Screening for Anal Cancer among Men Who Have Sex with Men with HIV: Benefits, Harms, and Cost-Effectiveness Analyses

Abstract

Background: Following the success of the ANCHOR (Anal Cancer-HSIL Outcomes Research) trial, the U.S. Department of Health and Human Services recommends anal cancer screening for high-risk persons, particularly men who have sex with men (MSM) with HIV. Objective: To quantify the cost-effectiveness and benefits versus harms of different anal cancer screening strategies. Design: Microsimulation model. Data Sources: The ANCHOR trial and published literature. Target Population:MSM with HIV. Time Horizon: Lifetime. Perspective: Health care sector. Intervention: Cytology alone and human papillomavirus (HPV) testing (high-risk HPV [hrHPV], HPV16/18, and HPV16), co-testing, and triage options; ages at which to begin screening (≥35, ≥40, or ≥45 years); screening interval (annual, biennial, triennial, or quadrennial). Outcome Measures: Incremental cost-effectiveness ratios (ICERs) of dollars per quality-adjusted life-year (QALY) and the tradeoff of harms (high-resolution anoscopies [HRAs]) versus benefits (cancer cases averted and life-years gained). Results of Base-Case Analysis: Screening initiation at age 35 years or older using cytology dominated initiation at ages 40 and 45 years or older, with ICERs ranging from $87 731 for a quadrennial interval to $350 100 for an annual interval. In the comparative analysis, the following unique strategies were on the cost-effectiveness frontier: quadrennial HPV16, quadrennial HPV16/18, triennial HPV16/18, triennial hrHPV, biennial HPV16/18, biennial hrHPV, annual cytology with hrHPV triage, and annual hrHPV; ICERs ranged from $81 341 to $2 510 847. In the harm-to-benefit analysis, triage options offered the most efficient HRA use. Results of Sensitivity Analysis: ICERs decreased for newly eligible persons. For 35-year-old newly eligible MSM with HIV, ICERs for cytology ranged from $70 750 (quadrennial) to $223 895 (annual). Limitation: Findings are not generalizable to other high-risk populations. Conclusion: Anal cancer screening among MSM with HIV aged 35 years or older is cost-effective, but valuebased prioritization of strategies is needed to optimize screening use.