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WOMEN'S MEDICAL ISSUES, WOMEN'S HEALTH

Pap Smear, Once every 5 years recommended

England makes sound dollar choice as to Pap Smear Testing 

Analysis shows that a 3 year interval (compared to existing 5) would result in one life saved for every 195,000 women in the 25-40 year range.  Given follow testing, there would be an additional 15,550 screenings per year.  Just the lab work runs But the costs amount an extra an extra 385 000 each year just for the lab work; however, 1,000 more would be found with abnormal results, which is an emotional stress on them plus the inconvenience of additional testing.  Finally, the additional tests entail that funds are deprived from other programs.

 

Should there be testing given the cost, low sensitivity, inconvenience for a cancer that accounts for between 2 & 4% of cancer deaths among women, this makes screening questionable (AND AT AN AGE WHERE THE RATE IS MUCH LOWER THAN THOSE ABOVE 60 YEARS).  The screening program costs 4 times that for breast cancer, and as another article pointed out spending those funds on a program to support people and encourage people to quit smoking would save over 10 times as many lives.

 

What troubles, troubles me since the Pap smear test began in the 60s, was that it seemed to be another case of the AMA and in Canada the CMA looking out for the financial interests of doctors first.  Why isn’t women’s birth control pills available over the counter, like other forms of contraception?  Are we not responsible enough to make a sensible health choice for a drug that has no abuse potential?  Doctors aren’t cheap, and those who need most an effective means of contraception are often relying on the man to pull out.--JK  

Cervical screening

From bmj.com (British Medical Journal), 5/29/04, vol. 328, p. 1273

Recent changes in policy regarding age and frequency are a poor use of resources

 

Two expensive healthcare practices have recently been endorsed as policy in England and Wales.1 One is continuing to invite women over 50 for cervical screening; the other is shortening the screening interval from five years to three for younger women. National decisions on single issues disregard competing needs and force local decision makers to neglect other, more pressing, problems.

 

To inform its decision the NHS cervical screening programme commissioned a case-control analysis.2 The difference between three yearly and five yearly screening is too small to measure, which is why we are having to use estimates, despite a huge natural experiment involving widely differing screening intervals throughout the nation and worldwide. The analysis estimated that, for women under 40, the risk reduction is 30% with five yearly screening and 41% with three yearly screening.2 For women aged 40-54 years it is 63% and 69% respectively. The paper mentioned that three yearly screening costs 60% to 66% more than five yearly, and harm from over-diagnosis and over-treatment increases as screening interval decreases. This seems to have had no influence on the recommendations.

 

What does the new guidance mean for a typical local programme? The Avon programme offers five yearly screening to 250 000 eligible women. Each year 59 000 women are tested, of whom 39 000 are aged 25-49.3 Switching to three yearly intervals means nine routine tests by age 50 instead of six. Allowing for the number already having tests for follow up, the actual change in workload for women aged 25-49 will be around 40%, or 15 500 additional women screened each year, together with consequent investigations, treatments, and counselling. At a conservative estimate, with liquid based cytology, of 25 ($46; 36) per woman per year,4 this will cost an extra 385 000 each year.

The estimates from the commissioned case-control study2 suggest this could at best add one woman to the existing 24 women annually (assuming proportional share of national benefit) in whom death from cervical cancer is prevented by our local programme.5 Given known problems with case-control analyses it could be less.6 With five yearly screening, for each death prevented at least 150 women have abnormal results, and at least 50 are treated.7 During any one year in Avon 3000 women aged 25-49 receive abnormal results.3 Changing to three yearly screening could add another 1000 women to this group.

So for districts efficiently regulating a five yearly programme the new policy requires diversion of 385 000 annually into an activity that possibly helps one, and adds 1000 to the "worried sick" category. If the NHS were flush with money and no more beneficial activities were in the queue needing funding then this would be acceptable. But there is no spare money and there are other unmet needs.

 

How unstoppable is three yearly screening? Avon dealt with it in 1987, described its approach in the BMJ in 1991,8 and has been cited as an example of good practice.9 During 15 years with a strict five year interval, returning non-indicated tests to the sender, we receive perhaps three queries a year from women, their partners, their members of parliament, or the press. We respond promptly, with a full explanation, and have never encountered disagreement. I have attended many meetings, seminars, and workshops with women's groups to discuss the issue. Always there is keen interest and real readiness to understand the prioritisation issues we face in health care.

 

The new guidance recommends no screening for women under 25. This is welcome, as the harm to benefit ratio makes screening unethical; for one woman who could be helped by screening in this age group there are tens of thousands who have abnormal results. Controlling this work will help offset the extra cost of three yearly screening. Stopping routine screening beyond 50 would also help, but the NHS cervical screening programme has not sanctioned this. It takes 17 793 three yearly tests to detect one new high grade abnormality in well screened women over 50,10 and at most one death is prevented for each 36 high grades.7 To help one person older than 50 through routine five yearly screening therefore takes 420 000 tests, costing over 8m.

 

Suppose you are faced with the decision about investing 385 000 annually to benefit your local population. You can prevent one death every 22 years by routine five yearly screening beyond age 50, one death a year and harm an extra 1000 by switching to three yearly screening under 50, or 10 deaths a year through support that helps smokers stop,11 and have enough spare to provide first rate nursing care and family support at home for 183 patients facing death from cancer.12

Which would you choose?

 

Angela E Raffle, consultant in public health

Bristol North Primary Care Trust, Bristol BS2 8EE (angela.raffle@bristolnorth-pct.nhs.uk )


Competing interests: None declared.

References

  1. NHS Cervical Screening Programme. Modernising the NHS cervical screening programme—introduction of LBC and change to national policy. Sheffield: NHS Cervical Screening Programme, 22 October 2003. www.cancerscreening.nhs.uk/cervical/news/009.html (accessed 30 Dec 2003)
  1. Sasieni P, Adams J, Cuzick J. Benefit of cervical screening at different ages: evidence from the UK audit of screening histories. Br J Cancer 2003;89: 88-93.[CrossRef][ISI][Medline]
  1. Department of Health. Local KC53 statistics 2002/03. Avon primary care support agency. London: DoH, 2003
  1. NHS Cervical Screening Programme. How much does the programme cost and how is it funded? www.cancerscreening.nhs.uk/cervical/index.html#cost (accessed 27 Oct 2003).
  1. Quinn M, Babb P, Jones J, Allen E. Effect of screening on incidence of and mortality from cancer of cervix in England: evaluation based on routinely collected statistics. BMJ 1999;318: 904-8.[Abstract/Free Full Text]
  1. Moss SM. Case-control studies of screening. Int J Epidemiol 1991;20: 1-6.[Abstract]
  1. Raffle AE, Alden B, Quinn M, Babb PJ, Brett MT. Outcomes of screening to prevent cancer: analysis of cumulative incidence of cervical abnormality and modelling of cases and deaths prevented. BMJ 2003;326: 901.[Abstract/Free Full Text]
  1. Raffle AE, Alden B, Mackenzie EF. Six years' audit of laboratory workload and rates of referral for colposcopy in a cervical screening programme in three districts. BMJ 1990;301: 907-11.[ISI][Medline]
  1. National Audit Office. Performance of the NHS cervical screening programme in England. London, Stationery Office, 1998.
  1. Duncan ID. Guidelines for clinical practice and programme management. Oxford: NHS Cervical Screening Programme, 1992.
  1. Joint Annual Report from the Directors of Public Health. The health of Bristol 2002. Bristol North and Bristol South and West Primary Care Trusts. Bristol: Bristol North Primary Care Trust, 2003.
  1. Avon Palliative Care Service for Home Support and Culturally Appropriate Care. Report for primary care trusts: October 2001-November 2002. Bristol: Bristol North Primary Care Trust, 2003. www.aswcs.nhs.uk/supportivecare/APCreport.pdf (accessed 19 Jan 2004).

 

JK--

Again an agency, the AMA is looking out for its members at the expense of the public.  Analysis that t here would be more harm then good from doing a Pap smear test more often than once every 5 years.   Harm to women who have to undergo the expense and further testing when there is a suspicious result, harm from occupying the medical profession with marginally useful testing, harm by diverting diverting insurance and public health dollar from better alternatives, and harm to those who pay for the procedure by emptying their wallets more than is prudent.  Too bad the US doesn’t have the British type system of medical coverage and our government doesn’t view each of its citizens as its child, and promulgate better policies in the public’s interest.

 

When it first came out, I realized that it was a way for the medical profession to justify making birth control pills a prescription item.  This is of course in the physician’s self interest, and contrary to the public’s interest.  For a number of women endure the uncertain protection of condoms and coitus interruptus.  And those who chose the pill must undergo an inconvenient, embarrassing, costly, and unnecessarily frequent medical procedure.  As George Bernard Shaw said, “Ever trade organization is a conspiracy against the public.” 

 

 

The Role of Human Papilloma Virus Testing in Cervical Cancer Prevention

Posted 02/24/2004

Molly C. Fey, FNP, MSN; Margaret W. Beal, CNM, PhD

Abstract and Introduction

Abstract

A clear causal relationship has been established between human papilloma virus (HPV) infection and the development of cervical cancer. Genital HPV infection is currently the most common sexually transmitted disease worldwide. The recent 2001 American Society for Colposcopy and Cervical Pathology Consensus Guidelines have included HPV testing for management of women with cervical cytological abnormalities. Clinicians now face the challenge of deciding when to use HPV testing in follow-up of abnormal Pap tests. This article includes updates on HPV, cervical cancer screening, and HPV testing technology. Recommendations for integration of HPV testing into clinical practice are provided.

Introduction

Genital human papilloma virus (HPV) infection is currently the most common sexually transmitted disease worldwide.[1-3] It is estimated that 5.5 million people in the United States become infected with HPV each year, and more than 20 million Americans are already infected.[4] Lifetime chance of HPV infection is proposed to be as high as 80% to 85% in sexually active individuals.[5] Acute infection is common soon after the initiation of sexual activity and is highly prevalent among women of reproductive age.[2] HPV infects the genital epithelium and is spread via skin-to-skin contact.[3] Condoms reduce but do not eliminate the risk of transmission, and infection may occur through genital contact without intercourse.[3,6-8] Some strains of HPV cause genital warts, but more often HPV infections produce no signs or symptoms. As a result, infected persons are frequently unaware that they are carriers, and transmission occurs unknowingly.[8]

The most significant risk factor for infection with HPV is the number of lifetime sexual partners.[6-9] Adolescent sexual activity has also proved to be associated with increased risk of HPV infection, yet other factors also influence this risk. The correlation between younger age of first intercourse and subsequent HPV infection is mediated by the number of sexual partners in the last 6 months, a history of sexually transmitted infections, alcohol and drug use related to sexual behaviors, and partner's number of sexual partners.[10]

HPV is a small, non-enveloped, double-stranded circular deoxyribonucleic (DNA) tumor virus, classified in the genus papillomavirus of the Papoviridae family of viruses.[8,11,12] More than 100 distinct types of HPV have been identified to date, and approximately 50 of these infect the epithelial membranes of the anogenital tract.[2,7,8] HPV DNA incorporates itself into the target cell genome, exerting effects through activation of oncogenes and suppression of host cell immune response. HPV protein products prevent DNA repair and programmed cell death, which leads to instability and unchecked cell growth.[9,11,12]

On cytologic examination, cervical cells infected with HPV may appear enlarged, with a clear zone around the nucleus, forming a perinuclear halo. These visible changes are referred to as koilocytosis, a term derived from the Greek word koilos, meaning "hollow." In the past, koilocytic Pap test abnormalities have been considered an indicator of HPV infection, but the reliability of this correlation is now in question and cannot be used to ascertain HPV status.[8,13]

 

 

 

Incidence of Pap Test Abnormalities Within 3 Years of a Normal Pap Test --- United States, 1991--1998

 

from Morbidity & Mortality Weekly Report

 

Report

Declines in cervical cancer incidence and mortality reported in the United States since the 1950s have been attributed to early detection and treatment of precancerous and cancerous lesions through the use of the Papanicolaou (Pap) test [1]. More than 50 million Pap tests are performed each year [2]; however, guidelines about the frequency of testing in women with a history of normal test results are inconsistent [3--5]. To determine the incidence of cervical cytologic abnormalities following a normal Pap test, 1991--1998 data from the National Breast and Cervical Cancer Early Detection Program (NBCCEDP) were analyzed for this report [6]. The findings indicated that within 3 years of a normal Pap test result, severe cytologic abnormalities were uncommon, and incidence rates were similar among women screened 1, 2, and 3 years following a normal Pap test.

For each woman, CDC received a report that included demographic characteristics, Pap test results, diagnostic procedures, and histopathologic results [6,7]. To be eligible for the analysis, women were required to have had a first NBCCEDP Pap test reported as normal during 1991--1998, and at least one subsequent Pap test performed within the following 9--36 months. Of 620,063 women tested during 1991--1998, 128,805 (20.8%) met the criteria for eligibility. Results of Pap tests were reported using Bethesda System categories: normal; infection, inflammation, or reactive changes; atypical squamous cells of undetermined significance (ASCUS); low-grade squamous intraepithelial lesion (LSIL); high-grade squamous intraepithelial lesion (HSIL); "suggestive of squamous cell carcinoma"; and "other" (e.g., glandular atypia and atypical endocervical glands).

Incidence rates of Pap test interpretations were calculated by dividing the number of women with each test result by the number of women retested within each age group (<30, 30--49, 50--64, and 65 years) and time interval (9--12, 13--24, and 25--36 months). Incidence rates were age-adjusted using the age distribution of the 1996 NBCCEDP population. Ordinary least-squared regression was used to evaluate the trend of increasing time between the first Pap test on the age-adjusted incidence of ASCUS, LSIL, HSIL, and suggestive of squamous cell carcinoma.

The average age of women included in the analysis was 48.9 years (range: 12--96 years); 73,631 (57.0%) were non-Hispanic whites, 22,672 (17.6%) were Hispanics, 17,314 (13.4%) were non-Hispanic blacks, 10,983 (8.5%) were American Indians/Alaska natives, 3070 (2.4%) were Asians/Pacific Islanders, and 1135 (0.9%) were categorized as "other" or "unknown." The mean time between the first and second test was 15.7 months. Approximately 121,576 (94.4%) of the 128,805 second test results were interpreted as normal or infection, inflammation, or reactive changes. The incidence rate of the second test results interpreted as HSIL and suggestive of squamous cell carcinomas was 66 per 10,000 women aged <30 years, 22 per 10,000 women aged 30--49 years, 15 per 10,000 women aged 50--64, and 10 per 10,000 women aged 65 years (trend test, p<0.001). Overall, as age increased, the incidence of ASCUS and LSIL also decreased (trend test, p<0.001, each category).

The age-adjusted incidence of results interpreted as LSIL increased over time (trend test, p=0.01) (Table 1). The incidence of ASCUS, the most common cytologic abnormality, did not change significantly over time (p=0.36). The differences in the age-adjusted incidence of HSIL and suggestive of squamous cell carcinoma for the time intervals also were not significant (p=0.42).

Reported by: GF Sawaya, MD, K Kerlikowske, MD, G Gildengorin, PhD, AE Washington, MD, Univ of California, San Francisco. Div of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion; CDC.

Editorial Note

The U.S. Preventive Services Task Force recommends Pap test screening at least every 3 years until age 65 years [5]. The American Cancer Society guidelines suggest that screening less frequent than annually may be adequate for Pap testing in women with a history of 3 negative annual Pap tests [3], and the American College of Obstetricians and Gynecologists recommends annual Pap tests for most women [4].

The difference in screening annually, biennually, or triennially is substantial in the number of tests performed and in the public health implications. In this analysis, women screened 1, 2, and 3 years after a normal Pap test had similar risk for developing HSIL and suggestive of squamous cell carcinoma. Other studies have indicated clinically insignificant additional protection in testing yearly compared with triennially [8]. However, low-grade abnormal Pap results (e.g., ASCUS and LSIL) constituted >95% of the cytologic abnormalities after the first normal results. The clinical significance of these abnormalities is unclear. Women who were screened annually rather than less frequently might have worse health outcomes if low-grade results of undetermined clinical importance lead to further testing and unnecessary patient morbidity and anxiety [9,10].

The findings in this report are subject to at least four limitations. First, the database used was intended for descriptive statistics and not for hypothesis testing; data were limited to a few variables. Second, NBCCEDP serves low-income and uninsured women; results may not be generalizable to other groups. However, low-income and uninsured women usually are at greater risk for developing cervical neoplasia than women with higher incomes; therefore, higher-income women should be less likely to exhibit higher rates during the 3-year interval examined in this study. Third, women may have received Pap testing outside the program during the time between the first and subsequent Pap tests; however, this probably occurred in only a few women. Finally, women who frequently get screened, specifically within 1 year after Pap test, might be low-risk women concerned about their health or high-risk women with histories of abnormal Pap tests who have been told to get annual tests. Other risks for cervical cancer in these women and whether these risks affected the findings in this study are unknown. NBCCEDP receives data from many cytopathology laboratories and clinical settings. The findings in this study may better represent actual clinical settings than the findings in a controlled trial.

CDC is working with state health departments to use this information as a basis for cost-effective strategies to reach women who have not received screening services for cervical disease. CDC will assist NBCCEDP in assessing program-provider practices, modifying patient recall systems, and developing professional and public education strategies to improve patient-provider decision making. Further research is needed to clarify the benefit and harm related to frequency of subsequent Pap testing in women with normal results.

Table 1.

Tripod failed to copy table

 



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