Obstet Gynecol Surv. 2005 Feb;60(2):96-7.
A cost-effectiveness analysis of screening strategies for cervical intraepithelial neoplasia.
Straughn JM Jr, Numnum TM, Rocconi RP, Leath CA 3rd, Partridge EE. Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, Alabama.
The authors created a decision model to compare the cost-effectiveness of 3 different screening strategies for cervical intraepithelial neoplasia (CIN). In strategy 1, patients were screened annually with a conventional Pap smear. If the results were normal, the patient was notified and scheduled for screening in 1 year. Patients with atypical squamous cell of undetermined significance (ASGUS) had repeat Pap smears every 6 months with referral to colposcopy after 2 ASGUS results.Strategy 2 involved annual screening with liquid-based cytology. Patients with normal results were scheduled for repeat screening in 1 year. When ASGUS was found, human papillomavirus (HPV) testing of the cervical specimen was performed, and patients with positive results were referred for immediate colposcopy. Negative patients were scheduled for rescreening in 1 year. In strategy 3, screening with liquid-based cytology was performed, and patients with normal results were scheduled for rescreening in 2 years. Cervical specimens containing ASGUS were subjected to HPV testing and referred for immediate colposcopy when positive results were found. Rescreening was scheduled in 1 year if results of HPV testing were negative.Direct costs of each strategy, rather than charges, were estimated using information from the University of Alabama at Birmingham and data from the state health department. Analyses used conservative cost estimates, which included a direct cost for a conventional Pap smear, for liquid-based cytology, for HPV testing, and for an office visit. Charges were estimated for a 24-month period.The least expensive strategy was biennial screening with liquid-based cytology, which had a total cost of million per 100,000 patients and referred the fewest patients to colposcopy (11.8%). In contrast, annual liquid-based screening had a total cost of million per 100,000 patients and was the most expensive strategy. Annual screening with conventional Pap smear was the intermediate option with a cost of million.Decreasing the estimated direct costs of the Pap smear, liquid-based cytology, or HPV testing did not change the outcome of the model. Similarly, increasing from 2 to 3 the number of ASGUS results from liquid-based screening necessary for referral to colposcopy, although it did reduce the number of colposcopic examinations, did not reduce the overall costs. The cost savings were more than offset by the increased cost of annual screening.
Diagn Cytopathol. 2005 Feb;32(2):125-32.
A cost-effectiveness analysis of four management strategies in the determination and follow-up of atypical squamous cells of undetermined significance.
Hughes AA, Glazner J, Barton P, Shlay JC. Department of Preventive Medicine, University of Colorado Health Sciences Center, Denver, Colorado 80204, USA. Alice.Hughes@rmpdc.org
Atypical squamous cells of undetermined significance (ASC-US) are the most common abnormal cytological result on Papanicolaou (Pap) smear. We analyzed four management strategies in a hypothetical cohort of women divided by age group: (1) immediate colposcopy, (2) repeat cytology after an ASC-US Pap smear result, (3) conventional Pap with reflex human papillomavirus (HPV) testing, and (4) liquid-based cytology with reflex HPV testing. Parameter variables were collected from previously published data. Strategies that included reflex HPV testing had the lowest overall costs for all age groups combined. Repeat Pap smears had the highest number of true positive results throughout all stages but also had the uppermost number of missed cancers and highest costs. Immediate colposcopy had the second highest overall costs and detected fewer true positive results than liquid-based cytology. Younger women (aged 18-24 yr) consistently had higher total costs for all strategies investigated. Using the incremental cost-effectiveness (CE) ratio, the immediate colposcopy strategy was more costly and less effective than liquid-based cytology and, therefore, was dominated. The incremental CE ratio was lowest for liquid-based cytology compared with conventional cytology and liquid-based cytology with reflex HPV testing was the most cost-effective strategy. Copyright (c) 2005 Wiley-Liss, Inc.
Lancet. 2004 Nov 6;364(9446):1678-83.
Regression of low-grade squamous intra-epithelial lesions in young women.
Moscicki AB, Shiboski S, Hills NK, Powell KJ, Jay N, Hanson EN, Miller S, Canjura-Clayton KL, Farhat S, Broering JM, Darragh TM. Department of Pediatrics, University of California, San Francisco, CA, USA. annam@itsa.ucsf.edu
BACKGROUND: The aim of this study was to assess the probability of low-grade squamous intra-epithelial lesion (LSIL) regression in young women, and to examine the factors associated with this regression. METHODS: In a longitudinal study of human papilloma virus (HPV) infection, female adolescents aged 13-22 years were examined every 4 months by cytology, colposcopy, and HPV DNA status. Both prevalent and incident LSIL cases were included in the analysis, with regression defined as at least three consecutive normal Pap smears. FINDINGS: Median follow-up time from baseline (defined as the time of first LSIL diagnosis) for the 187 women with LSIL was 61 months (IQR 34-80). Median time they had been sexually active at diagnosis was 3.2 years (2.6-6.5). Probability of regression for the entire cohort was 61% (95% CI 53-70) at 12 months and 91% (84-99) at 36 months of follow-up. No associations were found between LSIL regression and HPV status at baseline, sexual behaviour, contraceptive use, substance or cigarette use, incident sexually transmitted infection, or biopsy. Multivariate analysis showed that only HPV status at the current visit was associated with rate of regression, whether infection was caused by one or more viral types (relative hazard=0.3 [95% CI 0.21-0.42], and 0.14 [0.08-0.25], respectively). INTERPRETATION: The high rate of regression recorded in this study lends support to observation by cytology in the management of LSIL in female adolescents. Negative HPV status was associated with regression, suggesting that HPV testing could be helpful in monitoring LSIL.
Gynecol Oncol. 2004 Sep;94(3):693-8.
A comparison of modified MonoPrep2 of liquid-based cytology with ThinPrep Pap test.
Nam JH, Kim HS, Lee JS, Choi HS, Min KW, Park CS. Department of Pathology, Chonnam National University Medical School, Gwangju, South Korea.
OBJECTIVE: The purpose of this study is to evaluate a modified MonoPrep2 (MP) of liquid-based cytology (LBC) to search for a less expensive alternative technique usable for screening of cervical cancers. STUDY DESIGN: Cervicovaginal direct-to-vial samples from 1218 consecutive patients were processed with the modified MP technique and the results were compared with those of currently popular ThinPrep Pap test (TP) technique. RESULTS: Both MP and TP methods provide uniformly spread thin layers of cells without cellular overlap or significant obscuring elements. The diameter of the circular area was 20 mm in MP and 22 mm in TP. Obscuring factors were slightly more frequent in MP but not enough to affect interpretation. Thirteen specimens were excluded from the study because of poor specimen quality in MP. In 1205 patients, there was an absolute agreement in results (the Bethesda diagnosis system) between the two methods, and discordances were observed in only 18 (1.5%) in 1187 cases (98.5%). Furthermore, there was no significant difference in diagnostic accuracy in histopathologic correlation between the two methods. The sensitivity of MP was slightly lower than that of TP, and the specificity of MP was higher than that of TP. A human papillomavirus (HPV) test with polymerase chain reaction (PCR) using broad-spectrum probes has yielded good results in both MP and TP samples. CONCLUSIONS: The modification of the MP method gave comparable results to those of TP in terms of smear quality, cytologic diagnostic evaluation, and biopsy correlation with much less cost. The modified MP offers a cost-effective alternative to the currently popular expensive techniques of liquid-based cytology practical for cervical cancer screening.
Gynecol Oncol. 2004 Jul;94(1):181-6.
HPV DNA test and Pap smear in detection of residual and recurrent disease following loop electrosurgical excision procedure of high-grade cervical intraepithelial neoplasia.
Sarian LO, Derchain SF, Andrade LA, Tambascia J, Morais SS, Syrjanen KJ. Obstetrics and Gynecology Department, Universidade Estadual de Campinas, UNICAMP, Campinas, Sao Paulo 13083-370, Brazil.
OBJECTIVE: We compared the performance of cervical cytology and HPV DNA test in detection of residual or recurrent disease following the treatment of cervical intraepithelial neoplasia (CIN) 2/3 with loop electrosurgical excision procedure (LEEP). SUBJECTS AND METHODS: A series of 107 women subjected to LEEP due to histologically confirmed CIN 2/3 between March 2001 and December 2002 were followed-up biannually until January 2004. Follow-up visits consisted of interview and gynecological examination including cervical cytology, hybrid capture II (HCII), and colposcopy. Patients presenting with abnormal colposcopy or high-grade squamous intraepithelial lesion (HSIL) smear were subjected to new excision procedure, and presence of histologically confirmed CIN 2/3 or higher was considered as residual or recurrent disease. Performance indicators were calculated for cytology and HCII assay in detecting residual or recurrent disease. RESULTS: Eleven (10.2%) women showed residual or recurrent disease during the follow-up. Considering HCII and Pap smear as stand-alone tests, both techniques showed similar sensitivity, detecting 100% of CIN 2/3 at the first follow-up visit. At the second follow-up visit, Pap smear showed better specificity and positive predictive value (PPV) than HCII, and both tests had fairly the same high negative predictive value (NPV) and sensitivity. The combined positive HCII and abnormal cytology had the same sensitivity as each of the tests alone, but specificity and PPV were significantly higher than those of single tests. When only one of the tests was positive, the sensitivity and the NPV of the combination remained the same, but its specificity and PPV were lower than that of the combined two positive tests and that of the individual test, at both follow-up visits. CONCLUSIONS: Both tests performed well in detecting residual or recurrent disease after LEEP and combination of the tests did not increase sensitivity of the single tests.
Publication Types: - Clinical Trial
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