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Previous Volume 354:1535-1536 April 6, 2006 Number 14 Next

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To the Editor: The study by the Alliance for Cervical Cancer Prevention Cost Working Group, reported by Goldie et al. (Nov. 17 issue),¹ is biased against cytologic screening. Costs for cytologic tests are overestimated. Costs for human papillomavirus (HPV) tests are underestimated. Single-visit cytologic screening² is not considered. The Alliance was awarded a $50-million gift from the Bill and Melinda Gates Foundation on the assumption that noncytologic screening tests constitute the most likely solution to the problem of cervical cancer in developing countries.³ This assumption constitutes a potential source of bias against cytology that should be disclosed. Similarly, the partnership between the Program for Appropriate Technology in Health, a study cosponsor, and Digene,⁴ which markets HPV tests, should be disclosed.

Screening tests for cervical cancer are appropriately characterized as complementary, rather than competitive. Without cytology to triage HPV tests or visual primary screening tests, referral rates for colposcopy are unsustainable.⁵ Unlike single-visit cytologic screening,² single-visit visual screening and HPV screening require the administration of ablative treatment before the possibility of invasive carcinoma has been excluded, which necessitates considerable psychological morbidity.⁵

Eric J. Suba, M.D.
Kaiser Permanente Medical Center
South San Francisco, CA 94080
eric.suba{at}kp.org

William J. Frable, M.D.
Virginia Commonwealth University
Richmond, VA 23298

Stephen S. Raab, M.D.
University of Pittsburgh Medical Center
Pittsburgh, PA 15232

References

1. Goldie SJ, Gaffikin L, Goldhaber-Fiebert JD, et al. Cost-effectiveness of cervical-cancer screening in five developing countries. N Engl J Med 2005;353:2158-2168. [Free Full Text]
2. Brewster WR, Hubbell FA, Largent J, et al. Feasibility of management of high-grade cervical lesions in a single visit: a randomized controlled trial. JAMA 2005;294:2182-2187. [Free Full Text]
3. Pollack AE, Tsu VD. Preventing cervical cancer in low-resource settings: building a case for the possible. Int J Gynaecol Obstet 2005;89:Suppl 2:S1-S3. 
4. PATH and Digene partner to bring HPV testing for cervical cancer to developing countries. Press release of Digene, Gaithersburg, Md., February 18, 2004. (Accessed March 16, 2006, at http://investor.digene.com/phoenix.zhtml?c=82439&p=irol-newsArticle&ID=646134&highlight=.)
5. Suba EJ, Murphy SK, Donnelly AD, Furia LM, Huynh MLD, Raab SS. Systems analysis of real-world obstacles to successful cervical cancer prevention in developing countries. Am J Public Health 2006;96:480-487. [Free Full Text]

Clinical-trial outcomes that were associated with cytologic screening and same-day treatment that bypassed colposcopy and biopsy were published after our article was in press. Our study was conducted in the United States in a clinical-practice setting in close proximity to a laboratory with access to courier service. We are in agreement with Dr. Suba and colleagues that a strategy of one-visit cytologic screenings might be assessed for highly selected settings.

In our report, we discussed the consequences associated with overtreatment of patients with false positive results and inadequate treatment of advanced cervical intraepithelial neoplasia or early cancer, but these risks are relatively small, as compared with the lifetime risk of cervical cancer. All studies by the Alliance for Cervical Cancer Prevention have been approved after undergoing ethics review by institutions based either in the United States or in Europe and by in-country academic and government ethics review boards. Programs using the single-visit approach are considered safe and acceptable by the American College of Obstetricians and Gynecologists.²

In the past three decades, cytologic screening for cervical cancer has been available, and yet more than 6 million women have died of this disease. We encourage all efforts to accelerate the implementation of sustainable, cost-effective strategies to reduce mortality from a preventable cancer that disproportionately affects the poorest women in the world.

Sue J. Goldie, M.D., M.P.H.
Harvard School of Public Health
Boston, MA 02115
sue_goldie{at}harvard.edu

References

1. Goldhaber-Fiebert JD. Papanicolaou screening in developing countries. Am J Clin Pathol 2005;124:314-315. [Web of Science][Medline]
2. ACOG Executive Board, American College of Obstetricians and Gynecologists. ACOG statement of policy: cervical cancer prevention in low-resource settings. Obstet Gynecol 2004;103:607-609. [Medline]

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