impact of uncertainties in the key parameters. However, some other limitations are more difficult to address. For example, our model does not capture herd immunity effects, nor does it include the potential benefits of vaccination on other non-cervical HPV-related diseases such as other anogenital cancers or genital warts, and it does not reflect the impact of cross-protection against other non-vaccine HPV types.

HPV and Cervical Cancer: Achievements in Prevention and Future Prospects by Franco Borruto

These limitations may lead the health benefits of HPV vaccination to be under-estimated. Further, as our model is a simple representation of the natural history of HPV infection and cervical cancer and not a detailed model with screening complex strategies that incorporate different visits, all women diagnosed with a CIN lesion are treated and there is no loss-to-follow-up. In order to deal with all these issues, it would be necessary to use more complex approaches such as dynamic microsimulation models.

Finally, although the threshold based in the GDP is often used in cost-effectiveness analysis in low- and middle-income countries, recent papers suggest that thresholds representing likely health opportunity costs tend to be below one GDP per capita 44 Ochalek J , Lomas J , Claxton K. Cost effectiveness in low- and middle-income countries: a review of the debates surrounding decision rules. In our analysis, the ICER for vaccination represents an eleventh of the per capita GDP in Morocco, which may indicate that vaccination would be cost-effective with a much lower threshold; whereas the ICER for combined vaccination and existing screening with VIA and low coverage is between one and two times the per capita GDP, which may indicate that it could be displacing more health than it generates.

Based on our results, healthcare policymakers in Morocco should explore the possibility of supporting the implementation of pre-adolescent HPV vaccination for girls. However, they should also consider that introducing HPV vaccine into a national immunization program depends not only on the cost-effectiveness, but also on other important factors such as affordability, sustainable financing, avertable burden, feasibility, and equity.

Further analyses with more complex approaches that include other non-cervical HPV-related diseases, vaccines that provide protection against more high-risk HPV types, and other screening tests such as HPV testing as suggested by the WHO are needed in order to reconfirm our results and to help guide the next steps on cervical cancer prevention in Morocco. Finally, a country like Morocco, where there has been problems with screening coverage, should also consider evaluating the cost-effectiveness of HPV self-collection, which has demonstrated to be a powerful tool to increase coverage and has the potential to overcome many of the barriers shown by other screening techniques.


ERDF, a way to build Europe. Grants to support the activities of research groups SGR — None of these entities played a role in data collection or analysis, or in the interpretation of the results. The peer reviewers on this manuscript have no other relevant financial relationships or otherwise to disclose. Verbal informed consent was obtained from all participants in this study. Data of participants were anonymized for the purposes of this analysis.

The confidential information of the patients was protected according to national normative data. None reported. Skip to Main Content. Search in: This Journal Anywhere. Advanced search. Submit an article Journal homepage. Pages Received 19 Mar Cervical cancer prevention in Morocco: a model-based cost-effectiveness analysis. Abstract Objective: Cervical cancer is a huge public health issue in Morocco which represents the second most frequent and fatal cancer among women. Introduction Cost-effectiveness analyses are increasingly required in the healthcare decision-making process for the purpose of informing about which new products to include in national public healthcare systems or optimizing those that already exist 1 Rawlins MD.

Methods The model A Markov model was developed to simulate the natural history of HPV infection and cervical cancer in order to calculate the long-term health benefits and costs of different cervical cancer preventive strategies. Cervical cancer prevention in Morocco: a model-based cost-effectiveness analysis All authors. Published online: 17 June Display full size. CSV Display Table.

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Economic data Since it is important to use country-specific information but there is a lack of data on costs related to cervical cancer screening procedures in Morocco, a survey was carried out to estimate the direct medical costs of screening, diagnosis, and treatment of pre-cancerous lesions using loop electrosurgical excision procedure LEEP and treatment of cervical cancer from the public healthcare perspective in Moroccan dirhams.

Outcomes, measurements, and cost-effectiveness analysis For each strategy, the model predicts the life expectancy LE and the lifetime cost per woman. Conclusions Based on our results, healthcare policymakers in Morocco should explore the possibility of supporting the implementation of pre-adolescent HPV vaccination for girls.

HPV and Cervical Cancer: 25 Years from Discovery to Vaccine

Ethics approval and consent to participate This manuscript has been revised for its publication by the Clinical Research Ethics Committee of Bellvitge University Hospital. Acknowledgements None reported. Supplemental material. Article Metrics Views. Article metrics information Disclaimer for citing articles.

Cervical cancer prevention in Morocco: a model-based cost-effectiveness analysis

More Share Options. People also read review. Robert A. Published online: 20 Feb Epidemiology also has a critical role in the translation of scientific evidence into policy and practice Phases of translation: T0, discovery; T1, characterization; T2, evaluation; T3, implementation and health services ; and T4, outcome research. Figure adapted from Khoury and colleagues 7. These drivers complement one another and work in concert to accelerate epidemiologic findings through the translational research continuum to impress a true impact on cancer prevention and population health Fig.

Given the complexity of cancer, a concerted effort is needed to unravel the mechanisms underlying carcinogenesis, characterize risk factors, promote prevention and treatment efforts, and influence outcomes of cancer care. This approach requires thoughtful team science initiatives across a growing list of disciplines e.

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The concepts of team science and related scientific approaches e. At the NCI's Division of Cancer Control and Population Sciences, the Science of Team Science Initiative, for example, was specifically established to advance our understanding of cross-disciplinary research to accelerate progress in cancer control, prevention, and treatment In epidemiology, consortia of well-characterized cohort studies are needed to enable epidemiologists to address scientific questions that require large sample sizes for statistical precision While the need for collaboration seems obvious, there are technical and methodologic challenges that require the collective cooperation from experts to address, including data harmonization, population heterogeneity, and imprecise measurements of exposures across studies.

A forum to discuss the opportunities and challenges of consortia and large-scale cohorts was held in and summaries of the conversations have been published A single technologic advancement or innovation, such as affordable high-throughput genomic sequencing, can revolutionize a field. The promises and the potential rewards of a new technology can be intoxicating, but one should be mindful of the pitfalls of adapting a new technology too early and too soon.

The relationship between technologies and epidemiology is bidirectional. Technologies are tools that epidemiologists use to test a hypothesis and answer a scientific question; epidemiologic principles, concepts, and methods therefore should not be abandoned amidst the allure of a new technology. For example, in the context of discoveries of biologic mechanisms and etiology of cancer, the construct of gene—environment interactions has been integrated into epidemiologic studies of various cancers Environmental factors are broadly defined to include exposures ranging from personal to behaviors to social constructs.

A similar ecologic model of health and the need to examine multiple levels and interaction applies throughout translational phases. In the context of implementation and evaluation, Taplin and colleagues 27 described a multilevel analysis model for the cancer care continuum, which is firmly rooted in an epidemiologic foundation. The model includes interactions between the person e.

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Central among the drivers is knowledge integration. Knowledge integration is the process of combining information from many sources and disciplines to accelerate the translation of scientific discoveries into health benefits for both individuals and populations We recently published a commentary on how knowledge integration can be applied in cancer epidemiology Briefly, knowledge integration involves 3 components: knowledge management selecting, storing, curating, and tracking relevant information , knowledge synthesis applying technical methods, including meta-analyses, for the systematic review of published and unpublished data using a priori rules of evidence, as well as tools for modeling and decision analysis , and knowledge translation using synthesized information to broker stakeholder discussion and influence policy, guideline development, practice, and research.

As depicted in Fig. At any given point within the continuum, it provides methodologic guidance and applications to evaluate the robustness and accuracy of existing scientific discoveries, assess their implications for cancer care and prevention, and identify scientific gaps that warrant further research.

The infectious nature of cervical carcinogenesis, coupled with available vaccination and efficacious screening programs, offer a foreseeable scenario of global eradication of this disease Nevertheless, significant challenges and research gaps exist in the areas of etiology, screening, prevention, treatment, and policy development.

Experts have extensively discussed the nuances of the issues associated with these areas 23, Moreover, 5 articles 30—34 in the September special issue of Cancer Epidemiology, Biomarkers, and Prevention CEBP focused on existing obstacles relating to cervical cancer burden worldwide. The welcomed coincidence of this CEBP Focus, as we were drafting this commentary using cervical cancer to illustrate our argument, underscores the timeliness of the driver-driven translational framework we outlined.

Here, we highlight selected challenges in cervical cancer to illustrate how the cancer epidemiology drivers can be applied to accelerate progress to reduce the burden of cervical cancer worldwide Table 1. The identification of human papillomavirus HPV as a necessary cause of invasive cervical cancer 35 and its precursors is a shining achievement of discovery in epidemiologic research—an epidemiologic evolution of scientific progress, dating as far back as 36 and reaching critical mass in the late s with early indications that sexual behaviors played an etiologic role in cervical cancer risk 37— Technologic advances in HPV-DNA testing provided molecular epidemiologists with the tools to sort through the plurality of HPV types and to identify oncogenic strains associated with cervical cancer.

Nevertheless, our understanding of cervical carcinogenesis remains incomplete. For example, although HPV-infection is a necessary etiologic factor for cervical cancer, it is not a sufficient factor The role of cofactors e. HPV infection is highly prevalent in the population, yet little is known about its natural history Basic scientists along with molecular epidemiologists can help provide critical information about the mechanism s underlying HPV persistence and clearance. Strong evidence about HPV-associated cancers in men may be critical in providing scientific justification s for implementation of a widespread male-HPV vaccination policy 46, Consortia are needed to gather adequate sample sizes to study less common HPV-associated cancers e.

The 3 components of knowledge integration are essential to synthesize existing knowledge from distinct fields to identify research gaps. For example, a Cochrane review of 23 randomized control trials on behavioral interventions and transmission of sexually transmitted diseases in young women concluded that these type of interventions are effective, but identified gaps, including the need for greater emphasis on education about HPV and cervical cancer risk as well as focused research on resource-poor countries For example, characterization of the natural history of HPV may inform the decision models for policy development-relating cervical cancer prevention Widespread implementation of Pap tests has averted an epidemic of cervical cancer over the past several decades Recently, technologic advances in HPV-DNA testing have transformed the conventional cytology-based screening protocol.