Study: Dutch cancer screening model more cost-effective than U.S.

U.S. cervical cancer screening services are not as cost-effective as the centralized system in The Netherlands, with U.S. women receiving three to four times more screenings while mortality rates in the two countries remain similar, according to research published in the March issue of the Milbank Quarterly.

Researchers with the National Cancer Institute (NCI) in Bethesda, Md., and the Erasmus MC University Medical Center in Rotterdam, The Netherlands, chose to focus on cervical cancer screening, which accounts for a small fraction of overall healthcare spending, because it represents broader preventive health services.

“Preventive medicine is seen as being cost-effective compared to the costs sustained through illness,” Martin L. Brown, PhD, a study author from the NCI, said in a statement. “However, practical cost saving depends on how the preventive services are implemented.”

The authors used national cancer incidence and mortality data from both the U.S. and The Netherlands to estimate the number of Pap smears and cervical cancer mortality rates. Over a period of three decades, three to four times more Pap smears per woman were conducted in the U.S. than in The Netherlands, while both countries’ mortality trends were similar.

The two countries had comparable five-year screening coverage rates of 80 to 90 percent for women aged 30 to 64. The big difference between the two nations came in coverage rates for women outside this age group. In The Netherlands, screening is limited to women aged 30 to 60, so screening rates for younger and older women were much higher in the U.S.

In The Netherlands, the Ministry of Health, after being advised by the Health Council of The Netherlands, has final responsibility for population-based screening programs, according to the study authors. As a result of cost-effectiveness studies, The Netherlands limited its cervical cancer screening program and the Ministry of Health decided to no longer reimburse preventive smears performed outside the regular screening schedule. The result was a 75 percent drop in the number of smears for women younger than 30, according to Brown et al.

This contrasts with the U.S., where action to reduce the number of unnecessary screens has been slower. While The Netherlands has regional plans that exert more direct control over practice, the authors noted that practice in the U.S. is determined more by the individual preferences of physicians who are influenced by society guidelines.

For both the U.S. and The Netherlands, the “initial choice” of policy had a strong, inertia-like effect on subsequent policy decisions, but the public health approach of The Netherlands made evolution towards an efficient policy more likely, according to the authors.

“While the comparison of the two countries’ screening intensity and cervical cancer mortality trends does not, by itself, provide causal evidence, the data are nevertheless consistent with the historical evidence that the decentralized and nonintegrated approach to cervical cancer screening in the United States produces substantial clinical waste compared with the centralized, integrated, and organized system of The Netherlands,” wrote the authors.

Brown et al also suggested that cross-national studies of healthcare interventions can offer perspectives not provided by single country studies. “The newly established U.S. Patient Centered Outcome Research Institute therefore should consider cross-country studies eligible for sponsoring and funding.”