Cost-effectiveness of primary HPV screening for cervical cancer in Germany--a decision analysis.

OBJECTIVES: To systematically evaluate the long-term effectiveness and cost-effectiveness of HPV-based primary cervical cancer screening in the German health care context using a decision-analysis approach. METHODS: A Markov-model for HPV-infection and cervical cancer was developed for the German health care context, and applied to evaluate various screening strategies that differ by screening interval and test algorithms, including HPV-testing alone or in combination with cytology. German clinical, epidemiological, and economic data, and test accuracy data from international meta-analyses were used. Outcomes predicted included the reduction in cervical cancer cases and deaths, life expectancy and discounted incremental cost-effectiveness ratios (ICER). The analysis was performed from the perspective of the healthcare system adopting a 3% annual discount rate for costs and outcomes. Extensive sensitivity analyses were performed. RESULTS: HPV-based screening is more effective than cytology alone. It results in a 71-97% reduction in cervical cancer cases as compared to 53-93% for cytology alone. The ICER range from 2600 Euro/LYG (cytology, 5-year-interval) to 155,500 Euro/LYG (annual HPV-testing starting at age 30 years, cytology age 20-29 years). Annual cytology alone, the current recommended screening strategy in Germany, is dominated by HPV-strategies. Increasing the age at screening initiation from 20 to 25 years does not result in a relevant loss in effectiveness but results in lower costs. CONCLUSIONS: Based on our analyses, HPV-based cervical cancer screening is more effective than cytology alone and could be cost-effective if performed at intervals of two years or longer. In the German context, an optimal screening strategy may be biennial HPV screening starting at age 30 years preceded by biennial cytology for women aged 25-29 years. Longer screening intervals may be considered in low-risk women with good screening adherence and in populations with low HPV-incidence.

Diagnostic nuclear medicine procedures in Germany between 1996 and 2002: application frequencies and collective effective doses.

AIM: Man-made radiation exposure to the German population predominantly results from the medical use of ionizing radiation. It was therefore the aim of the present study, to provide public health information concerning diagnostic nuclear medicine procedures carried out in Germany between 1996 and 2002. MATERIAL AND METHODS: Application frequencies for 10 groups of procedures were estimated from official reimbursement data provided by the German health insurance companies. Mean effective doses for these examinations were estimated from data provided by 14 clinics and 10 practices concerning the radiopharmaceuticals in use and the activities administered. RESULTS: During the period 1996-2002, a total of (3.83 +/- 0.31) million nuclear medicine procedures were performed in average per year, which corresponds to a mean annual application frequency of approximately 47 examinations per 1 000 inhabitants. More than 90% of the examinations were scintigraphies of the thyroid (37%), skeleton (25%), myocardium (13%), lungs (8%) and kidneys (8%). The averaged collective effective dose was (10.2 +/- 1.4) . 10(3) mSv per year, which corresponds to a mean annual per caput effective dose of about (0.12 +/- 0.02) mSv. Three types of procedures were responsible for about 80% of the total collective effective dose: scintigraphies of the myocardium (36%), skeleton (33%) and thyroid (10%). Averaged over all procedures carried-out, the mean effective dose per examination was (2.7 +/- 0.8) mSv. CONCLUSION: The average effective dose per inhabitant and year caused by nuclear medicine examinations is markedly lower than that resulting from medical X-ray procedures (0.12 vs. 1.8 mSv). Reduction of patient exposure may be achieved, for example, by replacing (201)Tl-labeled radiopharmaceuticals by (99m)Tc-labeled compounds.

[Radiation exposure of patients undergoing nuclear medicine procedures in Germany between 1996 and 2000. Multicenter evaluation of age and gender-specific patient data]. / Strahlenbelastung durch nuklearmedizinische Untersuchungen in Deutschland 1996 bis 2000: Multicenter-Studie zur Evaluation altersund geschlechtsbezogener Patientendaten.

UNLABELLED: The aim of this study was to estimate both the frequency and effective dose of nuclear medicine procedures performed in Germany between 1996 and 2000 for different subgroups of patients. METHODS: Electronically archived data from 14 hospitals and 10 private practices were restored and statistically analyzed. The effective dose per examination was calculated according to ICRP publication 80 using the tissue weighting factors given in ICRP publication 60. Based on the data collected, statistical parameters were computed to characterize the frequency and effective dose of the various nuclear medicine procedures. RESULTS: In total, 604,771 nuclear medicine procedures performed in 433,709 patients were analyzed. On average, 1.4 examinations were carried out per patient and year. The median effective dose was 1.7 [5.-95. percentile; mean: 0.4-8.5; 2.9] mSv per examination and 2.3 [0.5-11.2; 3.5] mSv per patient. Interestingly, the mean effective dose per examination, but not the number of examinations per year increased with the age of the patients. Most frequent were examinations of the thyroid (36.7%), the skeleton (27.1%) and the cardiovascular system (11.1%), which were associated with a median effective dose of 0.5 [0.5-1.1; 0.7] mSv, 3.4 [2.9-5.1; 3.6] mSv and 7.3 [3.2-21.0; 9.5] mSv, respectively. Over the five-year period examined, the total annual number of PET procedures (222.3%) as well as of examinations of thyroid (24.5%), skeleton (17.9%), and the cardiovascular system (14.9%) increased markedly, whereas a decrease was observed for brain (-39.3%), lung (-20.2%) and renal (-15.0%) scans. CONCLUSION: The age- and gender-specific data presented in this study provide detailed public health information on both the current status and recent trends in the practice of diagnostic nuclear medicine examinations.

[Acquisition of age- and sex-dependent patient data for the calculation of annual radiation exposure in nuclear medicine: a German pilot study]. / Erfassung alters- und geschelechtsbezogener Daten nuklearmedizinischer Untersuchungen zur Berechnung der jährlichen Strahlenexposition in der BRD: eine Piltostudie.

AIM: A pilot study for estimation of radiation exposure due to diagnostic procedures in nuclear medicine using routine data of hospitals and practices in Germany. METHODS: Hospitals and practices willing to participate in the study supplied data of one year (1997), containing information on patients' identification number, age, sex, type of diagnostic procedure, radiopharmaceutical, administered activity, type of health insurance (private/public), inpatient/outpatient status, and so-called Leistungsziffer, which describes the type of medical performances in Germany. The effective dose per examination was calculated according to ICRP 80. Mean, standard deviation, median, 5th and 95th percentiles of the effective dose were calculated, stratified by type of organ system and also by sex and age, including patients of > or = 18 years. RESULTS: 82,039 examinations from patients of 9 hospitals and practices were analyzed. The median (5-95(th) percentiles) of the effective dose per examination for all patients was 2.9 mSv (0.4-8.5 mSv); 1.2 examinations per patient and year were performed on average. The three most frequent examinations were bone scans (median 3.4 mSv; 2.9-5.1), thyroid (0.9 mSv; 0.4-2.2) and cardiovascular studies (7.3 mSv; 3.8-20.2). The median effective dose for 18 to 40 years old women was 1.0 mSv (0.4-5.8), for women between 41 and 65 years 2.2 mSv (0.4-7.3) and for women older than 65 years 2.4 mSv (0.5-7.6). The corresponding values for men were 2.6 mSv (0.3-7.6); 3.3 mSv (0.4-9.1), and 3.4 mSv (0.5-8.8). CONCLUSION: It was possible to gain an accurate determination of radiation exposure of diagnostic procedures in nuclear medicine by routine data.

Thyroid cancer after diagnostic administration of iodine-131 in childhood.

Hahn, K., Schnell-Inderst, P., Grosche, B. and Holm, L-E. Thyroid Cancer after Diagnostic Administration of Iodine-131 in Childhood. Radiat. Res. 156, 61-70 (2001). To determine the carcinogenic effects of diagnostic amounts of (131)I on the juvenile thyroid gland, a multicenter retrospective cohort study was conducted on 4,973 subjects who either had been referred for diagnostic tests using uptake of (131)I (n = 2,262) or had had a diagnostic procedure on the thyroid without (131)I (n = 2,711) before the age of 18 years. Follow-up examinations were conducted after a mean period of 20 years after the first examination in 35% of the exposed subjects (n = 789) and in 41% of the nonexposed subjects (n = 1,118). Iodine-131 dosimetry of the thyroid was carried out according to ICRP Report No 53, and the median thyroid dose was 1.0 Gy. In the exposed group, two thyroid cancers were found during 16,500 person-years, compared to three cancers in the nonexposed group during 21,000 person-years. The relative risk for the exposed group was 0.86 (95% CI: 0.14-5.13). The study did not demonstrate an increased risk for thyroid cancer after administration of (131)I in childhood.