°“√ª√–‡¡‘π°“√§—¥°√Õß¡–‡√Áߪ“°¡¥≈Ÿ°√–¥—∫ª√–™“°√
„πª√–‡∑»‰∑¬¥â«¬·∫∫®”≈Õß∑“߇»√…∞»“ μ√å
π—¬π“ ª√–¥‘…∞å ‘∑∏‘°√
*,***‚§√ß°“√ª√–‡¡‘π‡∑§‚π‚≈¬’·≈–π‚¬∫“¬¥â“π ÿ¢¿“æ
** ”π—°‚√§‡Õ¥ å «—≥‚√§ ·≈–‚√§μ‘¥μàÕ∑“ß‡æ» —¡æ—π∏å °√¡§«∫§ÿ¡‚√§ °√–∑√«ß “∏“√≥ ÿ¢
∫∑§—¥¬àÕ ¡–‡√Áߪ“°¡¥≈Ÿ°°àÕ„À⇰‘¥§«“¡ Ÿ≠‡ ’¬„π μ√’‰∑¬ ¿“√°‘®∑’Ë∑â“∑“¬ºŸâ∫√‘À“√ §◊Õ °“√®—¥ √√∑√—欓°√∑’Ë¡’®”°—¥„Àâ
‡°‘¥ª√–‚¬™πå Ÿß ÿ¥„π°“√ªÑÕß°—π·≈–§«∫§ÿ¡‚√§ °“√»÷°…“¡’«—μ∂ÿª√– ߧå‡æ◊ËÕª√–‡¡‘𧫓¡§ÿâ¡§à“¢Õß¡“μ√°“√ªí®®ÿ∫—π
§◊Õ °“√§—¥°√Õß μ√’Õ“¬ÿ 30 - 60 ªï ∑ÿ° 5 ªï ‡ª√’¬∫‡∑’¬∫°—∫∑“߇≈◊Õ°Õ◊Ëπ ‰¥â·°à °“√¢¬“¬‡ªÑ“À¡“¬„Àâ§√Õ∫§≈ÿ¡ μ√’
Õ“¬ÿπâÕ¬°«à“ 30 ªï ·≈–‡æ‘Ë¡§«“¡∂’ˇªìπ∑ÿ° 3 ·≈– 1 ªï °“√»÷°…“ª√—∫ª√ÿß·∫∫®”≈Õß Markov ∑’Ëæ—≤π“„πªï 2550 μâπ∑ÿπ„™â¡ÿ¡¡Õß∑“ß —ߧ¡ ‚¥¬ª√—∫§à“‡ªìπªï 2555 ºà“π¥—™π’√“§“ºŸâ∫√‘‚¿§®“° ”π—°¥—™π’‡»√…∞°‘®°“√§â“ °√–∑√«ßæ“≥‘™¬å
·≈–ª√—∫§à“Õ√√∂ª√–‚¬™πå¢Õß¡–‡√Áߪ“°¡¥≈Ÿ°ºà“π ¡°“√¢Õߪ√–™“°√‰∑¬ °“√§—¥°√Õß¡–‡√Áߪ“°¡¥≈Ÿ°‡ªìπ°“√
≈ß∑ÿπ∑’˧ÿâ¡§à“‡¡◊ËÕ‡∑’¬∫°—∫°“√‰¡à§—¥°√Õß ¡“μ√°“√ªí®®ÿ∫—π ‡¡◊ËÕ¥”‡π‘π°“√¿“¬„μâÕ—μ√“§—¥°√Õß√âÕ¬≈– 80 ¡’ª√– ‘∑∏‘¿“æ Ÿß
™à«¬≈¥Õÿ∫—μ‘°“√≥å·≈–Õ—μ√“°“√‡ ’¬™’«‘μ∂÷ß√âÕ¬≈– 40 ∑“߇≈◊Õ°∑’Ë¥’∑’Ë ÿ¥·≈–§«√æ‘®“√≥“ À“°μâÕß°“√¢¬“¬°“√§—¥°√Õß
§◊Õ ‡æ‘Ë¡§«“¡∂’Ë°“√§—¥°√Õß®“°∑ÿ° 5 ªï‡ªìπ∑ÿ° 3 ªï ‚¥¬§ß°≈ÿà¡Õ“¬ÿ‡¥‘¡®–™à«¬≈¥Õÿ∫—μ‘°“√≥åÕ’°ªï≈– 900 √“¬ ·≈–
ªÑÕß°—π°“√‡ ’¬™’«‘μªï≈– 450 √“¬ ≈¥μâπ∑ÿπ°“√√—°…“¡–‡√Áߪ“°¡¥≈Ÿ°‰¥âªï≈– 1,200 ≈â“π∫“∑ §‘¥‡ªìπÕ—μ√“ à«πμâπ∑ÿπ ª√– ‘∑∏‘º≈ à«π‡æ‘Ë¡ -73,300 ∫“∑μàÕªï ÿ¢¿“«– ·μà®”‡ªìπμâÕßæ—≤π“π—°‡´≈≈å«‘∑¬“‡æ‘Ë¡Õ’°Õ¬à“ßπâÕ¬ 180 §π §‘¥‡ªìπ
√âÕ¬≈– 62 ¢Õß°”≈—ߧπ„πªí®®ÿ∫—π °“√§—¥°√Õß¡–‡√Áߪ“°¡¥≈Ÿ°„πªí®®ÿ∫—π∑’Ë„Àâ μ√’Õ“¬ÿ 30 - 60 ªï √—∫∫√‘°“√§—¥°√Õß ¡Ë”‡ ¡Õ∑ÿ° 5 ªï ‡ªìπ¡“μ√°“√∑’˧ÿâ¡§à“ ‡À¡“– ¡ ·≈–ªØ‘∫—쑉¥â ·μ৫√§«∫§ÿ¡ª√– ‘∑∏‘¿“æ·≈–§ÿ≥¿“æ¢Õß°“√
¥”‡π‘πß“π„Àâ∫√√≈ÿ‡ªÑ“À¡“¬Õ—μ√“§—¥°√Õß„πª√–™“°√∑’Ëμ—È߉«â√âÕ¬≈– 80 à«π°“√‡æ‘Ë¡§«“¡∂’Ë„π°“√§—¥°√Õ߇ªìπ∑ÿ° 3 ªï
∂÷ß·¡â®–¡’§«“¡§ÿâ¡§à“·≈–‰¥âª√–‚¬™πå‡æ‘Ë¡ ·μ৫√«“ß·ºπ¥â“π∫ÿ§≈“°√·≈–√–∫∫„Àâæ√âÕ¡
§” ”§—≠: ¡–‡√Áߪ“°¡¥≈Ÿ°, §—¥°√Õß√–¥—∫ª√–™“°√, ·∫∫®”≈Õß¡“√å§Õø, μâπ∑ÿπÕ√√∂ª√–‚¬™πå
Abstract Cervical Cancer Screening In Thailand: A Model-Based Economic Evaluation Naiyana Praditsitthikorn*,**
*Health Intervention and Technology Assessment Program (HITAP), Ministry of Public Health, **Bureau of AIDS TB and STIs, Department of Disease Control, Ministry of Public Health
As cervical cancer is the second most common cancer in Thai women, it is important for policy makers to effectively implement the screening program. The aim of this study was to assess the incremen- tal cost-effectiveness of the current 5-yearly screening practice for all women aged 30-60 years, compared with the alternative options that differ in the screening interval and target age groups. The study adopted a Markov model conducted in 2007 under the Thai healthcare setting. All costs were estimated under societal perspective and converted to the year 2012 values using the Thai consumer price index. Utility score was calculated based on the Thai scoring algorithm. We found that screening cervical cancer in Thai
¿Ÿ¡‘À≈—ß·≈–‡Àμÿº≈
–‡√Áߪ“°¡¥≈Ÿ°‡ªìπ¡–‡√Áß∑’Ëæ∫¡“°‡ªìπÕ—π¥—∫ Õß„π μ√’‰∑¬ √“¬ß“π≈à“ ÿ¥¢Õß ∂“∫—π¡–‡√Áß·Ààß™“μ‘· ¥ß Õÿ∫—μ‘°“√≥å„πªï 2548 ‡∑à“°—∫ 17.7 μàÕ· πª√–™“°√À≠‘ß(1)
„πÕ¥’μ‡¡◊ËÕªï 2542 Õÿ∫—μ‘°“√≥å Ÿß∂÷ß 24.7 μàÕ· πª√–™“°√
À≠‘ß ®÷ß∂◊Õ«à“¡“°∑’Ë ÿ¥„π∫√√¥“¡–‡√ÁߢÕ߇æ»À≠‘ß(2) ªí®®ÿ∫—π ª√–‡∑»‰∑¬¡’°“√μ√«®§—¥°√Õß¡–‡√Áߪ“°¡¥≈Ÿ° 2 «‘∏’ «‘∏’·√°
§◊Õ °“√μ√«®¥â«¬«‘∏’‡´≈≈å«‘∑¬“ À√◊Õ·ªª ‡¡’¬√å (Pap smear)
´÷Ëß„™â·æ√àÀ≈“¬∑—Ë«‚≈°°«à“ 60 ªï À≈—°°“√§◊Õ„™âÕÿª°√≥凰Á∫
μ—«Õ¬à“߇´≈≈媓°¡¥≈Ÿ° ªÑ“¬„ à ‰≈¥å·≈– àßμ√«® ‡®â“Àπâ“∑’Ë Õà“π·≈–·®âߺ≈°≈—∫¡“¬—ßÀπ૬ªÑ“¬‡°Á∫μ—«Õ¬à“ß ‡æ◊ËÕμ‘¥μ“¡
ºŸâ¡’º≈º‘¥ª°μ‘¡“μ√«®¬◊π¬—π·≈–√—∫°“√√—°…“ «‘∏’∑’Ë Õß §◊Õ
°“√μ√«®‚¥¬°“√™‚≈¡πÈ” â¡ “¬™Ÿ À√◊Õ«’‰Õ‡Õ (visual inspec- tion with acetic acid; VIA) ‡√‘Ë¡„™â„πª√–‡∑»‰∑¬μ—Èß·μàªï 2543 ‡ªìπ«‘∏’„™âπÈ” â¡ “¬™Ÿ‡®◊Õ®“ß (3-5% solution of acetic acid) ™‚≈¡ª“°¡¥≈Ÿ°„Àâ∑—Ë« ‡´≈≈å∑’Ë¡’§«“¡º‘¥ª°μ‘®–‡ª≈’ˬπ
‡ªìπ ’¢“«À√◊Õ acetowhite ‡®â“Àπâ“∑’Ë∑’˺à“π°“√Õ∫√¡®–√—°…“
¥â«¬°“√®’ȇ¬Áπ (cryotherapy) ∑—π∑’
°“√¥”‡π‘πß“π§«∫§ÿ¡·≈–ªÑÕß°—π¡–‡√Áߪ“°¡¥≈Ÿ°„π ª√–‡∑»‰∑¬™à«ß°àÕπªï 2548 ¬—߉¡à¥’‡∑à“∑’˧«√ ‡ÀÁπ‰¥â®“°
Õ—μ√“°“√§—¥°√Õß√–¥—∫ª√–™“°√¢Õß°≈ÿࡇªÑ“À¡“¬Õ“¬ÿ 35-60 ªïμË”°«à“√âÕ¬≈– 20(3) μàÕ¡“°√–∑√«ß “∏“√≥ ÿ¢ ‚¥¬ ∂“∫—π
¡–‡√Áß·Ààß™“μ‘ √à«¡°—∫°√¡Õπ“¡—¬ ·≈– ”π—°ß“πÀ≈—°ª√–°—π ÿ¢¿“æ·Ààß™“μ‘ ‡√‘Ë¡‚§√ß°“√§—¥°√Õß¡–‡√Áߪ“°¡¥≈Ÿ° 75
®—ßÀ«—¥ √–¬–‡«≈“μ—Èß·μàªï 2548-2552 ‚¥¬„Àâ μ√’∑’Ë¡’Õ“¬ÿ 35, 40, 45, 50, 55 ·≈– 60 ªï √—∫∫√‘°“√μ√«®§—¥°√Õߥ⫬«‘∏’
·ªª ‡¡’¬√å„π∑ÿ°®—ßÀ«—¥∑—Ë«ª√–‡∑» πÕ°®“°π’È ∂“π欓∫“≈
√–¥—∫ª∞¡¿Ÿ¡‘„π 15 ®—ßÀ«—¥∑’Ëæ√âÕ¡·≈– ¡—§√„®„Àâ∫√‘°“√
¥â«¬«‘∏’ VIA ¬—ß„Àâ∫√‘°“√„π μ√’ºŸâ¡’Õ“¬ÿ 30 - 44 ªï (Õ“¬ÿ 35
·≈– 40 ªï√—∫∫√‘°“√¥â«¬«‘∏’·ªª ‡¡’¬√å) ‚§√ß°“√¥—ß°≈à“«„Àâ
§«“¡√Ÿâ·°àª√–™“™π·≈–ª√–™“ —¡æ—π∏宓°¿“§√—∞ ‡¡◊ËÕ ª√–°Õ∫°—∫°√–· μ◊Ëπμ—«¢Õߪ√–™“™π®“° ◊ËÕ‚¶…≥“¿“§
‡Õ°™πºŸâ®”Àπà“¬«—§´’πªÑÕß°—π°“√μ‘¥‡™◊ÈÕŒ‘«·¡π·ªªªî‚≈¡“
‰«√— À√◊Շՙ撫’ μ—Èß·μàªï 2550 ‡ªìπμâπ¡“ ª√–™“™π®÷ß μ√–Àπ—°∂÷ߧ«“¡√ÿπ·√ߢÕß‚√§ ·≈–‡¢â“√—∫∫√‘°“√§—¥°√Õß
¡“°¢÷Èπ °“√»÷°…“‡™‘ß ”√«® ‚¥¬ ∏’√– »‘√‘ ¡ÿ¥ ·≈–§≥– „πªï 2552 „π°≈ÿࡇªÑ“À¡“¬ μ√’Õ“¬ÿ 30 - 60 ªï ®”π«π 4,512 §π
„π 12 ®—ßÀ«—¥∑—Ë«ª√–‡∑» æ∫Õ—μ√“°“√√—∫∫√‘°“√μ√«®§—¥
°√Õß„π√Õ∫ 5 ªï (æ.». 2548 - 2552) ‡∑à“°—∫√âÕ¬≈– 68 ´÷Ëß Ÿß°«à“„πÕ¥’μ ‚¥¬‡©æ“–ªï 2552 ªï‡¥’¬«¡’ºŸâ√—∫∫√‘°“√§—¥
°√Õ߇°◊Õ∫√âÕ¬≈– 40 ¢Õ߇ªÑ“À¡“¬(4) ¢âÕ§âπæ∫®“°°“√»÷°…“
π’È„°≈⇧’¬ßº≈°“√ ”√«®√–¥—∫ª√–™“°√‡°’ˬ«°—∫æƒμ‘°√√¡
‡ ’ˬßμàÕ‚√§‰¡àμ‘¥μàÕ·≈–°“√∫“¥‡®Á∫„πªï æ.». 2553 ‚¥¬
”π—°‚√§‰¡àμ‘¥μàÕ °√¡§«∫§ÿ¡‚√§ ´÷Ëß√“¬ß“π«à“°“√μ√«®À“
¡–‡√Áߪ“°¡¥≈Ÿ°„π√Õ∫ 3 ªï∑’˺à“π¡“„πª√–™“°√À≠‘ßÕ“¬ÿ 30 - 60 ªï ¡’Õ—μ√“√âÕ¬≈– 62.7(5)
„πª√–‡∑»‰∑¬ °“√»÷°…“§«“¡§ÿâ¡§à“¥â“π ÿ¢¿“æ¢Õß
¡“μ√°“√§«∫§ÿ¡·≈–ªÑÕß°—π¡–‡√Áߪ“°¡¥≈Ÿ° ‚¥¬‚§√ß°“√
ª√–‡¡‘π‡∑§‚π‚≈¬’·≈–π‚¬∫“¬¥â“π ÿ¢¿“æ ·≈– ”π—°ß“π æ—≤π“π‚¬∫“¬ ÿ¢¿“æ√–À«à“ߪ√–‡∑» „πªï 2550 √–∫ÿ«à“°“√
©’¥«—§´’πªÑÕß°—π°“√μ‘¥‡™◊ÈՇՙ撫’¬—߉¡à§ÿâ¡§à“„π∫√‘∫∑¢Õß ª√–‡∑»‰∑¬ ¥â«¬√“§“«—§´’π¬—ß Ÿß¡“° ·μà°“√‡√à߇æ‘Ë¡
women was cost-effective compared to no screening. The current practice showed a certain benefit of 40 percent reduction in incidence and mortality. The second most efficient strategy was a 3-yearly screening for women aged 30-60 years, with the incremental cost-effectiveness ratio -73,300 baht per quality-ad- justed life year gained and the expected prevention of 900 cervical cancer cases and 450 deaths per year.
Treatment cost was reduced to 1.2 billion baht per year. But more than 180 cytologists and pathologists are needed to cope with increasing demand. Strengthening the current program by increasing the number of women for screening to reach the targeted coverage rate of 80 percent is the most cost-effective and prag- matic option in Thailand.
Key words: cervical cancer, mass screening, Markov model, cost-utility
¡
ª√– ‘∑∏‘¿“æ°“√¥”‡π‘π°“√„Àâ¡’Õ—μ√“§—¥°√Õß Ÿß¢÷Èπ‡ªìπ∑“ß
‡≈◊Õ°∑’˧ÿâ¡§à“°«à“ Õ’°∑—È߇ πÕ„Àâª√—∫≈¥Õ“¬ÿ¢Õß°≈ÿࡇªÑ“
À¡“¬®“° 35 ªï ‡ªìπ 30 ªï §—¥°√Õß∑ÿ° 5 ªï ®π°√–∑—ËßÕ“¬ÿ 60 ªï √Ÿª·∫∫¢Õß°“√§—¥°√Õß∑’˧ÿ⡧à“∑’Ë ÿ¥„π·∫∫®”≈Õß §◊Õ «‘∏’
VIA „π μ√’Õ“¬ÿ‰¡à‡°‘π 45 ªï ”À√—∫ μ√’Õ“¬ÿ¡“°°«à“π—Èπ„Àâ
§—¥°√Õߥ⫬«‘∏’·ªª ‡¡’¬√å(6)
¿“¬À≈—ߧ«“¡ ”‡√Á®¢Õß°“√¥”‡π‘π‚§√ß°“√§—¥°√Õß
¡–‡√Áߪ“°¡¥≈Ÿ° 75 ®—ßÀ«—¥ „π«—π∑’Ë 1 μÿ≈“§¡ æ.». 2552
°√–∑√«ß “∏“√≥ ÿ¢·≈– ”π—°ß“πÀ≈—°ª√–°—π ÿ¢¿“æ·Ààß™“μ‘
®÷ß°”Àπ¥‡ªÑ“À¡“¬„À¡à ‚¥¬ª√—∫Õ“¬ÿ∑’˧—¥°√Õß®“° 35-60 ªï
‡ªìπ 30-60 ªï §«“¡∂’Ë∑ÿ° 5 ªï μ—È߇ªÑ“À¡“¬Õ—μ√“¬Õ¡√—∫
∫√‘°“√√âÕ¬≈– 80 ¿“¬„π√–¬–‡«≈“ 5 ªï √“¬ß“πª√–®”ªï ”π—°ß“πÀ≈—°ª√–°—π ÿ¢¿“æ·Ààß™“μ‘√–∫ÿ®”π«π μ√’Õ“¬ÿ 30-60 ªï ∑’Ë¡“√—∫∫√‘°“√μ√«®§—¥°√Õß¡–‡√Áߪ“°¡¥≈Ÿ°„πªï 2553 ·≈– 2554 ‡∑à“°—∫ 2.23 ·≈– 1.73 ≈â“π√“¬ §‘¥‡ªìπ√âÕ¬≈–
103 ·≈– 84 ¢Õ߇ªÑ“À¡“¬√“¬ªï μ“¡≈”¥—∫(7,8) °“√¥”‡π‘π ß“π§—¥°√Õß¡–‡√Áߪ“°¡¥≈Ÿ°„πªí®®ÿ∫—π®÷ß¡’°“√ª√—∫ª√ÿߥ’¢÷Èπ
™—¥‡®π ¥—ß®–‡ÀÁπ«à“Õ—μ√“§—¥°√Õß ´÷Ë߇ªìπ¥—™π’™’È«—¥ ”§—≠μ—«Àπ÷Ëß
¡’·π«‚πâ¡ Ÿß¢÷Èπ¡“°®“°„πÕ¥’μ ·≈–πà“®–∫√√≈ÿ‡ªÑ“À¡“¬∑’Ëμ—È߉«â
§◊Õ√âÕ¬≈– 80 „πªï 2557
°“√»÷°…“¡’«—μ∂ÿª√– ߧå‡æ◊ËÕ«‘‡§√“–À姫“¡§ÿâ¡§à“¥â“π ÿ¢¿“æ·≈–§«“¡‡ªìπ‰ª‰¥â„π°“√‡æ‘Ë¡ ‘∑∏‘ª√–‚¬™πå¢Õß°“√
§—¥°√Õß¡–‡√Áߪ“°¡¥≈Ÿ°„π√–∫∫À≈—°ª√–°—π ÿ¢¿“æ·Ààß™“μ‘
‚¥¬¢¬“¬°“√§—¥°√Õß√–¥—∫ª√–™“°√„Àâ§√Õ∫§≈ÿ¡ μ√’Õ“¬ÿ πâÕ¬°«à“ 30 ªï ·≈–ª√—∫§«“¡§«“¡∂’Ë„π°“√§—¥°√Õß®“°∑ÿ° 5 ªï ‡ªìπ∑ÿ° 3 ªï·≈– 1 ªï
√–‡∫’¬∫«‘∏’°“√»÷°…“
°“√»÷°…“π’ȇªìπ°“√ª√–‡¡‘𧫓¡§ÿâ¡§à“¥â“π “∏“√≥ ÿ¢
‚¥¬°“√«‘‡§√“–Àåμâπ∑ÿπÕ√√∂ª√–‚¬™πå∫π·∫∫®”≈Õß Markov
´÷Ëߪ√—∫ª√ÿß®“°·∫∫®”≈Õß∑’ˇ§¬æ—≤π“‚¥¬ Praditsitthikorn
·≈–§≥–(6) ¥â«¬°“√‡æ‘Ë¡∑“߇≈◊Õ°„π°“√‡ª√’¬∫‡∑’¬∫ §◊Õ °“√
§—¥°√Õß∑’ËÕ“¬ÿπâÕ¬≈ßμ—Èß·μà 15 - 20 ªï ·≈–/À√◊Õ §«“¡∂’Ë∑ÿ° 1
·≈– 3 ªï «‘‡§√“–Àå¿“¬„μâ¡ÿ¡¡Õßμâπ∑ÿπ∑“ß —ߧ¡ ª√—∫¡Ÿ≈§à“
‡ß‘π‡ªìπªï∑’Ë«‘‡§√“–Àå§◊Õ æ.». 2555 ºà“π¥—™π’√“§“ºŸâ∫√‘‚¿§
®“° ”π—°¥—™π’‡»√…∞°‘®°“√§â“ °√–∑√«ßæ“≥‘™¬å(9) Õ—μ√“ª√—∫
≈¥§ß‰«â∑’Ë√âÕ¬≈– 3 ∑—Èßμâπ∑ÿπ·≈–º≈≈—æ∏å ÿ¢¿“æ μ“¡
·π«∑“ߧŸà¡◊Õ°“√ª√–‡¡‘π‡∑§‚π‚≈¬’¥â“π ÿ¢¿“æ ”À√—∫ª√–‡∑»
‰∑¬(10) °√Õ∫‡«≈“§◊Õμ≈Õ¥™’æ √Õ∫√–¬–‡«≈“¢Õß°“√
‡ª≈’ˬπ·ª≈ß ∂“π– ÿ¢¿“æ§◊Õ 1 ªï
À≈—ß°“√«‘‡§√“–Àåμâπ∑ÿπÕ√√∂ª√–‚¬™πå·≈–∑√“∫
¡“μ√°“√∑’˧ÿâ¡§à“ ®÷ß«‘‡§√“–À姫“¡‡ªìπ‰ª‰¥â„π∑“ߪؑ∫—μ‘
‚¥¬¡ÿà߇πâπÕ—μ√“°”≈—ߧπ ‡æ◊ËÕ√Õß√—∫°“√¢¬“¬¢Õ∫‡¢μ°“√
¥”‡π‘πß“π„πÕπ“§μ
μ—«·ª√„π·∫∫®”≈Õß
μ—«·ª√∑“ߧ≈‘π‘°·≈–§«“¡πà“®–‡ªìπ„π°“√‡ª≈’ˬπ ∂“π–
ÿ¢¿“æÕâ“ßÕ‘ß®“°ß“π¢Õß Praditsitthikorn ·≈–§≥–(6) °“√
»÷°…“π’È®–¢Õ°≈à“«∂÷ß√“¬≈–‡Õ’¬¥¢Õßμ—«·ª√∑’Ë„™â„π·∫∫
®”≈Õß∑’ËπÕ°‡Àπ◊Õ®“°∑’ˇ§¬√“¬ß“π μ—«·ª√À≈—°„π·∫∫
®”≈Õ߉¥â®“°°“√∑∫∑«π«√√≥°√√¡∑—Èß„π·≈–μà“ߪ√–‡∑»
·≈–‡°Á∫¢âÕ¡Ÿ≈„π‚√ß欓∫“≈¡À“«‘∑¬“≈—¬·≈–»Ÿπ¬å¡–‡√Áß 12
·Ààß ·∫∫®”≈Õß‚√§‰¥âºà“π°“√μ√«® Õ∫§«“¡∂Ÿ°μâÕß ‚¥¬
°“√æ‘®“√≥“¢Õ∫‡¢μ·≈–§«“¡ ¡‡Àμÿ ¡º≈¢Õß‚§√ß √â“ß
·≈–‚¥¬ºŸâ‡™’ˬ«™“≠∑“ߧ≈‘π‘° ·≈–∑¥ Õ∫§«“¡∂Ÿ°μâÕ߇™‘ß æ¬“°√≥å ‚¥¬‡ª√’¬∫‡∑’¬∫º≈≈—æ∏宓°·∫∫®”≈Õß·≈–¢âÕ¡Ÿ≈
®“°°“√ ”√«®§«“¡™ÿ°°“√μ‘¥‡™◊ÈՇՙ撫’„π®—ßÀ«—¥≈”ª“ß·≈–
ߢ≈“(11) ·≈–Õÿ∫—μ‘°“√≥å¡–‡√Áߪ“°¡¥≈Ÿ°®“°¢âÕ¡Ÿ≈∑–‡∫’¬π
¡–‡√Áß„πª√–‡∑»‰∑¬(2) (√Ÿª∑’Ë 1)
μ—«·ª√ª√– ‘∑∏‘¿“æ¢Õß°“√μ√«®§—¥°√Õß ‰¥â·°à §«“¡
‰«·≈–§«“¡®”‡æ“–¢Õß°“√μ√«®§—¥°√Õß ‰¥â®“°°“√∑∫∑«π
«√√≥°√√¡·≈–°“√«‘‡§√“–À凙‘ßÕπÿ¡“π §à“§«“¡‰«·≈–§«“¡
®”‡æ“–‡∑à“°—∫√âÕ¬≈– 68 ·≈– 77 ”À√—∫«‘∏’ VIA ·≈– 54 ·≈–
91 ”À√—∫«‘∏’·ªª ‡¡’¬√å (√Ÿª∑’Ë 2)
μ—«·ª√μâπ∑ÿπ§√Õ∫§≈ÿ¡§à“„™â®à“¬μ—Èß·μà‡√‘Ë¡§—¥°√Õß μ√«®¬◊π¬—πº≈ √—°…“‡´≈≈庑¥ª°μ‘ μ‘¥μ“¡ àßμàÕ ·≈–√—°…“
¡–‡√Áß√–¬–≈ÿ°≈“¡ ®÷ߧ√Õ∫§≈ÿ¡μâπ∑ÿπ 3 ª√–‡¿∑
1) μâπ∑ÿπ∑“ßμ√ß∑“ß°“√·æ∑¬å ‰¥â·°à §à“∫√‘°“√
√Ÿª∑’Ë 1 °“√∑¥ Õ∫§«“¡∂Ÿ°μâÕߢÕß·∫∫®”≈Õß ‚¥¬‡ª√’¬∫‡∑’¬∫
º≈≈—æ∏宓°·∫∫®”≈Õß°—∫¢âÕ¡Ÿ≈®“°°“√ ”√«®·≈–
∑–‡∫’¬π¡–‡√Áß„πª√–‡∑»‰∑¬
√Ÿª∑’Ë 2 º≈°“√«‘‡§√“–À凙‘ßÕπÿ¡“π§à“§«“¡‰«·≈–§«“¡®”‡æ“–¢Õß°“√§—¥°√Õß«‘∏’ VIA (¿“æ∫π) ·≈–«‘∏’·ªª ‡¡’¬√å (¿“æ≈à“ß) μ√«®§—¥°√Õß §à“∫√‘°“√∑“ß°“√·æ∑¬å·≈–欓∫“≈ §à“¬“
·≈–‡«™¿—≥±å §à“μ√«®∑“ßÀâÕߪؑ∫—μ‘°“√·≈–À—μ∂°“√ §à“
ÀâÕß·≈–§à“Õ“À“√ (°√≥’ºŸâªÉ«¬„π)
2) μâπ∑ÿπ∑“ßμ√ß∑’Ë¡‘„™à∑“ß°“√·æ∑¬å ‰¥â·°à §à“„™â
®à“¬¢ÕߺŸâªÉ«¬·≈–≠“μ‘√–À«à“ß√—∫∫√‘°“√∑“ß°“√·æ∑¬å √«¡
∂÷ß°“√¥Ÿ·≈Õ◊ËπÊ ∑’ˇ°’ˬ«¢âÕß ‡™àπ §à“‡¥‘π∑“ß ∑’Ëæ—° Õ“À“√
‡¡◊ËÕ¡“æ∫·æ∑¬å §à“¥Ÿ·≈Õ¬à“߉¡à‡ªìπ∑“ß°“√ §à“„™â®à“¬„π°“√
ª√—∫ª√ÿß∑’Ëæ—° ´◊ÈÕÕÿª°√≥å®”‡ªìπ‡π◊ËÕß¡“®“°°“√‡®Á∫ªÉ«¬ ‡ªìπμâπ 3) μâπ∑ÿπ∑“ßÕâÕ¡ ‰¥â·°à μâπ∑ÿπº≈‘μ¿“æ∑’Ë Ÿ≠‡ ’¬
‰ª¢Õß≠“μ‘
∑—Èßπ’È μâπ∑ÿπ„π°“√§—¥°√Õߧ√Õ∫§≈ÿ¡μ—Èß·μà °√–∫«π°“√
§—¥°√Õß øíߺ≈ μ√«®¬◊π¬—π √—°…“§«“¡º‘¥ª°μ‘ √—°…“
Õ“°“√¢â“߇§’¬ß μ≈Õ¥®πμ√«®μ‘¥μ“¡ ®÷ߺ—π·ª√μ“¡ ¿“«–
ÿ¢¿“æ ·≈–¢÷Èπ°—∫§«“¡ “¡“√∂¢Õß«‘∏’§—¥°√Õß ‚¥¬º≈
≈—æ∏å°“√§—¥°√Õß “¡“√∂·∫à߇ªìπ 4 °≈ÿà¡ §◊Õ ∫«°®√‘ß (true positive) ∫«°≈«ß (false positive) ≈∫®√‘ß (true negative)
0.05%
0.06%
0.07%
0.08%
0.09%
0.10%
Baseline cancer incidence derived from the model: cumulative lifetime incidence = 2.7%
0.00%
0.01%
0.02%
0.03%
0.04%
Cervical cancer incidence (%)
Age (year) Population data (1998-2000): cumulative lifetime incidence = 2.7 %
25 Community survey
20
Baseline HPV prevalence derived from the model
15
10
HPV prevalence (%) 5
0 Age (year)
15 20 25 30 35 40 45 50 55 60 65 70 75 15 20 25 30 35 40 45 50 55 60 65 70 75
Study
Fixed effect model Random effects model
Heterogeneity: I-squared=86%, tau-squared=0.0069, p<0.0001 U.ofZimbabwe,1999
Basu,2003 Basu,2004 Winkler,2003 Bhatla,2004 Sankaranarayanan,2004 Sankaranarayanan,2004 Sankaranarayanan,2004 DeVuyst,2005 Shastri,2005 Shastri,2005 Sangwa-Lugoma,2006
TE
0.77 0.56 0.61 0.60 0.88 0.65 0.68 0.79 0.73 0.64 0.67 0.76
seTE
0.0309 0.0402 0.0402 0.0702 0.1569 0.0257 0.0257 0.0122 0.0573 0.0481 0.0481 0.0824
0 0.2 0.4 0.6 0.8 1 1.2 Sensitivity of VIA
Sensitivity
0.73 0.68 0.77 0.56 0.61 0.60 0.88 0.65 0.68 0.79 0.73 0.64 0.67 0.76
95%-CI
[0.71; 0.75]
[0.63; 0.74]
[0.71; 0.83]
[0.48; 0.64]
[0.53; 0.69]
[0.46; 0.74]
[0.57; 1.18]
[0.60; 0.70]
[0.63; 0.73]
[0.77; 0.82]
[0.62; 0.85]
[0.54; 0.73]
[0.58; 0.76]
[0.60; 0.92]
W(fixed)
100%
-- 7.7%
4.5%
4.5%
1.5%
0.3%
11.1%
11.1%
49.6%
2.2%
3.2%
3.2%
1.1%
W(random)
-- 100%
10.0%
9.2%
9.2%
6.6%
2.5%
10.4%
10.4%
11.1%
7.7%
8.5%
8.5%
5.7%
Study
Fixed effect model Random effects model
Heterogeneity: I-squared=99.4%, tau-squared=0.0028, p<0.0001 U.ofZimbabwe,1999
Basu,2003 Basu,2004 Winkler,2003 Bhatla,2004 Sankaranarayanan,2004 Sankaranarayanan,2004 Sankaranarayanan,2004 DeVuyst,2005 Shastri,2005 Shastri,2005 Sangwa-Lugoma,2006
TE
0.64 0.82 0.83 0.69 0.63 0.87 0.87 0.85 0.78 0.88 0.88 0.42
seTE
0.0081 0.0047 0.0047 0.0382 0.0371 0.0028 0.0028 0.0015 0.0146 0.0057 0.0057 0.0155
0.4 0.6 0.8 1
Specifity of VIA
Specificity
0.85 0.77 0.64 0.82 0.83 0.69 0.63 0.87 0.87 0.85 0.78 0.88 0.88 0.42
95%-CI
[0.85; 0.85]
[0.74; 0.80]
[0.62; 0.66]
[0.81; 0.83]
[0.82; 0.84]
[0.61; 0.76]
[0.56; 0.70]
[0.86; 0.87]
[0.86; 0.87]
[0.85; 0.86]
[0.75; 0.80]
[0.87; 0.90]
[0.87; 0.89]
[0.39; 0.45]
W(fixed)
100%
-- 1.8%
5.2%
5.2%
0.1%
0.1%
15.2%
15.2%
49.1%
0.5%
3.6%
3.5%
0.5%
W(random)
-- 100%
8.8%
8.9%
8.9%
5.9%
6.0%
9.0%
9.0%
9.0%
8.4%
8.9%
8.9%
8.3%
Study
Fixed effect model Random effects model
Heterogeneity: I-squared=93.7%, tau-squared=0.0338, p<0.0001 Hall,1996
U.ofZimbabwe,1999 Singh,2001 Witt,2003 Basu,2003 Singer,2003 Lee,2004 Sarian,2004 DeVuyst,2005 Goel,2005 Shastri,2005 Boonlikit,2005 Doh,2005 Sangwa-Lugoma,2006 Monsonego,2006
TE
0.35 0.44 0.81 0.64 0.29 0.60 0.76 1.00 0.72 0.69 0.32 0.07 0.67 0.46 0.42
seTE
0.0974 0.0350 0.0428 0.0382 0.0469 0.0542 0.0353 0.1878 0.0641 0.1378 0.0368 0.1283 0.0316 0.0939 0.0350
0 0.2 0.4 0.6 0.8 1 1.2 Sensitivity of PAP Smear
Sensitivity
0.56 0.54 0.35 0.44 0.81 0.64 0.29 0.60 0.76 1.00 0.72 0.69 0.32 0.07 0.67 0.46 0.42
95%-CI
[ 0.53; 0.58]
[ 0.44; 0.64]
[ 0.16; 0.54]
[ 0.37; 0.51]
[ 0.73; 0.90]
[ 0.57; 0.72]
[ 0.20; 0.39]
[ 0.49; 0.70]
[ 0.69; 0.83]
[ 0.63; 1.37]
[ 0.59; 0.84]
[ 0.42; 0.96]
[ 0.25; 0.39]
[-0.18; 0.32]
[ 0.61; 0.73]
[ 0.28; 0.65]
[ 0.35; 0.49]
W(fixed)
100%
-- 1.5%
12.0%
8.0%
10.1%
6.7%
5.0%
11.8%
0.4%
3.6%
0.8%
10.8%
0.9%
14.7%
1.7%
12.0%
W(random)
-- 100%
6.1%
7.5%
7.4%
7.5%
7.3%
7.2%
7.5%
3.8%
6.9%
5.0%
7.5%
5.2%
7.6%
6.2%
7.5%
Study
Fixed effect model Random effects model
Heterogeneity: I-squared=98.3%, tau-squared=0.0046, p<0.0001 Hall,1996
U.ofZimbabwe,1999 Singh,2001 Witt,2003 Basu,2003 Singer,2003 Lee,2004 Sarian,2004 DeVuyst,2005 Goel,2005 Shastri,2005 Boonlikit,2005 Doh,2005 Sangwa-Lugoma,2006 Monsonego,2006
TE
0.98 0.91 0.79 0.95 0.92 0.95 0.66 0.81 0.96 0.96 0.99 0.98 0.88 0.98 0.92
seTE
0.0231 0.0059 0.0158 0.0245 0.0037 0.0109 0.0130 0.0287 0.0106 0.0366 0.0043 0.0166 0.0067 0.0116 0.0189
0.4 0.6 0.8 1
Specifity of PAP Smear Specificity
0.93 0.91 0.98 0.91 0.79 0.95 0.92 0.95 0.66 0.81 0.96 0.96 0.99 0.98 0.88 0.98 0.92
95%-CI
[0.92; 0.93]
[0.87; 0.94]
[0.94; 1.03]
[0.89; 0.92]
[0.76; 0.82]
[0.90; 0.99]
[0.92; 0.93]
[0.93; 0.98]
[0.63; 0.68]
[0.76; 0.87]
[0.94; 0.98]
[0.89; 1.03]
[0.98; 1.00]
[0.94; 1.01]
[0.87; 0.89]
[0.96; 1.00]
[0.88; 0.96]
W(fixed)
100%
-- 0.8%
12.6%
1.8%
0.7%
33.1%
3.8%
2.6%
0.5%
3.9%
0.3%
23.7%
1.6%
9.9%
3.3%
1.2%
W(random)
-- 100%
6.4%
7.0%
6.7%
6.3%
7.1%
6.9%
6.8%
6.0%
6.9%
5.5%
7.1%
6.7%
7.0%
6.9%
6.6%
·≈–≈∫≈«ß (false negative) °√≥’·ªª ‡¡’¬√å °≈ÿà¡∑’Ë¡’º≈
∫«°®–¡’μâπ∑ÿπ‡æ‘Ë¡„π¢—ÈπμÕπ°“√μ√«®¬◊π¬—πº≈ ·≈–‡©æ“–
°≈ÿà¡∑’Ë¡’º≈∫«°®√‘ß®–¡’μâπ∑ÿπ‡æ‘Ë¡„π°“√√—°…“§«“¡º‘¥ª°μ‘
¢Õ߇´≈≈媓°¡¥≈Ÿ° Õ“°“√¢â“߇§’¬ß∑’ËÕ“®‡°‘¥®“°°“√√—°…“
√«¡∂÷ß§à“„™â®à“¬„π°“√μ√«®μ‘¥μ“¡À≈—ß°“√√—°…“ ∑—Èß Õß«‘∏’
À“°„Àâº≈°“√§—¥°√Õ߇ªìπ≈∫ ‰¡à«à“º≈≈∫®√‘ßÀ√◊Õ≈∫≈«ß ®–
¡’μâπ∑ÿπ‡∑à“°—π §◊Õ μâπ∑ÿπ„π¢—ÈπμÕπμ√«®§—¥°√Õß·≈–øíߺ≈
√ÿªμâπ∑ÿπ∑“ßμ√ß∑“ß°“√·æ∑¬å¥—ßμ“√“ß∑’Ë 1
¢âÕ¡Ÿ≈μâπ∑ÿπ°“√√—°…“¡–‡√Áߪ“°¡¥≈Ÿ°·≈–μ—«·ª√
Õ√√∂ª√–‚¬™π剥⮓°∞“πª√–«—μ‘°“√√—°…“·≈– —¡¿“…≥废⠪ɫ¬∑’Ë¡“√—∫°“√√—°…“„π‚√ß欓∫“≈¡À“«‘∑¬“≈—¬ 4 ·Ààß ·≈–
»Ÿπ¬å¡–‡√Áß 12 ·Ààß „πªï æ.». 2549-2550 ®”π«π 1,035 §π
¿“¬„μ₧√ß°“√«‘®—¬¢Õß°≈ÿà¡»÷°…“¡–‡√Áßπ√’‡«™‰∑¬ ·≈–
‡§√◊Õ¢à“¬«‘®—¬§≈‘π‘° À ∂“∫—π (ªí®®ÿ∫—π§◊Õ‡§√◊Õ¢à“¬«‘®—¬°≈ÿà¡
∂“∫—π·æ∑¬»“ μ√å·Ààߪ√–‡∑»‰∑¬) μâπ∑ÿπ√«¡μ—Èß·μࢗÈπ μÕπ°“√«‘π‘®©—¬ √—°…“ ®πºŸâªÉ«¬‡¢â“ Ÿà√–¬– ß∫¢Õß‚√§ À√◊Õ
°≈—∫‡ªìπ´È” ®π°√–∑—Ë߇ ’¬™’«‘μ √ÿª‡ªìπμâπ∑ÿπμ≈Õ¥™’æ¢Õß
°“√√—°…“¡–‡√Áߪ“°¡¥≈Ÿ° ·¬°μ“¡√–¬–¢Õß‚√§ ¥—ß¿“æ∑’Ë 3
´÷Ëß®–‡ÀÁπ«à“μâπ∑ÿπ°“√√—°…“μàÕ§π¡’¡Ÿ≈§à“ Ÿß¡“° §‘¥‡ªìπ 1,398,000 (§à“§«“¡§≈“¥‡§≈◊ËÕπ¡“μ√∞“πÀ√◊Õ SE = 8,870) 1,212,000 (SE = 7,620) 1,195,000 (SE = 7,520) ·≈– 920,000 (SE = 10,443) ∫“∑ ”À√—∫°“√√—°…“¡–‡√Áß√–¬–∑’Ë 1, 2, 3
·≈– 4 μ“¡≈”¥—∫
μ—«·ª√Õ√√∂ª√–‚¬™π剥⮓°°“√ —¡¿“…≥废âªÉ«¬¥â«¬
·∫∫ Õ∫∂“¡ EQ-5D-3L ©∫—∫¿“…“‰∑¬ ª√–°Õ∫¥â«¬ 2 à«π
§◊Õ à«π∑’Ë 1 Õ∫∂“¡ ÿ¢¿“æ¢ÕߺŸâªÉ«¬„π 5 ¡‘μ‘ ÿ¢¿“æ ‰¥â·°à
°“√‡§≈◊ËÕπ‰À« °“√¥Ÿ·≈μπ‡Õß °‘®°√√¡∑’Ë∑”‡ªìπª√–®”
§«“¡‡®Á∫ª«¥À√◊Õ§«“¡‰¡à ÿ¢ ∫“¬ §«“¡«‘μ°°—ß«≈À√◊Õ´÷¡‡»√â“
§”μÕ∫¢Õß à«π∑’Ë 1 ®–∂Ÿ°·ª≈߇ªìπ§–·ππÕ√√∂ª√–‚¬™πå
‚¥¬‡∑’¬∫°—∫ ¡°“√¢Õߪ√–‡∑»‰∑¬ à«π∑’Ë 2 ª√–‡¡‘π¿“«–
ÿ¢¿“æ‚¥¬„™â ‡°≈·∫∫‡ âπμ√ß∑’Ë¡’§à“μ—Èß·μà 0 ∂÷ß 100 ´÷Ëß®–
∂Ÿ°ª√—∫‡ªìπ§à“Õ√√∂ª√–‚¬™πå√–À«à“ß 0 - 1 ‚¥¬ 0 À¡“¬∂÷ß ¿“«– ÿ¢¿“æ∑’Ë·¬à∑’Ë ÿ¥ 1 À¡“¬∂÷ß ¿“«– ÿ¢¿“æ∑’Ë¥’∑’Ë ÿ¥ ∑—Èßπ’È
„πªï∑’Ë∑”°“√‡°Á∫¢âÕ¡Ÿ≈ ¬—߉¡à¡’ ¡°“√ ”À√—∫ª√–™“°√‰∑¬
‡æ◊ËÕ„™â·ª≈ߧà“Õ√√∂ª√–‚¬™π宓° à«π∑’Ë 1 Praditsitthikorn
·≈–§≥–®÷ß„™â§à“Õ√√∂ª√–‚¬™πå∑’ˉ¥â®“° à«π∑’Ë 2 °“√»÷°…“
§√—Èßπ’È®÷ߪ√—∫ª√ÿߧà“Õ√√∂ª√–‚¬™πå„π à«π∑’Ë 1 ‚¥¬„™â ¡°“√
¢Õߪ√–™“°√‰∑¬∑’Ëæ—≤π“‚¥¬ Tongsiri ·≈–§≥–„πªï 2552
®÷߉¥â§à“Õ√√∂ª√–‚¬™π套߷ ¥ß„π√Ÿª∑’Ë 4 §à“Õ√√∂ª√–‚¬™πå
¢Õß√–¬–°àÕπ‡ªìπ¡–‡√Áß°”Àπ¥ ¡¡ÿμ‘∞“π¡’§à“‡∑à“°—∫ 1 À√◊Õ
√Ÿª∑’Ë 3 μâπ∑ÿπμ≈Õ¥™’æ¢Õß°“√√—°…“¡–‡√Áߪ“°¡¥≈Ÿ° ·∫àßμ“¡
√–¬–‚√§ (μâπ∑ÿ𧑥®“°¡ÿ¡¡Õß∑“ß —ߧ¡) μ“√“ß∑’Ë 1 μâπ∑ÿπ∑“ßμ√ß∑“ß°“√·æ∑¬å¢Õß°“√§—¥°√Õß ¥â«¬«‘∏’ VIA ·≈– ·ªª ‡¡’¬√å
º≈°“√§—¥°√Õß
«‘∏’°“√μ√«®§—¥°√Õß
≈∫®√‘ß/≈«ß ∫«°≈«ß* ∫«°®√‘߆
«’‰Õ‡Õ (∫“∑/√“¬) 28 675 4,036
·ªª ‡¡’¬√å (∫“∑/√“¬) 57 1,165 5,173
*√«¡∂÷ß°“√μ√«®æ∫§«“¡º‘¥ª°μ‘√–¬– CIN-1
†À¡“¬∂÷ßμ√«®æ∫§«“¡º‘¥ª°μ‘√–¬– CIN-2/3
Lifetime cost of treatment for cervical cancer (Baht/person) 3,000,000
2,500,000
2,000,000
1,500,000
1,000,000
500,000
0
Stage I Stage II Stage III Stage IV
¿“«– ÿ¢¿“æ∑’Ë¥’∑’Ë ÿ¥
º≈°“√»÷°…“
°“√«‘‡§√“–Àåμâπ∑ÿπμ≈Õ¥™’æ·≈–º≈≈—æ∏å∑“ß ÿ¢¿“æ „π
·ßàÕÿ∫—μ‘°“√≥å¡–‡√Áߪ“°¡¥≈Ÿ° ®”π«π°“√‡ ’¬™’«‘μ∑’Ë≈¥≈ß
¿“¬À≈—ß°“√§—¥°√Õß æ‘®“√≥“„π¡ÿ¡¡ÕߢÕß —ߧ¡ ¿“¬„μâ ∂“π°“√≥å∑’ˇ√‘Ë¡§—¥°√Õß∑’ËÕ“¬ÿμà“ßÊ ·≈–∑’˧«“¡∂’Ë∑ÿ° 5 ªï
∑ÿ° 3 ªï ·≈–∑ÿ° 1 ªï ¥—ßμ“√“ß∑’Ë 2 ·≈–√Ÿª∑’Ë 5
°“√«‘‡§√“–Àåæ∫«à“À“°‰¡à¡’¡“μ√°“√§«∫§ÿ¡·≈–
ªÑÕß°—π‚√§ ®–¡’º≈‡ ’¬∑“ß ÿ¢¿“æ¡“°∑’Ë ÿ¥ §◊Õ¡’®”π«πºŸâ ªÉ«¬¡–‡√Áߪ“°¡¥≈Ÿ°„À¡àªï≈–°«à“ 9,000 √“¬ ·≈–‡ ’¬™’«‘μ‡°◊Õ∫
4,000 √“¬μàÕªï μâπ∑ÿπμ≈Õ¥™’æ Ÿß∑’Ë ÿ¥‡©≈’ˬ 9,800 ∫“∑μàÕ μ√’ 1 §π ‡¡◊ËÕ®”≈Õß ∂“π°“√≥åªí®®ÿ∫—π∑’Ë¡’°“√μ—È߇ªÑ“À¡“¬
√–¥—∫™“μ‘¢Õß°“√§—¥°√Õß„Àâ§√Õ∫§≈ÿ¡√âÕ¬≈– 80 ¢Õß μ√’∑’Ë
¡’Õ“¬ÿ 30 - 60 ªï ‚¥¬§—¥°√Õß∑ÿ° 5 ªï º≈°“√«‘‡§√“–Àå· ¥ß
·π«‚πâ¡∑’Ë≈¥≈ßÕ¬à“ß¡“°¢Õß®”π«πºŸâªÉ«¬„À¡à·≈–®”π«πºŸâ
‡ ’¬™’«‘μ®“°¡–‡√Áߪ“°¡¥≈Ÿ° §◊Õ ≈¥°«à“√âÕ¬≈– 40 ‡¡◊ËÕ
‡∑’¬∫°—∫°“√‰¡à¡’¡“μ√°“√§—¥°√Õß ¢≥–‡¥’¬«°—πμâπ∑ÿπ‚¥¬
√«¡≈¥‡À≈◊Õª√–¡“≥ 7,100 ∫“∑μàÕ μ√’ 1 §π Õ—π‡ªìπº≈
®“°μâπ∑ÿπ°“√§—¥°√Õß·≈–√—°…“§«“¡º‘¥ª°μ‘√–¬–°àÕπ‡ªìπ
¡–‡√Áß∑’ˇæ‘Ë¡¢÷Èπ‡©≈’ˬ§π≈– 590 ∫“∑ ·μà°≈—∫™à«¬ª√–À¬—¥
‡ß‘π„π°“√√—°…“‚√§¡–‡√Áß∂÷ß 3,300 ∫“∑μàÕ μ√’ 1 §π À“°„Àâ¡’°“√§—¥°√Õß∑ÿ° 5 ªï¥—߇¥‘¡ ·μà≈¥Õ“¬ÿ∑’ˇ√‘Ë¡
§—¥°√Õß≈߇ªìπ 25, 20 ·≈– 15 ªï ‚¥¬§—¥°√Õß®π∂÷ßÕ“¬ÿ 60 ªï ®”π«πºŸâªÉ«¬¡–‡√Áß√“¬„À¡à®–≈¥≈߉¥âÕ’°ªï≈– 320, 440 ·≈–
450 √“¬μ“¡≈”¥—∫ ·≈–°“√‡ ’¬™’«‘μ≈¥≈߉¥âÕ’°ªï≈– 150, 200
·≈– 210 √“¬μ“¡≈”¥—∫ §‘¥‡ªìπº≈≈—æ∏å ÿ¥∑⓬¥â“π ÿ¢¿“æ
„π√Ÿª¢Õß®”π«πªï ÿ¢¿“«–∑’ˇæ‘Ë¡¢÷Èπ‡©≈’ˬμàÕ μ√’ 1 §π§◊Õ 0.004, 0.006 ·≈– 0.007 ªï À√◊Õ‡∑à“°—∫ 1.5, 2.2 ·≈– 2.5
«—πμ“¡≈”¥—∫ °“√§—¥°√Õß∑’ËÕ“¬ÿπâÕ¬®–¡’μâπ∑ÿπ°“√ªÑÕß°—π
‡æ‘Ë¡¢÷Èπ „π∑“ß°≈—∫°—π§à“„™â®à“¬∑’ËμâÕ߇ ’¬‰ª„π°“√√—°…“
¡–‡√Áß°≈—∫≈¥≈ß ·≈–‡¡◊ËÕæ‘®“√≥“¡“μ√°“√§—¥°√Õß∑ÿ° 3 ·≈–
1 ªï ·μର‡«âπ°“√§—¥°√Õß«—¬√ÿàπÕ“¬ÿμË”°«à“ 20 ªï °“√≈ß∑ÿπ
‡æ◊ËÕ§—¥°√Õߙ૬ªÑÕß°—π°“√‡ªìπ¡–‡√Áߪ“°¡¥≈Ÿ°‡æ’¬ß‡≈Á°πâÕ¬
·≈–§à“„™â®à“¬°“√√—°…“¡–‡√Áߪ“°¡¥≈Ÿ°≈¥≈ßπâÕ¬¡“° À√◊Õ
·∑∫‰¡à≈¥‡≈¬
√Ÿª∑’Ë 4 §à“‡©≈’ˬ·≈–§à“§≈“¥‡§≈◊ËÕπ¡“μ√∞“π¢Õßμ—«·ª√Õ√√∂ª√–‚¬™πå∑’Ë„™â„π·∫∫®”≈Õß ·∫àßμ“¡√–¬–‚√§
Utility
1.00
0.75
0.50
0.25
0.00
-0.25
Initial Persistence Recurrence Remission
I II III IV
Initial 0.699 (0.015) 0.711 (0.016) 0.646 (0.022) 0.558 (0.044) Persistence 0.847 (0.154) 0.682 (0.044) 0.620 (0.054) 0.176 (0.119) Recurrence 0.714 (0.047) 0.710 (0.034) 0.619 (0.050) 0.737 (0.070) Remission 0.815 (0.015) 0.766 (0.014) 0.776 (0.016) 0.686 (0.081)
Stage
μ“√“ß∑’Ë 2 º≈≈—æ∏å∑“ß ÿ¢¿“æ μâπ∑ÿπμ≈Õ¥™’æ (μâπ∑ÿπ∑’ˇ°‘¥®“°°“√ªÑÕß°—π‚√§‚¥¬°“√§—¥°√Õß·≈–μâπ∑ÿπ∑’ˇ°‘¥®“°°“√√—°…“) ·≈–Õ—μ√“ à«π μâπ∑ÿπª√– ‘∑∏‘º≈ à«π‡æ‘Ë¡ (ICER) „π ∂“π°“√≥åμà“ßÊ ‡¡◊ËÕÕ—μ√“°“√§—¥°√Õ߇∑à“°—∫√âÕ¬≈– 80
Case averted (cases) Total Cost outcome (Baht) Total ICER
Strategy Cervical Death QALYs Prevention Treatment Cost (Baht/QALY)
cancer (years) (Baht)
5-year screening
VIA (30-45) + Pap (50-60)* 5,380* 2,120* 28.067 590 6,530 7,120 Reference
VIA (25-45) + Pap (50-60) 320 150 28.071 730 6,120 6,850 Dominated
VIA (20-45) + Pap (50-60) 440 200 28.073 890 5,930 6,820 Dominated
VIA (15-45) + Pap (50-60) 450 210 28.074 1,050 5,900 6,950 Dominated
3-year screening
VIA (30-45) + Pap (48-60) 930 450 28.076 910 5,540 6,450 -73,320
VIA (27-45) + Pap (48-60) 1,210 570 28.080 1,040 5,200 6,240 -53,790
VIA (24-45) + Pap (48-60) 1,430 670 28.083 1,180 4,890 6,070 -51,470
VIA (21-45) + Pap (48-60) 1,550 720 28.085 1,330 4,690 6,020 -26,010
VIA (18-45) + Pap (48-60) 1,580 740 28.085 1,500 4,610 6,110 Dominated
VIA (15-45) + Pap (48-60) 1,590 740 28.086 1,660 4,590 6,250 Dominated
1-year screening
VIA (30-45) + Pap (46-60) 2,870 1,170 28.090 2,440 3,490 5,930 Dominated
VIA (29-45) + Pap (46-60) 3,010 1,230 28.092 2,560\ 3,330 5,890 Dominated
VIA (28-45) + Pap (46-60) 3,130 1,280 28.093 2,690 3,170 5,860 Dominated
VIA (27-45) + Pap (46-60) 3,250 1,330 28.095 2,810 3,000 5,810 Dominated
VIA (26-45) + Pap (46-60) 3,360 1,380 28.097 2,950 2,840 5,790 -20,100
VIA (25-45) + Pap (46-60) 3,460 1,420 28.098 3,080 2,680 5,760 -16,650
VIA (24-45) + Pap (46-60) 3,560 1,460 28.099 3,220 2,530 5,750 -8,150
VIA (23-45) + Pap (46-60) 3,640 1,500 28.100 3,370 2,390 5,760 Dominated
VIA (22-45) + Pap (46-60) 3,700 1,530 28.101 3,520 2,270 5,790 Dominated
VIA (21-45) + Pap (46-60) 3,750 1,550 28.102 3,670 2,160 5,830 Dominated
VIA (20-45) + Pap (46-60) 3,780 1,560 28.103 3,830 2,080 5,910 Dominated
VIA (19-45) + Pap (46-60) 3,810 1,570 28.103 3,990 2,030 6,020 Dominated
VIA (18-45) + Pap (46-60) 3,820 1,580 28.103 4,150 1,990 6,140 Dominated
VIA (17-45) + Pap (46-60) 3,830 1,580 28.104 4,310 1,960 6,270 Dominated
VIA (16-45) + Pap (46-60) 3,840 1,590 28.104 4,480 1,950 6,430 Dominated
VIA (15-45) + Pap (46-60) 3,840 1,590 28.104 4,640 1,950 6,590 Dominated
Pap = «‘∏’·ªª ‡¡’¬√å
* ∂“π°“√≥åªí®®ÿ∫—π · ¥ß§à“Õâ“ßՑ߇ªìπ®”π«πºŸâªÉ«¬„À¡à·≈–®”π«πºŸâ‡ ’¬™’«‘μ
°“√«‘‡§√“–Àåμâπ∑ÿπÕ√√∂ª√–‚¬™πå · ¥ß¥â«¬§à“
Õ—μ√“ à«πμâπ∑ÿπª√– ‘∑∏‘º≈ à«π‡æ‘Ë¡ (incremental Cost-Ef- fectiveness Ratios; ICERs) ¥—ßμ“√“ß∑’Ë 2 ‚¥¬À“°„Àâ
§«“¡∂’Ë¢Õß°“√§—¥°√Õ߇∑à“‡¥‘¡§◊Õ∑ÿ° 5 ªï ·μà≈¥Õ“¬ÿ∑’ˇ√‘Ë¡
§—¥°√Õß®“° 30 ‡ªìπ 25, 20 ·≈– 15 ªï ICER ®–‡∑à“°—∫
-56,500 -45,800 ·≈– -25,200 ∫“∑μàÕªï ÿ¢¿“«–μ“¡≈”¥—∫
°≈à“«§◊Õ°“√§—¥°√Õß∑’ËÕ“¬ÿπâÕ¬≈ߙ૬‡æ‘Ë¡®”π«πªï ÿ¢¿“«–
‡π◊ËÕß®“°ªÑÕß°—π°“√ Ÿ≠‡ ’¬®“°°“√‡ªìπ¡–‡√Áß·≈–≈¥°“√‡ ’¬
™’«‘μ ∑—È߬—ß„™âμâπ∑ÿπ‚¥¬√«¡πâÕ¬°«à“ À√◊Õª√–À¬—¥‡ß‘π‰¥â¡“°
°«à“¡“μ√°“√ªí®®ÿ∫—π ·μà‡¡◊ËÕæ‘®“√≥“μ“¡À≈—°§«“¡§ÿ⡧à“
∑“ß ÿ¢¿“æ·≈â« °“√§ßÕ“¬ÿ∑’˧—¥°√Õ߇∑à“‡¥‘¡§◊Õ 30-60 ªï
‡À¡◊Õπ„πªí®®ÿ∫—π ·μà‡ª≈’Ë¬π§«“¡∂’Ë®“°∑ÿ° 5 ªï ‡ªìπ∑ÿ° 3 ªï
‡ªìπ¡“μ√°“√∑’˧ÿâ¡§à“°«à“ ‡ÀÁπ‰¥â®“° ICER ‡∑à“°—∫ -73,300
∫“∑μàÕªï ÿ¢¿“«– ‡¡◊ËÕ‡∑’¬∫°—∫¡“μ√°“√„πªí®®ÿ∫—π À√◊Õ‡¡◊ËÕ
‡∑’¬∫º≈≈—æ∏å ÿ¥∑⓬∑“ß ÿ¢¿“æ∑’ˇæ‘Ë¡‡∑à“°—π§◊Õ 1 ªï ÿ¢¿“«–
°“√§—¥°√Õß¡–‡√Áߪ“°¡¥≈Ÿ°∑ÿ° 3 ªï„π μ√’Õ“¬ÿ 30-60 ªï ®–
ª√–À¬—¥μâπ∑ÿπ„π¡ÿ¡¡ÕߢÕß —ߧ¡¡“°∑’Ë ÿ¥ §◊Õ 73,300 ∫“∑
‡¡◊ËÕæ‘®“√≥“¡“μ√°“√∑’Ë¡’§«“¡§ÿâ¡§à“ °“√§—¥°√Õß∑ÿ° 3 ªï ·μà‡√‘Ë¡∑’ËÕ“¬ÿπâÕ¬≈ߧ◊Õ 27 ‡ªìπ¡“μ√°“√∑’Ë¡’§«“¡§ÿâ¡§à“ ‚¥¬¡’
ICER ‡∑à“°—∫ -53,800 ∫“∑μàÕªï ÿ¢¿“«–‡¡◊ËÕ‡ª√’¬∫‡∑’¬∫°—∫
°“√‡√‘Ë¡§—¥°√Õß∑’ËÕ“¬ÿ 30 ªï °“√‡√‘Ë¡§—¥°√Õß∑’ËÕ“¬ÿ 24 ·≈–
21 ªï‡ªìπ¡“μ√°“√∑’Ë¡’§«“¡§ÿâ¡§à“„π≈”¥—∫∂—¥¡“ °“√§—¥°√Õß
∑ÿ° 3 ªï ‚¥¬‡√‘Ë¡∑’ËÕ“¬ÿ 18 ·≈– 15 ªï ‡ªìπ¡“μ√°“√∑’ˉ¡à¡’
§«“¡§ÿâ¡§à“‡¡◊ËÕ‡∑’¬∫°—∫°“√‡√‘Ë¡∑’Ë 21 ªï ‡π◊ËÕß®“°¡’ ICER Ÿß
∂÷ß 124,800 ·≈– 289,000 ∫“∑μàÕªï ÿ¢¿“«– Õ’°π—¬Àπ÷Ëߧ◊Õ
‡ªìπ°“√≈ß∑ÿπ‡æ‘Ë¡‡æ◊ËÕ¢¬“¬°“√§—¥°√Õß ·μà°≈—∫¡’®”π«πªï ÿ¢¿“«– à«π‡æ‘Ë¡πâÕ¬¡“° ®÷߉¡à§«√π”¡“æ‘®“√≥“ª√–°Õ∫
°“√μ—¥ ‘π„®„π√–¥—∫ª√–™“°√ ≈”¥—∫∂—¥‰ª∑’˧«√§”π÷ß®÷ß
‡ªìπ°“√§—¥°√Õß∑ÿ°ªï ‡√‘Ë¡∑’ËÕ“¬ÿ 26, 25 ·≈– 24 ªï μ“¡≈”¥—∫
°“√§—¥°√Õß∑ÿ°ªï„π μ√’Õ“¬ÿμË”°«à“ 24 ªï‰¡à¡’§«“¡§ÿâ¡§à“‡™àπ
°—π ‡π◊ËÕß®“°¡’μâπ∑ÿπ Ÿß°«à“ ·μàº≈≈—æ∏å∑“ß ÿ¢¿“æ‡æ‘Ë¡‡æ’¬ß
‡≈Á°πâÕ¬ À“°π”¢âÕ √ÿª®“°μ“√“ß∑’Ë 2 ¡“ √â“ß°√“ø®–‰¥âμ“¡
√Ÿª∑’Ë 6
√Ÿª∑’Ë 6 ·°ππÕπ§◊Õº≈μà“ߢÕß®”π«πªï ÿ¢¿“«– ·°π μ—Èߧ◊Õº≈μà“ߢÕßμâπ∑ÿπ §à“μ‘¥≈∫À¡“¬∂÷ß¡’μâπ∑ÿπ≈¥≈ß —≠≈—°…≥å ◊ §◊Õ°“√§—¥°√Õß∑ÿ° 5 ªï —≠≈—°…≥å Δ §◊Õ°“√
§—¥°√Õß∑ÿ° 3 ªï —≠≈—°…≥å ●● §◊Õ°“√§—¥°√Õ߇ªìπª√–®”
∑ÿ°ªï μ—«‡≈¢„π —≠≈—°…≥åÀ¡“¬∂÷ßÕ“¬ÿ∑’ˇ√‘Ë¡§—¥°√Õß ∑ÿ°
√Ÿª∑’Ë 5 º≈≈—æ∏å∑“ß ÿ¢¿“æ μâπ∑ÿπ°“√ªÑÕß°—π·≈–√—°…“¡–‡√Áߪ“°¡¥≈Ÿ°¢Õß∑“߇≈◊Õ°μà“ßÊ P = Pap smear; V = Visual Inspection with Acetic acid
4,000 6,000 8,000 10,000
4,000 6,000 8,000 10,000
Total cost (Baht / person) Health outcomes
(cases / year)
Treatment cost for cancer Prevention cost for screening New cervical cancer cases Death
0 2,000
,
0 2,000
,
V(30-45) P(50-60)
V(25-45) P(50-60)
V(20-45) P(50-60)
V(15-45) P(50-60)
V(30-45) P(48-60)
V(27-45) P(48-60)
V(24-45) P(48-60)
V(21-45) P(48-60)
V(18-45) P(48-60)
V(15-45) P(48-60)
V(30-45) P(46-60)
V(25-45) P(46-60)
V(20-45) P(46-60)
V(15-45) P(46-60)
5-yearly
80% coverage of screening
Do nothing
3-yearly Annually
¡“μ√°“√®– ‘Èπ ÿ¥∑’ËÕ“¬ÿ 60 ªï ®ÿ¥μ—¥√–À«à“ß·°πμ—Èß·≈–·°π πÕπ§◊Õμ—«·∑π¢Õß ∂“π°“√≥åªí®®ÿ∫—π Õ’°π—¬Àπ÷Ëߧ◊Õ°“√§—¥
°√Õß∑ÿ° 5 ªï ”À√—∫ μ√’Õ“¬ÿ 30 - 60 ªï ‡ âπ°√“ø≈“°‡™◊ËÕ¡
μàÕ‡©æ“–∑“߇≈◊Õ°∑’Ë¡’§«“¡§ÿâ¡§à“‡æ◊ËÕ‡ªìπ·π«∑“ß„π°“√
μ—¥ ‘π„®μ“¡≈”¥—∫¢—Èπ‡√’¬°«à“ efficiency frontier §à“§«“¡
™—π¢Õ߇ âπμ√ß√–À«à“ß·μà≈–∑“߇≈◊Õ°®–‡∑à“°—∫ ICER
‡π◊ËÕß®“°„πª√–‡∑»‰∑¬¡’ —¥ à«π°“√„Àâ∫√‘°“√«‘∏’
·ªª ‡¡’¬√å·≈– VIA ·μ°μà“ß°—π ‚¥¬«‘∏’ VIA ¡’¢âÕ®”°—¥
¢Õß°“√¢¬“¬∫√‘°“√∑’Ë∑”‰¡à‰¥â√«¥‡√Á« ‡π◊ËÕß®“°μâÕß¡’°√–∫«π-
°“√Ωñ°Õ∫√¡·≈–ª√–‡¡‘πº≈ Õ’°∑—Èß«‘∏’π’ȉ¡à “¡“√∂μ√«®‰¥â„π μ√’∑ÿ°§π ‚¥¬‡©æ“–ºŸâ∑’ËÕ“¬ÿ¡“° ‡æ√“–√Õ¬μàÕ√–À«à“߇¬◊ËÕ∫ÿ ‡§«å¡— ·≈–§Õ≈—¡π“√å (squamocolumnar junction)
¡â«πμ—«·≈–¡Õ߇ÀÁπ‰¡à™—¥ ªí®®ÿ∫—𧫓¡ “¡“√∂„π°“√√Õß√—∫
∫√‘°“√«‘∏’ VIA Õ¬Ÿà∑’Ë 200,000 √“¬μàÕªï ¥—ßπ—ÈπÀ“°®–¢¬“¬
°“√§—¥°√Õß„π√–¥—∫ª√–™“°√ «‘∏’·ªª ‡¡’¬√å®÷߇ªìπ«‘∏’À≈—°
Õ¬à“߉√°Áμ“¡ Õ—μ√“°”≈—ߢÕß∫ÿ§≈“°√¿“§√—∞ ‚¥¬‡©æ“–
‡®â“Àπâ“∑’ËÕà“π ‰≈¥å¿“¬À≈—߇°Á∫μ—«Õ¬à“߇¬◊ËÕ∫ÿ¡¥≈Ÿ° ‡ªìπ ª√–‡¥Áπ∑’˧«√æ‘®“√≥“ °“√»÷°…“π’È«‘‡§√“–À姫“¡‡ªìπ‰ª‰¥â
„π°“√√Õß√—∫∫√‘°“√‚¥¬π—°‡´≈≈å«‘∑¬“„π —ß°—¥°√–∑√«ß “∏“√≥ ÿ¢ ´÷Ëßªí®®ÿ∫—π¡’ª√–¡“≥ 290 §π º≈≈—æ∏套ßμ“√“ß∑’Ë 3 °≈à“«§◊Õ À“°¢¬“¬°“√§—¥°√Õß„π°≈ÿࡇªÑ“À¡“¬∑’Ë¡’Õ“¬ÿ 30 - 60 ªï ‚¥¬‡ª≈’Ë¬π§«“¡∂’Ë®“°∑ÿ° 5 ªï ‡ªìπ∑ÿ° 3 ªï ª√‘¡“≥
‰≈¥å®–‡æ‘Ë¡®“° 2 ≈â“π‡ªìπ 3.4 ≈â“π·ºàπμàÕªï ®÷ß®”‡ªìπμâÕß
¡’π—°‡´≈≈å«‘∑¬“ 470 §π À√◊Õ§‘¥‡ªìπ 1.62 ‡∑à“¢Õß®”π«π ªí®®ÿ∫—π
√Ÿª∑’Ë 6 μâπ∑ÿπ·≈–ªï ÿ¢¿“«– à«π‡æ‘Ë¡¢Õß¡“μ√°“√μà“ßÊ ‡∑’¬∫°—∫
¡“μ√°“√ªí®®ÿ∫—π
μ“√“ß∑’Ë 3 §«“¡‡ªìπ‰ª‰¥â¢Õß®”π«ππ—°‡´≈≈å«‘∑¬“ ‡¡◊ËÕ¡’°“√¢¬“¬°“√§—¥°√Õß
§—¥°√Õß∑ÿ° 5 ªï §—¥°√Õß∑ÿ° 3 ªï
À—«¢âÕ „π μ√’Õ“¬ÿ 30-60 ªï „π μ√’
( ∂“π°“√≥åªí®®ÿ∫—π) Õ“¬ÿ 30-60 ªï
®”π«π‡ªÑ“À¡“¬∑—ÈßÀ¡¥ 15.8 ≈â“π§π*
®”π«π‡ªÑ“À¡“¬ ‡¡◊ËÕÕ—μ√“§—¥°√Õߧ◊Õ√âÕ¬≈– 80 12.7 ≈â“π§π
®”π«π‡ªÑ“À¡“¬μàÕªï 2.5 ≈â“π§π 4.2 ≈â“π§π
ª√–¡“≥°“√≥å®”π«π‡ªÑ“À¡“¬∑’Ë√—∫∫√‘°“√„πÀπà«¬ß“π¿“§√—∞ √âÕ¬≈– 85† 2.2 ≈â“π§π 3.6 ≈â“π§π
- «‘∏’·ªª ‡¡’¬√å 2 ≈â“π§π 3.4 ≈â“π§π
- «‘∏’ VIA 2 · π§π 2 · π§π
®”π«ππ—°‡´≈≈å«‘∑¬“∑’ËμâÕß°“√‡ 270 §π 470 §π
Õ—μ√“ à«π‡∑’¬∫°—∫Õ—μ√“°”≈—ߧπ„πªí®®ÿ∫—π 0.94 1.62
*∑’Ë¡“: ¢âÕ¡Ÿ≈ ”¡–‚πª√–™“°√·≈–‡§À– ªï 2553 ”π—°ß“π ∂‘μ‘·Ààß™“μ‘(12)
†∑’Ë¡“: °“√»÷°…“‡™‘ß ”√«® μ√’Õ“¬ÿ 30-60 ªï ®”π«π 4,500 §π ªï 2552 ‚§√ß°“√ª√–‡¡‘π‡∑§‚π‚≈¬’·≈–π‚¬∫“¬¥â“π ÿ¢¿“æ(4)
‡§”π«π®“°®”π«π«—π∑”ß“π 20 «—πμàÕ‡¥◊Õπ ª√‘¡“≥°“√Õà“π 30 ‰≈¥åμàÕ«—π
-500
00 0.005 0.01 0.015 0.02 0.025 0.03 0.035 0.04
al cost (Baht)
Incremental QALYs (years)
-1,500 -1,000
Incrementa
30
30
27
24 21
2625 24 30
25 20 15
18 15
30 29 28
27 2322
21 20
19 18 17 16 15
«‘®“√≥å
∂“π°“√≥奔‡π‘πß“π§—¥°√Õß¡–‡√Áߪ“°¡¥≈Ÿ°¡’·π«
‚πâ¡¥’¢÷Èπμ—Èß·μàªï 2550 ‡ªìπμâπ¡“ Õ—μ√“°“√§—¥°√Õß Ÿß¢÷Èπ‡√◊ËÕ¬Ê
®“°ª√–¡“≥√âÕ¬≈– 20 „πªï 2550 ‡ªìπ√âÕ¬≈– 60-70 „πªï 2552 μàÕ¡“°√–∑√«ß “∏“√≥ ÿ¢·≈– ”π—°ß“πÀ≈—°ª√–°—π ÿ¢¿“æ·Ààß™“쑉¥âμ—È߇ªÑ“„Àâ¡’°“√√≥√ߧå·≈–¢¬“¬°“√√—∫
∫√‘°“√§—¥°√Õß¡–‡√Áߪ“°¡¥≈Ÿ°‰¡àμË”°«à“√âÕ¬≈– 80 ¢Õß
°≈ÿࡇªÑ“À¡“¬ ®÷߇ªìπ∑’Ë¡“¢Õß°“√»÷°…“π’È∑’Ë«‘‡§√“–Àåμâπ∑ÿπ Õ√√∂ª√–‚¬™πå ‚¥¬Õâ“ßÕ‘ß ∂“π°“√≥åªí®®ÿ∫—π‡æ◊ËÕ„™â„π°“√
‡ª√’¬∫‡∑’¬∫ §◊Õ μ√’Õ“¬ÿ√–À«à“ß 30-60 ªï √—∫°“√§—¥°√Õß
¡–‡√Áߪ“°¡¥≈Ÿ°‡ªìπª√–®”∑ÿ° 5 ªï ¥â«¬«‘∏’·ªª ‡¡’¬√å À√◊Õ VIA «‘∏’À≈—ß®”°—¥Õ“¬ÿ‰¡à‡°‘π 45 ªï
º≈°“√«‘‡§√“–Àå· ¥ß„Àâ‡ÀÁπ«à“¡“μ√°“√ªí®®ÿ∫—π¡’
ª√– ‘∑∏‘º≈ªÑÕß°—π°“√‡°‘¥¡–‡√Áߪ“°¡¥≈Ÿ°·≈–≈¥°“√‡ ’¬
™’«‘쉥â∂÷ß√âÕ¬≈– 40 ‡¡◊ËÕ‡∑’¬∫°—∫°“√‰¡à¡’¡“μ√°“√ ‚¥¬æ∫
«à“°“√‡æ‘Ë¡§«“¡∂’Ë®“°∑ÿ° 5 ªï ‡ªìπ∑ÿ° 3 ªï ·μà‰¡à¢¬“¬°≈ÿà¡
Õ“¬ÿ ‡ªìπ¡“μ√°“√∑’Ë¡’§«“¡§ÿâ¡§à“ §«√π”¡“æ‘®“√≥“ ‡æ√“–
§“¥«à“®–≈¥®”π«πºŸâªÉ«¬„À¡à‰¥âªï≈–°«à“ 900 √“¬ ·≈–ªÑÕß°—π
°“√‡ ’¬™’«‘μÕ’°ªï≈– 450 √“¬ ‡∑à“°—∫≈¥§«“¡ Ÿ≠‡ ’¬∑“ß
‡»√…∞»“ μ√宓°°“√‡ªìπ¡–‡√Á߉¥âªï≈–°«à“ 1,200 ≈â“π∫“∑
‡¡◊ËÕ‡∑’¬∫°—∫ ∂“π°“√≥åªí®®ÿ∫—π
∑—Èßπ’È ª√–‚¬™πå¢Õß°“√§—¥°√Õß®–‡ÀÁπ™—¥‡®π„π√–¬–
5-10 ªï¢â“ßÀπâ“ ·μà„π™à«ßμâπ¢Õß°“√¢¬“¬§«“¡§√Õ∫§≈ÿ¡
ß“π§—¥°√Õß ®”π«πºŸâ¡’º≈‡´≈≈庑¥ª°μ‘·≈–Õÿ∫—μ‘°“√≥å
¡–‡√Áß®–‡æ‘Ë¡¢÷Èπ√–¬–Àπ÷Ëß Õ—π‡ªìπº≈®“°§«“¡ ”‡√Á®¢Õß°“√
§âπÀ“ºŸâ¡’‡´≈≈庑¥ª°μ‘·≈–«‘π‘®©—¬ ®“°π—Èπ®÷߇¢â“ Ÿà√–¬–§ßμ—«
§◊ÕÕÿ∫—μ‘°“√≥å¡–‡√Áß≈¥≈ß·≈– —¥ à«πºŸâªÉ«¬¡–‡√Áß√–¬–‡√‘Ë¡
μâπμàÕ¡–‡√Áߪ“°¡¥≈Ÿ°∑—ÈßÀ¡¥‡æ‘Ë¡¢÷Èπ
°“√¢¬“¬∫√‘°“√§—¥°√Õß®“°∑ÿ° 5 ªï‡ªìπ∑ÿ° 3 ªï¬—߇ªìπ
‰ª‰¥â¬“°„πªí®®ÿ∫—π‚¥¬‡©æ“–¢âÕ®”°—¥‡√◊ËÕßÕ—μ√“°”≈—ßπ—°
‡´≈≈å«‘∑¬“ Õ—μ√“°”≈—ߧπ„πªí®®ÿ∫—π “¡“√∂√Õß√—∫ª√‘¡“≥
ß“π‰¥âæÕ¥’ ·μàÀ“°¡’°“√¢¬“¬‚ª√·°√¡§—¥°√Õ߇ªìπ∑ÿ° 3 ªï
®”‡ªìπμâÕßæ—≤π“Õ—μ√“°”≈—ߧπÕ’° 180 §π À√◊Õ‡∑à“°—∫√âÕ¬≈–
62 ¢Õß®”π«ππ—°‡´≈≈å«‘∑¬“„πªí®®ÿ∫—π
°“√»÷°…“π’È«‘‡§√“–Àå‚¥¬„™â«‘∏’∫Ÿ√≥“°“√√–À«à“ß VIA (30-45 ªï) ·≈–·ªª ‡¡’¬√å (45 ªï¢÷Èπ‰ª) ´÷Ë߇ªìπ¡“μ√°“√∑’Ë
§ÿâ¡§à“¡“°°«à“«‘∏’„¥«‘∏’Àπ÷Ëß ·μà„π∑“ߪؑ∫—μ‘°“√„Àâ∫√‘°“√ VIA
¡’¢âÕ®”°—¥„π ∂“π∫√‘°“√ª∞¡¿Ÿ¡‘·≈–‰¡à§√Õ∫§≈ÿ¡∑ÿ°æ◊Èπ∑’Ë
„πª√–‡∑»‰∑¬ °“√»÷°…“π’È®÷ß∑¥ Õ∫‡æ‘Ë¡‡μ‘¡¿“¬„μâ ∂“π°“√≥å∑’Ë¡’·ªª ‡¡’¬√å‡æ’¬ßÕ¬à“߇¥’¬«„π∑ÿ°°≈ÿà¡Õ“¬ÿ ¢âÕ √ÿª‡ªìπ‰ª„π·π«∑“߇¥’¬«°—∫«‘∏’∫Ÿ√≥“°“√ π—Ëπ§◊Õ §«√§ß Õ“¬ÿ¢Õß°≈ÿࡇªÑ“À¡“¬‰«â‡™àπ‡¥‘¡∑’Ë 30-60 ªï ®÷ß®–‡À¡“– ¡
·≈–§ÿ⡧à“∑’Ë ÿ¥„π∫√‘∫∑¢Õߪ√–‡∑»‰∑¬
Õπ÷Ëß °“√»÷°…“π’ȉ¡à‰¥âæ‘®“√≥“μ—«‡≈◊Õ°°“√§—¥°√Õß«‘∏’Õ◊Ëπ
‡™àπ ·ªª ‡¡’¬√å∑’Ë„™â‡∑§π‘§ liquid-based ·≈–°“√μ√«® HPV DNA ´÷Ëß¡’√“§“§àÕπ¢â“ß Ÿß·≈–¬—߉¡à·æ√àÀ≈“¬„πª√–‡∑»‰∑¬
πÕ°®“°π’È °“√»÷°…“¬—ß¡’¢âÕ®”°—¥„π°“√«‘‡§√“–À姫“¡‡ªìπ
‰ª‰¥â¥â“πÕ—μ√“°”≈—ß ‡æ√“–æ‘®“√≥“‡©æ“–°”≈—ߧπ„π —ß°—¥
°√–∑√«ß “∏“√≥ ÿ¢ ‰¡à√«¡§π∑’Ë —ß°—¥Àπà«¬ß“π¿“§√—∞Õ◊ËπÊ
¢âÕ¬ÿμ‘
¡“μ√°“√§—¥°√Õß„πªí®®ÿ∫—π¡’§«“¡§ÿâ¡§à“¥â“π ÿ¢¿“æ·≈–
ª√‘¡“≥ß“π ‡À¡“– ¡°—∫Õ—μ√“°”≈—߇®â“Àπâ“∑’Ë„πªí®®ÿ∫—π °“√
¢¬“¬ ‘∑∏‘ª√–‚¬™πå¢Õß°“√§—¥°√Õß¡–‡√Áߪ“°¡¥≈Ÿ°„π√–∫∫
À≈—°ª√–°—π ÿ¢¿“æ·Ààß™“μ‘ ºŸâ°”Àπ¥π‚¬∫“¬μâÕ߇μ√’¬¡°“√
≈à«ßÀπâ“·≈–»÷°…“‡æ‘Ë¡‡μ‘¡„πªí®®—¬Õ◊Ë𠇙àπ √–∫∫∫√‘À“√
®—¥°“√·≈–æ—≤π“∫ÿ§≈“°√„π “¢“∑’ˇ°’ˬ«¢âÕß √–∫∫§«∫§ÿ¡
§ÿ≥¿“æ °“√®—¥°“√¢âÕ¡Ÿ≈Õ¬à“߇ªìπ√–∫∫·≈–‡™◊ËÕ¡μàÕ√–À«à“ß Àπ૬∫√‘°“√μà“ßÊ ‡ªìπμâπ
°‘μμ‘°√√¡ª√–°“»
°“√»÷°…“π’ȇªìπ à«πÀπ÷ËߢÕß ç‚§√ß°“√æ—≤π“™ÿ¥ ‘∑∏‘
ª√–‚¬™πå¥â“π°“√§—¥°√Õß∑“ß ÿ¢¿“æ√–¥—∫ª√–™“°√„π ª√–‡∑»‰∑¬é¿“¬„μâ°“√ π—∫ πÿπß∫ª√–¡“≥®“° ”π—°ß“π À≈—°ª√–°—π ÿ¢¿“æ·Ààß™“μ‘ ‚¥¬§≥–ºŸâ«‘®—¬®“°‚§√ß°“√
ª√–‡¡‘π‡∑§‚π‚≈¬’·≈–π‚¬∫“¬¥â“π ÿ¢¿“æ (HITAP) ´÷Ë߇ªìπ Õߧå°√∑’ˉ¥â√—∫°“√ π—∫ πÿπ®“° ”π—°ß“π°Õß∑ÿπ π—∫ πÿπ
°“√«‘®—¬ ¿“¬„μâ∑ÿπ‡¡∏’«‘®—¬Õ“«ÿ‚ ‡æ◊ËÕæ—≤π“»—°¬¿“æ°“√
