Cost-effectiveness of cervical cancer screening with primary HPV testing for unvaccinated women in Sweden

Background: Sweden revised their cervical cancer screening program in 2017 to include cytology-based screening for women aged 23–29 years and primary human papillomavirus (HPV) testing for women aged 30–64 years; however, alternative strategies may be preferred. To inform cervical cancer prevention policies for unvaccinated women, we evaluated the cost-effectiveness of alternative screening strategies, including the current Swedish guidelines. Methods: We adapted a mathematical simulation model of HPV and cervical cancer to the Swedish context using primary epidemiologic data. We compared the cost-effectiveness of alternative screening strategies that varied by the age to start screening, the age to switch from cytology to HPV testing, HPV strategies not preceded by cytology, screening frequency, and management of HPV-positive/cytology-negative women. Results: We found that the current Swedish guidelines were more costly and less effective than alternative primary HPV-based strategies. All cost-efficient strategies involved primary HPV testing not preceded by cytology for younger women. Given a cost-effectiveness threshold of €85,619 per quality-adjusted life year gained, the optimal strategy involved 5-yearly primary HPV-based screening for women aged 23–50 years and 10-yearly HPV-based screening for women older than age 50 years. Conclusions: Primary screening based on HPV alone may be considered for unvaccinated women for those countries with similar HPV burdens.