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Eric J. Suba, M.D.
Kaiser Permanente Medical Center
San Francisco, CA 94115
eric.suba{at}kp.org
Edmund S. Cibas, M.D.
Harvard Medical School
Boston, MA 02115
Stephen S. Raab, M.D.
University of Colorado Health Sciences Center
Aurora, CO 80045
References
Jain Ankit, M.D.
Kidwai Memorial Institute of Oncology
Bangalore 560030, India
ankitjaindm{at}gmail.com
Jain Prakriti, M.B., B.S., D.G.O.
Bhagwan Mahaveer Jain Hospital
Bangalore 560052, India
K.C. Lakshmaiah, M.D., D.M.
Kidwai Memorial Institute of Oncology
Bangalore 560030, India
References
The current data cast doubt on VIA, which is an invaluable asset to cervical-cancer prevention in developing countries. The benefit of VIA in low-resource settings is that it can be used to detect cervical precancer inexpensively and that it enables the examiner to institute immediate and appropriate therapy. This strategy decreases the risk that a patient with a potentially precancerous lesion will be lost to follow-up.
We strongly believe that the lack of survival benefit reported in the current article should not preclude the lifesaving results of screen-and-treat programs that have been demonstrated previously.
Miriam L. Cremer, M.D., M.P.H.
Basic Health International
San Salvador, El Salvador
mlcremer{at}hotmail.com
Elizabeth Conlisk, Ph.D.
Hampshire College
Amherst, MA 01002
Juan C. Felix, M.D.
University of Southern California
Los Angeles, CA 90033
Dr. Felix reports receiving lecture fees from Qiagen and Hologic. No other potential conflict of interest relevant to this letter was reported.
References
Programs for the prevention and treatment of human immunodeficiency virus (HIV) infection and the acquired immunodeficiency syndrome (AIDS) are being implemented in many developing nations, where cervical-cancer incidence and mortality rates are also high. HIV–AIDS programs are slowly but substantially contributing to improved health infrastructures and increasing access to health care.2 Integration of cervical-cancer prevention services within HIV–AIDS programs is an excellent opportunity to target women at highest risk for cervical cancer, as we recently showed in Zambia.3,4 Such efforts hold the promise of both saving lives from an eminently preventable cancer and strengthening the broader primary care context that is so essential for the sustainability of vertical health programs.
Mulindi H. Mwanahamuntu, M.B., B.S., M.Med.
University Teaching Hospital
Lusaka, Zambia
Vikrant V. Sahasrabuddhe, M.B., B.S., Dr.P.H.
Vanderbilt University Institute for Global Health
Nashville, TN 37203
vikrant.sahasrabuddhe{at}vanderbilt.edu
Groesbeck P. Parham, M.D.
Center for Infectious Disease Research in Zambia
Lusaka, Zambia
References
, the number of assays one would need to conduct, on average, would be only
N x [1/
+ 1 – (1 – )].
In the study by Sankaranarayanan et al., was approximately 0.10. Suppose an assay tolerates a dilution of 1:3 and the budget permits N assays. Pooling in groups of three would require (0.6)N assays, and the number of women who could be screened would be (1/0.6)N, or 1.67N. Further gains would accrue if women who presented for screening could be grouped according to risk, with individual-level assays reserved for high-risk women and pooling used for lower-risk women.
Clarice R. Weinberg, Ph.D.
National Institute of Environmental Health Sciences
Research Triangle Park, NC 27709
References
The reasons for the discrepancies are not entirely clear to us. There were no differences in the follow-up care among the study groups. That HPV testing had a higher sensitivity for detecting potentially progressive precursor lesions than that of cytologic testing or VIA is clear from our findings. Nevertheless, long-term follow-up of the study cohorts may clarify the current lack of effect after VIA or cytologic testing. Perhaps the health education provided to the control women had an effect on the burden of cervical cancer, resulting in the absence of a significant detectable difference in the rate of advanced disease or deaths from cervical cancer between the control group and the VIA or cytologic-testing groups. An underestimation of the number of cervical-cancer cases and deaths in the control group cannot be ruled out either, since cervical cancers were diagnosed in the control group in women with symptoms who were seeking diagnostic services, and health services in the Osmanabad district are underdeveloped. Some women with disease might not have sought clinical care, and such cases and deaths might have been missed because of the lack of hospital records for such patients.
The above possibilities may account for the apparent lack of effectiveness of VIA and cytologic screening at this time. However, since we plan to continue the follow-up of the study groups for cervical-cancer incidence and mortality for several years, we will clarify the long-term effects of the interventions, including any delayed reductions in mortality in the cytologic-testing and VIA groups.
In reply to Mwanahamuntu et al. and Weinberg: approaches to the screening of women older than 30 years of age that involve using fewer rounds of screening with a highly sensitive test and targeting early diagnosis among women who are positive for high-risk HPV types are already good strategies to maximize the utilization of public health budgets. We hope that HPV testing will become affordable in all settings in the near future.
Rengaswamy Sankaranarayanan, M.D.
International Agency for Research on Cancer
69372 Lyon CEDEX 08, France
sankar{at}iarc.fr
Kasturi Jayant, M.Sc.
Nargis Dutt Memorial Cancer Hospital
Barshi 413 401, India
Surendra S. Shastri, M.D.
Tata Memorial Center
Mumbai 400 012, India
References
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