Cost-effectiveness of primary human papillomavirus triage approaches among vaccinated women in Norway: A model-based analysis

As Norway considers revising triage approaches following their first adolescent cohort with human papillomavirus (HPV) vaccination entering the cervical cancer screening program, we analyzed the health impact and cost-effectiveness of alternative primary HPV triage approaches for women initiating cervical cancer screening in 2023. We used a multimodeling approach that captured HPV transmission and cervical carcinogenesis to evaluate the health benefits, harms and cost-effectiveness of alternative extended genotyping and age-based triage strategies under five-yearly primary HPV testing (including the status-quo screening strategy in Norway) for women born in 1998 (ie, age 25 in 2023). We examined 35 strategies that varied alternative groupings of high-risk HPV genotypes ("high-risk" genotypes; "medium-risk" genotypes or "intermediate-risk" genotypes), number and types of HPV included in each group, management of HPV-positive women to direct colposcopy or active surveillance, wait time for re-testing and age at which the HPV triage algorithm switched from less to more intensive strategies. Given the range of benchmarks for severity-specific cost-effectiveness thresholds in Norway, we found that the preferred strategy for vaccinated women aged 25 years in 2023 involved an age-based switch from a less to more intensive follow-up algorithm at age 30 or 35 years with HPV-16/18 genotypes in the "high-risk" group. The two potentially cost-effective strategies could reduce the number of colposcopies compared to current guidelines and simultaneously improve health benefits. Using age to guide primary HPV triage, paired with selective HPV genotype and follow-up time for re-testing, could improve both the cervical cancer program effectiveness and efficiency. With its first human papillomavirus (HPV)-vaccinated cohorts now reaching the cervical cancer screening age, Norway may design strategies to follow up women who test positive on primary HPV testing more efficiently. Here, the authors used a multimodeling approach to evaluate the health benefits, harms and cost-effectiveness of alternative extended genotyping and age-based triage strategies. Using age to guide triage ensures balancing resource use among vaccinated women, who face a lower risk of cervical cancer compared to unvaccinated women. Examining the choice of genotypes and follow-up time for re-testing for each level of triage could improve both program effectiveness and efficiency.image