Table 3.

Overview of cost-effectiveness studies included in the review

Study	Main conclusions about screening policies in post-vaccination area	Screening changes evaluated
		Cytology/Change in age initiation	Cytology/Change in screening intervals	DNA HPV test (triage or primary test)	Others
Acetta et al. 2010 [38] (Italy)	Findings support changing the Pap screening policy to the use of HPV DNA as a primary test with Pap test triage for both vaccinated and unvaccinated women.	X	X	X
Berkhof et al. 2013 [44] (Slovenia, Poland)	Screening with short intervals of 3 years yield only moderate benefits in term of cancer risk reduction compared to longer screening intervals. Combined vaccination and 6 to 10-yearly HPV (DNA) screening were generally cost-effective.	X	X	X
Burger et al. 2012 [42] (Norway)	Strategies involving a switch to HPV testing for primary screening in older women are expected to be cost-effective compared with current recommendations in Norway. In the primary analysis and regardless of vaccination status, the current cytology-based screening strategy was less effective and more costly (i.e. strongly dominated) than proposed strategies that involve switching to primary HPV testing at 34 years of age.	X		X
Coupe, de Melker et al. 2009 [35] (Netherlands)	Screening 5 times with HPV DNA (D 11,133/QALY) or 7 times with cytology (D 17,627/QALY) were scenarios with comparable costs and effects and incremental cost-effectiveness ratios below the threshold in The Netherlands (D 20,000 per QALY).	X	X	X
Coupe, van Ginkel et al. 2009 [36] (Netherlands)	The influence of a decreasing screening compliance in vaccinated women (70% instead of 80%) has only a limited effect on the cost-effectiveness of HPV16/18 vaccination.				Changes in compliance of screening
Coupe et al. 2012 [37] (Netherlands)	In a cohort of HPV16/18 vaccinated women, four rounds of HPV DNA screening is cost-effective. One screen during lifetime remains cost-effective in addition to broad spectrum vaccination offering protection against many high-risk HPV types. In addition to broad spectrum vaccination, one screen during lifetime was cost-effective up to an 11-valent vaccine.	X	X	X
Demarteau et al. 2011 [41] (France)	The change in screening interval was only assessed in a sensitivity analysis and had only a small effect on the ICER.		X
Diaz et al. 2010 [43] (Spain)	After the introduction of HPV vaccination, screening will need to continue, and strategies that incorporated HPV testing are more effective and cost-effective than those with cytology alone. For vaccinated girls, 5-year organised cytology with HPV testing as triage from ages 30 to 65 costs 24,350€ per year of life saved (YLS), assuming life-long vaccine immunity against HPV-16/18 by 3 doses with 90% coverage. If high vaccination coverage among pre-adolescent girls is achieved, organized cytology screening with HPV triage starting at ages 30 to at least 65 every 4– 5 years represents the best balance between costs and benefits.	X	X	X
Goldie et al. 2004 [29] (US)	If one imposed a minimum threshold (e.g. the reduction in cervical cancer risk over a woman’s lifetime must be at least equivalent to or greater than that in our current screening program), then the most effective strategy with an incremental cost-effectiveness ratio of less than $60,000 per QALY is one combining vaccination at age 12 with triennial conventional cytological screening beginning at age 25 years.	X	X		Liquid-based cytology is assessed
Goldhaber-Fiebert et al. 2008 [33] (US)	For both vaccinated and unvaccinated women, age-based screening by use of HPV DNA testing as a triage test for equivocal results in younger women and as a primary screening test in older women is expected to be more cost-effective than current screening recommendations.	X	X	X (HPV primary & triage)	Different screening strategy for younger and older women
Kim et al. 2008 [31] (US)	The cost-effectiveness ratios of vaccination strategies were more favourable if screening was delayed and performed at less frequent screening intervals and with more sensitive tests. The analyses concluded that cytology starting at age 25 every 3 years (with HPV DNA testing as triage), with a switch to cytology combined with HPV DNA testing starting at age 35 was similar to the base case in term of cost-effectiveness. (Base-case analysis assumes current cytology screening beginning at an average age 20–53% screened annually, 17% every 2 years, 11 every 3 years, 14% every 5 years and 5% never screened).	X	X	X
Kim et al. 2009 [30] (US)	This study confirmed the results of Kim et al. 2008. Vaccinating preadolescent girls with cytology (HPV test for triage) every 3 years starting at age 25 and a switch to a combined cytology at age 35 had a cost-effectiveness ratio below $50,000/QALY.	X	X	X
Kim, Ortendahl et al. 2009 [34] (US)	This US study assessed the cost-effectiveness of different strategies that combined HPV vaccination given to women older than 30 years in with different screening policies and concluded that none of the strategies were not cost-effective.		X	X
Kulasingam et al. 2003 [27] (US)	Screening with pap tests may be delayed to a later age than currently recommended when an HPV16-18 vaccine has been given. Vaccination plus biennial screening delayed until age 24 years had the most attractive cost-effectiveness ratio ($44,889) compared with screening only beginning at age 18 years and conducted every 3 years.	X	X
Kulasingam et al. 2007 [39] (Australia)	Vaccination of young girls and changing the screening interval and or/age of first screening would reduce costs considerably and would still be more effective than the current screening program at reducing cancer incidence and mortality.	X	X
Sanders et al. 2003 [28] (US)	The availability of the vaccine may justify less frequent pap tests.		X
Taira et al. 2004 [32] (US)	With a vaccine program in place, physicians must be comfortable moving to less frequent screening.		X
Tully et al. 2012 [40] (Canada)	With a vaccine program in place for girl’s aged 12 and a coverage rate of 80%, delaying initial screening until age 21 or 25 saves costs but may cause small increases in SCC incidence and life-years lost. However, delaying the initial age of screening combined with catch-up immunization (at age 21 or 25) is predicted to save costs and reduce cancer incidence, but reduce QALYs.	X	X

X indicates inclusion in the respective study