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Epidemiology

Vaccination and screening strategies to accelerate cervical cancer elimination in Norway: a model-based analysis

British Journal of Cancer (2024)Cite this article

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Abstract

Background

Experts have proposed an ‘EVEN FASTER’ concept targeting age-groups maintaining circulation of human papillomavirus (HPV). We explored effects of the vaccination component of these proposals compared with cervical cancer (CC) screening-based interventions on age-standardized incidence rate (ASR) and CC elimination (<4 cases/100,000) timing in Norway.

Methods

We used a model-based approach to evaluate HPV vaccination and CC screening scenarios compared with a status-quo scenario reflecting previous vaccination and screening. For cohorts ages 25–30 years, we examined 6 vaccination scenarios that incrementally increased vaccination coverage from current cohort-specific rates. Each vaccination scenario was coupled with three screening strategies that varied screening frequency. Additionally, we included 4 scenarios that alternatively increased screening adherence. Population- and cohort-level outcomes included ASR, lifetime risk of CC, and colposcopy referrals.

Results

Several vaccination strategies coupled with de-intensified screening frequencies lowered ASR, but did not accelerate CC elimination. Alternative strategies that increased screening adherence could both accelerate elimination and improve ASR.

Conclusions

The vaccination component of an ‘EVEN FASTER’ campaign is unlikely to accelerate CC elimination in Norway but may reduce population-level ASR. Alternatively, targeting under- and never-screeners may both eliminate CC faster and lead to greater health benefits compared with vaccination-based interventions we considered.

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Fig. 1
Fig. 2: Age-standardised human papillomavirus (HPV) type 16 prevalence associated with ‘EVEN FASTER’ vaccination-only scenarios in Norway.
Fig. 3

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Data availability

The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.

References

  1. World Health Organization. Accelerating cervical cancer elimination. Report by the Director-General. Nov 30, 2018. [Online] Accessed 25 May 2020. Available at: http://apps.who.int/gb/ebwha/pdf_files/EB144/B144_28-en.pdf.

  2. Bosch FX, Robles C, Díaz M, Arbyn M, Baussano I, Clavel C, et al. HPV-FASTER: broadening the scope for prevention of HPV-related cancer. Nat Rev Clin Oncol. 2016;13:119–32.

    Article  CAS  PubMed  Google Scholar 

  3. Dillner J, Elfström M, Baussano I The EVEN FASTER concept for cervical cancer elimination. www.HPVWorld.com, 182. [Online] Accessed 2 May 2022. Available at: https://www.hpvworld.com/articles/the-even-faster-concept-for-cervical-cancer-elimination/. (2021).

  4. Lehtinen M, Bruni L, Elfström M, Gray P, Logel M, Mariz FC, et al. Scientific approaches toward improving cervical cancer elimination strategies. Int J Cancer. 2024;154:1537–48.

    Article  CAS  PubMed  Google Scholar 

  5. Dillner J, Elfström KM, Baussano I. Prospects for accelerated elimination of cervical cancer. Prev Med. 2021;153:106827.

    Article  PubMed  Google Scholar 

  6. Portnoy A, Pedersen K, Trogstad L, Hansen BT, Feiring B, Laake I, et al. Impact and cost-effectiveness of strategies to accelerate cervical cancer elimination: a model-based analysis. Prevent Med. 2021;144:106276.

    Article  Google Scholar 

  7. Burger EA, Smith MA, Killen J, Sy S, Simms KT, Canfell K, et al. Projected time to elimination of cervical cancer in the USA: a comparative modelling study. Lancet Public Health. 2020;5:e213–22.

    Article  PubMed  PubMed Central  Google Scholar 

  8. Hall MT, Simms KT, Lew JB, Smith MA, Brotherton JM, Saville M, et al. The projected timeframe until cervical cancer elimination in Australia: a modelling study. Lancet Public Health. 2019;4:e19–27.

    Article  PubMed  Google Scholar 

  9. Burger EA, de Kok I, Groene E, Killen J, Canfell K, Kulasingam S, et al. Estimating the natural history of cervical carcinogenesis using simulation models: a CISNET comparative analysis. J Natl Cancer Inst. 2020;112:955–63.

    Article  PubMed  Google Scholar 

  10. Burger EA, Sy S, Nygård M, Kristiansen IS, Kim JJ. Too late to vaccinate? The incremental benefits and cost-effectiveness of a delayed catch-up program using the 4-valent human papillomavirus vaccine in Norway. J Infect Dis. 2015;211:206–15.

    Article  CAS  PubMed  Google Scholar 

  11. Burger EA, Kim JJ, Sy S, Castle PE. Age of acquiring causal Human Papillomavirus (HPV) infections: leveraging simulation models to explore the natural history of HPV-induced cervical cancer. Clin Infect Dis. 2017;65:893–9.

    Article  PubMed  PubMed Central  Google Scholar 

  12. Lozar T, Nagvekar R, Rohrer C, Dube Mandishora RS, Ivanus U, Fitzpatrick MB. Cervical cancer screening postpandemic: self-sampling opportunities to accelerate the elimination of cervical cancer. Int J Women’s Health. 2021;13:841–59.

    Article  Google Scholar 

  13. Pedersen K, Burger EA, Nygård M, Kristiansen IS, Kim JJ. Adapting cervical cancer screening for women vaccinated against human papillomavirus infections: the value of stratifying guidelines. Eur J Cancer. 2018;91:68–75.

    Article  PubMed  PubMed Central  Google Scholar 

  14. Portnoy A, Pedersen K, Nygård M, Trogstad L, Kim JJ, Burger EA. Identifying a single optimal integrated cervical cancer prevention policy in Norway: a cost-effectiveness analysis. Med Decis Mak. 2022;42:795–807.

    Article  Google Scholar 

  15. van Schalkwyk C, Moodley J, Welte A, Johnson LF. Estimated impact of human papillomavirus vaccines on infection burden: the effect of structural assumptions. Vaccine. 2019;37:5460–5.

    Article  PubMed  Google Scholar 

  16. O’Mahony JF, van Rosmalen J, Zauber AG, van Ballegooijen M. Multicohort models in cost-effectiveness analysis: why aggregating estimates over multiple cohorts can hide useful information. Med Decis Mak. 2013;33:407–14.

    Article  Google Scholar 

  17. Nygård M, Nygård S, Falkenthal T. Faster elimination of HPV and cervical cancer in Norway - the time window is open in 2023 and 2024. Cancer Registry of Norway. White Paper. 2023. [Online] Available at: https://www.kreftregisteret.no/globalassets/publikasjoner-og-rapporter/andre-publikasjoner/white-paper_raskere-eliminering-av-hpv-og-livmorhalskreft.pdf.

  18. Garland SM, Stanley MA, Giuliano AR, Moscicki AB, Kaufmann A, Bhatla N, et al. IPVS statement on “Temporary HPV vaccine shortage: Implications globally to achieve equity. Papillomavirus Res. 2020;9:100195.

    Article  PubMed  PubMed Central  Google Scholar 

  19. Portnoy A, Nygård M, Trogstad L, Kim JJ, Burger EA. Impact of delaying effective and cost-effective policy decisions: an example from cervical cancer prevention in Norway. MDM Policy Pract. 2022;7:23814683211071093.

    PubMed  PubMed Central  Google Scholar 

  20. FUTURE II Study Group. Quadrivalent vaccine against human papillomavirus to prevent high-grade cervical lesions. N. Engl J Med. 2007;356:1915–27.

    Article  Google Scholar 

  21. Paavonen J, Naud P, Salmerón J, Wheeler CM, Chow SN, Apter D, et al. Efficacy of human papillomavirus (HPV)-16/18 AS04-adjuvanted vaccine against cervical infection and precancer caused by oncogenic HPV types (PATRICIA): final analysis of a double-blind, randomised study in young women. Lancet. 2009;374:301–14.

    Article  CAS  PubMed  Google Scholar 

  22. Naud PS, Roteli-Martins CM, De Carvalho NS, Teixeira JC, de Borba PC, Sanchez N, et al. Sustained efficacy, immunogenicity, and safety of the HPV-16/18 AS04-adjuvanted vaccine: final analysis of a long-term follow-up study up to 9.4 years post-vaccination. Hum Vaccin Immunother. 2014;10:2147–62.

    Article  PubMed  PubMed Central  Google Scholar 

  23. Kavanagh K, Pollock KG, Potts A, Love J, Cuschieri K, Cubie H, et al. Introduction and sustained high coverage of the HPV bivalent vaccine leads to a reduction in prevalence of HPV 16/18 and closely related HPV types. Br J Cancer. 2014;110:2804–11.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  24. Cancer Registry of Norway. Cervical Cancer Screening Programme. [Online] Last updated: 22 February 2023. Accessed: 28 June 2023. Available at: https://www.kreftregisteret.no/en/screening/cervix/org/.

  25. Pedersen K, Burger EA, Campbell S, Nygård M, Aas E, Lönnberg S. Advancing the evaluation of cervical cancer screening: development and application of a longitudinal adherence metric. Eur J Public Health. 2017;27:1089–94.

    Article  PubMed  Google Scholar 

  26. Andreassen T, Hansen BT, Engesaeter B, Hashim D, Støer NC, Tropé A, et al. Psychological effect of cervical cancer screening when changing primary screening method from cytology to high-risk human papilloma virus testing. Int J Cancer. 2019;145:29–39.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  27. Baussano I, Lazzarato F, Ronco G, Lehtinen M, Dillner J, Franceschi S. Different challenges in eliminating HPV16 compared to other types: a modeling study. J Infect Dis. 2017;216:336–44.

    Article  PubMed  PubMed Central  Google Scholar 

  28. Cancer Registry of Norway. Cancer in Norway 2019 - Cancer incidence, mortality, survival and prevalence in Norway. Oslo: Cancer Registry of Norway, 2020. [Online] Available at: https://www.kreftregisteret.no/globalassets/cancer-in-norway/2019/cin_report.pdf.

  29. United Nations Population Division. World Population Prospects: The 2019 Revision. [Online] Accessed 30 April 2020. Available at: https://esa.un.org/unpd/wpp/. (2019).

  30. Brisson M, Kim JJ, Canfell K, Drolet M, Gingras G, Burger EA, et al. Impact of HPV vaccination and cervical screening on cervical cancer elimination: a comparative modelling analysis in 78 low-income and lower-middle-income countries. Lancet. 2020;395:575–90.

    Article  PubMed  PubMed Central  Google Scholar 

  31. Canfell K, Kim JJ, Brisson M, Keane A, Simms KT, Caruana M, et al. Mortality impact of achieving WHO cervical cancer elimination targets: a comparative modelling analysis in 78 low-income and lower-middle-income countries. Lancet. 2020;395:591–603.

    Article  PubMed  PubMed Central  Google Scholar 

  32. Castellsagué X, Muñoz N, Pitisuttithum P, Ferris D, Monsonego J, Ault K, et al. End-of-study safety, immunogenicity, and efficacy of quadrivalent HPV (types 6, 11, 16, 18) recombinant vaccine in adult women 24-45 years of age. Br J Cancer. 2011;105:28–37.

    Article  PubMed  PubMed Central  Google Scholar 

  33. Szarewski A, Poppe WA, Skinner SR, Wheeler CM, Paavonen J, Naud P, et al. Efficacy of the human papillomavirus (HPV)-16/18 AS04-adjuvanted vaccine in women aged 15-25 years with and without serological evidence of previous exposure to HPV-16/18. Int J Cancer. 2012;131:106–16.

    Article  CAS  PubMed  Google Scholar 

  34. Osei EA. Innovations in healthcare delivery: human papilloma virus self sampling diagnostics and participatory innovations for CCS. Cancer Med. 2023;12:15544–51.

    Article  PubMed  PubMed Central  Google Scholar 

  35. Daponte N, Valasoulis G, Michail G, Magaliou I, Daponte AI, Garas A, et al. HPV-based self-sampling in cervical cancer screening: an updated review of the current evidence in the literature. Cancers. 2023;15:1669.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  36. Burger EA, Sy S, Nygård M, Kim JJ. The cost-effectiveness of cervical self-sampling to improve routine cervical cancer screening: the importance of respondent screening history and compliance. Cancer Epidemiol Biomark Prev. 2017;26:95–103.

    Article  Google Scholar 

  37. Knauss T, Hansen BT, Pedersen K, Aasbø G, Kunst N, Burger EA. The cost-effectiveness of opt-in and send-to-all HPV self-sampling among long-term non-attenders to cervical cancer screening in Norway: the Equalscreen randomized controlled trial. Gynecol Oncol. 2023;168:39–47.

    Article  PubMed  Google Scholar 

  38. Saraiya M, Unger ER, Thompson TD, Lynch CF, Hernandez BY, Lyu CW, et al. US assessment of HPV types in cancers: implications for current and 9-valent HPV vaccines. J Natl Cancer Inst. 2015;107:djv086.

    Article  PubMed  PubMed Central  Google Scholar 

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Acknowledgements

The authors thank Bo T. Hansen, Berit Feiring, Ida Laake, Mari Nygård, Lill Trogstad, Megan A. Smith, and Stephen Sy for their collaboration and support on the previous analysis that this work builds on.

Funding

This study was funded by the Norwegian Cancer Society [grant number 198073; PI: EAB]. The views expressed in this Article are those of the authors and do not necessarily represent the views of the Norwegian Cancer Society.

Author information

Authors and Affiliations

  1. Department of Global Health, Boston University School of Public Health, Boston, MA, USA

    Allison Portnoy

  2. Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, MA, USA

    Allison Portnoy, Jane J. Kim & Emily A. Burger

  3. Department of Health Management and Health Economics, University of Oslo, Oslo, Norway

    Kine Pedersen & Emily A. Burger

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Contributions

AP and EAB conceptualized the study, conducted the data analysis, and drafted the initial manuscript. KP and JJK critically reviewed the analysis and manuscript. All authors approved the final version of the manuscript.

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Correspondence to Allison Portnoy.

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Portnoy, A., Pedersen, K., Kim, J.J. et al. Vaccination and screening strategies to accelerate cervical cancer elimination in Norway: a model-based analysis. Br J Cancer (2024). https://doi.org/10.1038/s41416-024-02682-y

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