An economic evaluation of two cervical screening algorithms in Belgium: HR-HPV primary compared to HR-HPV and liquid-based cytology (LBC) co-testing

Objective To assess the costs and benefits of two algorithms for cervical cancer screening in Belgium 1) high-risk human papillomavirus (HR-HPV) primary screening and 2) HR-HPV and liquid-based cytology (LBC) co-testing. Methods A decision tree was adapted from published work and parameterised using HORIZON study data and Belgian cost and population data. The theoretical model represents two different screening algorithms for a cohort of 577,846 women aged 25 – 64 attending routine cervical screening. Scenario analyses were used to explore the impact of including vaccinated women and alternative pricing approaches. Uncertainty analyses were conducted. Results The cost per woman screened was €113.50 for HR-HPV primary screening and €101.70 for co-testing, representing a total cost of €65,588,573 and €58,775,083 respectively for the cohort; a 10% difference. For one screening cycle, compared to HR-HPV primary, co-testing resulted in 13,173 more colposcopies, 67,731 more HR-HPV tests and 477,020 more LBC tests. Co-testing identified 2,351 more CIN2+ cases per year (27% more than HR-HPV primary) and 1,602 more CIN3+ cases (24% more than HR-HPV primary) than HR-HPV primary. Conclusion In Belgium, a co-testing testing algorithm could increase cervical precancer detection rates compared to HR-HPV primary. Co-testing would cost less than HR-HPV primary if the cost of the HPV test and LBC were cost-neutral compared to the current cost of LBC screening but would cost more if the cost per HPV test and LBC were the same in both co-testing and HR-HPV primary strategies. ### Competing Interest Statement At the time of writing, CD, YM, AM, AP, KT, SH and EA were all part of Aquarius Population Health Ltd, an independent consultancy which has previously worked on projects related to diagnostic screening for numerous commercial and non-commercial organisations. ### Funding Statement Aquarius Population Health received funding from Hologic for this study; the design, results and interpretation of the study are independent and the authors' own. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes All data relevant to the study are included in the online Supplementary Material. No additional data are available.