Prevention of cervical cancer in Austria – Implementation of HPV testing into the existing screening programme

Research area: Prevention and screening

Duration: April/May 2019 – October 2019
Suggested by: Main Association of Austrian Social Security Institutions
Language: German

Publication: LBI-HTA Project report No. 121: https://eprints.aihta.at/1223/
 

Background:
In Austria, an opportunistic cervical cancer screening programme has been established in 1974, which is based on a traditional cytology testing (Pap-test). However, new developments in the diagnostics of Human Papilloma Virus (HPV) infections require a rethinking of existing cervical cancer screening strategies. Internationally, numerous countries (e.g., USA, Norway, Sweden) have already responded with an adaptation of their screening programmes.

Prior to a possible implementation of an HPV testing strategy into the Austrian setting, potential organisational impacts and logistical consequences have to be defined and estimated. Furthermore, the consideration of accompanying quality control and assurance measures  are crucial.

Aim of the project:
The aim of the project is to generate a decision-support document for the integration of an HPV testing strategy into the existing Austrian cervical cancer screening programme with the main focus on organisational and logistical aspects, as well as on questions of quality assurance.

Research questions:

1. What is the international evidence on the efficacy and cost-effectiveness of cervical cancer screening programmes with an HPV test as part of the screening strategy?
2. According to international evidence-based guidelines, how should an HPV test be integrated into a screening programme (description of suitable examination intervals, possible age groups to be included or excluded, actors involved, critical processes and quality standards)?
3. How are HPV tests implemented in actual practice in pre-selected countries?

(preliminary country selection proposal: a country with a similar healthcare system (Germany), a country with long experience in HPV testing (tba), a country with HPV testing in organised screening (tba), a country with HPV testing as part of an opportunistic screening programme (tba), a country with a low cervical cancer incidence / mortality rate (tba))

4. What is the existing cervical cancer screening strategy in Austria (description of all involved actors and processes including existing quality standards)?
5. Which scenarios arise for Austria with regard to the integration of HPV testing? What are the differences between the defined scenarios in terms of added-benefit and budget impact?
6. What are the organisational and logistical requirements for the implementation of an HPV testing strategy in Austria?

Methods:
The following methods will be used to answer the research questions:

Ad 1) In cooperation with the UMIT -Private Universität für Gesundheitswissenschaften, Medizinische Informatik und Technik - and on the basis of their preliminary work, a summary of recent reviews and meta-analyses on the efficacy and cost-effectiveness of different cervical cancer screening strategies, which include HPV testing, will be generated.

Ad 2) A systematic literature search (possibly based on previous work of the UMIT) on international guidelines for cervical cancer screening programmes in Europe will be performed. In addition, the authors will search manually for guidelines and programmes.

Inclusion criteria for the systematic literature search ad 2) are as follows:

Population	Girls and women taking part in cervical cancer screening programmes
Intervention	Screening programmes for cervical cancer with integrated HPV testing
Control	-
Outcomes	Definition of subgroups Testing intervals Co-testing Involved actors Quality standards Etc.
Study design	Guidelines
Publication period	2009 to 05/2019

Ad 3) A hand search for policy documents in selected countries will be conducted, possibly in the form of an expert survey.

Ad 4) A hand search for existing guidelines, policy documents etc. will be conducted and experts in the field of gynaecology, cytology and pathology will be contacted.

Ad 2-4) After concluding the literature searches and gathering the information, the results will be extracted and summarised.

Ad 5) In cooperation with modelling experts of the UMIT, different scenarios for the implementation of an HPV test in Austria are modelled taking into account the current situation in Austrian and international standards. The different models will be compared in terms of the added benefits and the budget impacts of the different scenarios.

Preliminary proposals for the scenarios: 1) Integration of the HPV test into the existing opportunistic cervical screening system without control (assumption: implementation takes place in the same frequency as Pap smear). 2) Integration of the HPV test into the existing opportunistic screening system according to a defined algorithm (note: billing of the test is linked to this algorithm); 3) Introduction of the HPV test is linked to a transformation of the overall screening strategy based on existing international evidence on efficacy and cost-effectiveness of cervical cancer screening programmes. The final selection of the scenarios will be carried out in coordination with HVB.

Ad 6) An iterative literature search (hand search) and qualitative synthesis of the information to the following questions will be performed:

a) How would the implementation of the HPV test affect current processes and/or pathways of the participants in Austria?
b) Is a special know-how necessary for the quality-assured execution of the HPV testing and what measures are needed to ensure the knowledge transfer among the specialists involved?
c) Are there any concrete communication and cooperation initiatives needed to be set in place?
d) How should the quality assurance and monitoring systems look like?
e) How can access and mobilisation be ensured for those women who, according to questions 1, 2 and 5, are qualified for HPV testing?
f) How does the implementation of the HPV testing change the need for other technologies (e.g., Pap, HPV vaccination, etc.)?
e) How many HPV testing centres would be needed in Austria?

Schedule:

Months	Tasks
April-beginning of June 2019	Scoping, preparation of the project protocol, literature search, selection of literature, hand search, contact with experts, defining Austrian scenarios
Mid-June-July 2019	Data extraction
June-September 2019	Modelling of the different scenarios (UMIT)
August-October 2019	Writing/drafting of report
November 2019	Internal and external review

References:

Ebell M.H., Thai T. N., Royalty K.J.. Cancer screening recommendations: an international comparison of high income countries. Public Health Rev. 2018; 39:7.

Kirnbauer M. Übersicht-Empfehlungen zum Zervixkarzinom-Screening. Hauptverband der österreichischen