Academic journal article Bulletin of the World Health Organization

Cost, Effectiveness of Oral Cancer Screening: Results from a Cluster Randomized Controlled Trial in India/Rapport Cout-Efficacite Du Depistage Du Cancer Buccal: Resultats D'un Essai Controle Randomise En Grappes En Inde/Costoeficacia del Cribado del Cancer De Boca: Resultados De Un Ensayo Aleatorizado Controlado Por Conglomerados En la India

Academic journal article Bulletin of the World Health Organization

Cost, Effectiveness of Oral Cancer Screening: Results from a Cluster Randomized Controlled Trial in India/Rapport Cout-Efficacite Du Depistage Du Cancer Buccal: Resultats D'un Essai Controle Randomise En Grappes En Inde/Costoeficacia del Cribado del Cancer De Boca: Resultados De Un Ensayo Aleatorizado Controlado Por Conglomerados En la India

Article excerpt

Une traduction en francais de ce resume figure 2, la fin del article. Al final de/articulo se facilita una traduccion al espanol

Introduction

Oral cancer is a major health problem in certain parts of the world. Globally, there are around 270 000 new cases annually and 145 000 deaths, of which two-thirds occur in developing countries. (1) The Indian subcontinent accounts for one-third of the world burden. Oral cancer is the most common form Of cancer and accounts for much cancer-related death among men in India. The main risk factors for developing oral cancer are tobacco and alcohol use. (2,3) The detection of small, early-stage oral cancer has been shown to lead to significantly reduced mortality and morbidity. (4)

Low- and middle-income countries have limited healthcare resources available for cancer screening and it is therefore critical that costs and benefits are assessed and that the most cost-effective approach is identified. The cost-effectiveness analyses of oral cancer screening performed to date have provided estimates for high-income countries that are not generalizable to settings where resources are limited. (5,6) In addition, these studies have used decision-analysis models in which there was considerable uncertainty in parameter values. For instance, no reliable data are available on the malignant transformation rate or on disease progression. The results obtained using these models may, therefore, not be accurate and many authors acknowledge the need for additional clinical studies to provide better estimates of the parameters used. (6)

In this study, the cost-effectiveness of visual inspection in oral cancer screening in a limited-resource setting was determined using data from a randomized controlled trial performed in a number of population clusters in the Trivandrum district of Kerala in southern India. The screening trial was initiated in 1996 and results for the 9-year period up to 2004 have been published previously. (7) Of the 13 clusters (i.e. panchayaths or municipal administrative units) included in the study, seven were randomly allocated to take part in three rounds of oral visual inspection by trained health-care workers, while six received standard care and educational messages and served as a control arm. All healthy individuals aged 35 years and older were eligible for inclusion in the study. Visual screening was performed by university graduates in non-medical subjects. These individuals received training on how to perform oral visual inspections, how to identify lesions that could be precancerous and how to detect oral cancer. A previous study had shown that the sensitivity and specificity of oral visual inspection by health-care workers were 94.3% and 99.3%, respectively, and that there was a very high level of agreement between the findings of healthcare workers and physicians. (8)

Results for the time after the initial 9-year trial period (i.e. 1996-2004) are not yet available and we have, therefore, limited the cost-effectiveness analysis to the period covered by the trial. The results of comparisons between intervention and control arms are reported in terms of the number of oral cancers detected and the number of life-years saved by screening. We estimated the costs of the screening programme (for example, for recruiting health-care workers and screening individuals), of diagnosing and treating the oral cancers detected, and of research activities. In addition, we estimated the cost from a societal perspective by including the cost to the patient of the time spent undergoing diagnosis and treatment. It is important that social costs are assessed, since the true burden of screening goes beyond that associated with the healthcare system and should include, for instance, loss of income during the time spent undergoing screening.

Methods

The design of the cluster randomized controlled trial, the visual screening method used, compliance with screening, and cancer detection and mortality rates have been described in detail elsewhere. …

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