Economic modelling assessment of cervical cancer screening and HPV vaccination in Brazil

More than 85% of the global burden of cervical cancer occurs in developing countries, where it is the second most common cancer among women. In Brazil alone, a total of 17,500 new cases and 3,300 deaths of cervical cancer are expected in 2012. Despite the investments in cytologybased screening in the country, the reduction of cervical cancer incidence has been less than expected. The aim of this thesis was to investigate the cost-effectiveness of alternative cervical cancer screening and HPV vaccination strategies in Brazil. This was achieved by focusing on three specific objectives: 1) To evaluate the cost-effectiveness of cervical cancer screening strategies for women presenting equivocal cytological results, 2) To evaluate the costeffectiveness of cervical cancer screening strategies for HIV-infected women, 3) To evaluate the cost-effectiveness of HPVvaccination for pre-adolescent women. An additional objective was to review and provide guidance on the use of model calibration methods in economic modelling assessments,as they are particularly important in screening and vaccination studies. The first empirical analysis found that HPV triage for women above 30 years-old presenting equivocal cytology results was likely to be very cost-effective. The second empirical analysis found that to screen HIV-infected women with HPVtesting followed by cytology annually was also likely to be very cost-effective. The third empirical analysis demonstrated that adding the quadrivalent vaccination of pre-adolescent girls to the current efforts to control cervical cancer in Brazil was very cost-effective for most of the scenarios analyzed. The vaccine was even cost saving when considering low coverage and cost of vaccination. This thesis presents findings that will inform cervical cancer screening and HPV vaccination policies in middle-income countries like Brazil and also provides guidance to help improve the standards of model calibration approaches used in cost-effectiveness analysis.