Fig 1.
Decision Tree Diagram, Health States, and Annual Transitions Diagram.
A) Decision tree diagram. The square represents a decision node, where a choice between strategies is made. The circle represents a chance node, capturing probabilistic events such as test outcomes or treatment success. The stacked symbols with arrows denote a Markov node, indicating transitions between health states in a Markov model; B) Health states and annual transition diagram. Solid arrows represent annual transitions between health states. Dashed arrows indicate transitions that occur only after a successful LEEP procedure, which is assumed to be applied in CIN 2 and CIN 3.The model simulates patients through multiple health states, representing high-risk HPV-negative with normal histology (no lesion); HPV-positive 16 or 18 (16/18) or 12 other high-risk genotypes (12 other+) – with normal histology; precancerous condition or HPV-positive with (CIN grade 1, 2, or 3, and invasive cervical cancer (ICC) – in any of its corresponding clinical stages, from stage I to IV. Patients were simulated under both the SoC (PAP-3) and the intervention strategy, enabling a within-subject comparison of clinical and economic outcomes.
Fig 2.
Screening algorithms for the PAP-3, hrHPV-CINtec, and hrHPV-PAP comparators.
In the hrHPV–PAP-5 strategy, colposcopy is recommended for patients testing positive for HPV 16/18, or for 12 other+ when the reflex cytology result is ASC-US or higher. If the reflex cytology is NILM, shortened surveillance is advised. A negative test for high-risk HPV returns women to routine screening, with the next HPV DNA test scheduled in 5 years.
Table 1.
Model Input Base Case Values.
Table 2.
Model Initialization Based on High-Risk HPV types and Histopathological Status.
Table 3.
Incremental Results.
Fig 3.
Probabilistic Sensitivity Analysis Results for Cervical Cancer Screening Strategies.
A) Scatter plot of PSA simulations for the hrHPV-CINtec-5 strategy versus PAP-3; B) Scatter plot for the hrHPV-PAP-5 strategy versus PAP-3; C) Cost-effectiveness acceptability curve (CEAC) corresponding to panel (A); D) CEAC corresponding to panel (B). Dashed vertical lines represent the willingness-to-pay threshold set at one GDP per capita (USD$17.093 according to World Bank).
Fig 4.
One-Way Sensitivity Analysis (OWSA).
A) hrHPV-CINtec-5 strategy versus PAP-3; B) hrHPV-PAP-5 strategy versus PAP-3. Dashed vertical lines represent the willingness-to-pay threshold set at one GDP per capita (USD$17.093 according to World Bank).