Strategies for global control of cervical cancer

Pontén, Jan; Adami, Hans‐Olov; Bergström, Reinhold; Dillner, Joakim; Friberg, Lars Göran; Gustafsson, L.; Miller, Anthony B.; Parkin, Donald Maxwell; Sparén, Pär; Trichopoulos, D

doi:10.1002/ijc.2910600102

Cited by 255 publications

(174 citation statements)

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“…The currently available evidence suggests that a shift toward early stages may be achieved at considerably lower costs by health education and improved awareness, as revealed by the findings from Sweden and Barshi, India. 25,26 In summary, the low-threshold test lacks specificity, resulting in huge numbers of false positives requiring follow-up investigations, whereas the high-threshold test lacks sensitivity and fails to detect one-quarter to one-third of invasive cancers present. In any case, in many low-resource countries with a high incidence of cervical cancer, where such a test might be considered for screening (e.g., countries in sub-Saharan Africa), facilities for treating invasive cancer are inadequate.…”

Section: Discussionmentioning

confidence: 99%

Evaluation of downstaging in the detection of cervical neoplasia in Kolkata, India

Basu

Sankaranarayanan

Mandal

et al. 2002

Intl Journal of Cancer

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Unaided visual inspection or "downstaging" has been suggested as a potential alternative method for cervical cancer screening in developing countries. Our study was designed to evaluate the accuracy of downstaging to detect cervical neoplasia in a low-resource setting. A total of 6,399 women aged 30 -64 years were screened with downstaging by trained nonmedical health workers. Two thresholds were used to define positive downstaging: "low threshold" when any visible abnormality on the cervix was considered positive and "high threshold" when selected abnormalities such as bleeding on touch, bleeding erosion, hypertrophied oedematous cervix, congested stippled cervix and growth or ulcer constituted the positive test. All women underwent a colposcopy examination. Biopsies were directed when colposcopy revealed abnormal lesions. True disease status was defined as histologically proven moderate dysplasia and worse lesions. Since all the participants received a diagnostic (reference) investigation (biopsy and/or colposcopy), sensitivity, specificity and predictive values were estimated directly. Low-and high-threshold downstaging were positive in 1,585 (24.8%) and 460 (7.2%) women, respectively. Cytology screening for cervical cancer has been successful in reducing the incidence of and mortality from cervical cancer in many developed countries. 1-3 On the other hand, cervical cancer incidence and mortality rates have either remained unchanged or slowly declined in many low-resource developing countries. 4 -7 The primary reason for this is that most of these countries and regions lack effective cervical cancer screening programmes. Some of them have implemented cytology-based screening programmes nationally or regionally that have had very little impact on the incidence and mortality from cervical cancer. 7-9 The prerequisites for the success of cytology-based screening programmes are high coverage of the target population, preparation of goodquality cytology smears, well-equipped laboratory service with internal and external quality-control measures, adequate numbers of well-trained technical personnel, stringent quality assurance, efficient referral system and treatment and follow-up of those with precursor lesions, most of which are not feasible in underdeveloped countries. Therefore, the need for a relatively inexpensive and low-technology alternative to detect cervical neoplasia in low-resource settings has long been felt.Naked-eye visualization of the cervix (without application of acetic acid) by trained health workers has been considered as an option for low-resource countries to detect cervical cancer early and to improve the survival from the disease. 10,11 This approach, known as downstaging or unaided visual inspection (UVI), has been defined as "the detection of the disease in an earlier stage when still curable, by nurses and other nonmedical health workers using a speculum for visual inspection of the cervix". 11Here we report the findings from a cross-sectional study that evaluated the performance of d...

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Section: Discussionmentioning

confidence: 99%

Evaluation of downstaging in the detection of cervical neoplasia in Kolkata, India

Basu

Sankaranarayanan

Mandal

et al. 2002

Intl Journal of Cancer

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“…53 The sojourn time with screen-detectable HPV infection and CIN is on average 15-20 years on average before invasive cancer. 34,54,55 Because histologic diagnosis of CIN2-3 may vary 5,56 and since most CIN 2-3 lesions will never progress to invasive cancer, 8,57 the majority of women diagnosed with CIN2-3 will have unnecessary treatment. The number of diagnostic procedures, over-treatments and follow-up examinations is reduced by extending screening intervals, resulting in cost savings without changes in the clinical outcome, as found both by us and others.…”

Section: Discussionmentioning

confidence: 99%

“…The prevalence and predictive values of cytology-and HPV DNA-test for biopsy-confirmed CIN2-3 were derived from results from a population-based study that included random colposcopies and blind biopsies to avoid verification bias. 32 Probabilities of invasive cervical cancer and mortality rates for cervical cancer and other causes were derived from the Swedish Cancer Registry 34,35 (Table I). The background risk for cervical cancer in the absence of screening was assumed to be the same as the cumulative life-time risk for cervical cancer before screening started in 1965, namely at 2%.…”

Section: Methodsmentioning

confidence: 99%

“…The background risk for cervical cancer in the absence of screening was assumed to be the same as the cumulative life-time risk for cervical cancer before screening started in 1965, namely at 2%. 34,35 Modeling assumptions are presented in Table II. Outcomes are presented as average and incremental costs and life-years gained or lost over the lifetime of women aged 32 and older and who were exposed to each screening option, although not necessarily attending.…”

Section: Methodsmentioning

confidence: 99%

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Cost‐effectiveness of primary cytology and HPV DNA cervical screening

Bistoletti

Sennfält

Dillner

2007

Intl Journal of Cancer

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Because cost-effectiveness of different cervical cytology screening strategies with and without human papillomavirus (HPV) DNA testing is unclear, we used a Markov model to estimate life expectancy and health care cost per woman during the remaining lifetime for 4 screening strategies: (i) cervical cytology screening at age 32, 35, 38, 41, 44, 47, 50, 55 and 60, (ii) same strategy with addition of testing for HPV DNA persistence at age 32, (iii) screening with combined cytology and testing for HPV DNA persistence at age 32, 41 and 50, iv) no screening. Input data were derived from population-based screening registries, health-service costs and from a population-based HPV screening trial. Impact of parameter uncertainty was addressed using probabilistic multivariate sensitivity analysis. Cytology screening between 32 and 60 years of age in 3-5 year intervals increased life expectancy and life-time costs were reduced from 533 to 248 US Dollars per woman compared to no screening. Addition of HPV DNA testing, at age 32 increased costs from 248 to 284 US Dollars without benefit on life expectancy. Screening with both cytology and HPV DNA testing, at ages 32, 41 and 50 reduced costs from 248 to 210 US Dollars with slightly increased life expectancy. In conclusion, population-based, organized cervical cytology screening between ages 32 to 60 is highly cost-efficient for cervical cancer prevention. If screening intervals are increased to at least 9 years, combined cytology and HPV DNA screening appeared to be still more effective and less costly. ' 2007 Wiley-Liss, Inc.Key words: Markov model; health economics; cervical cancer; organized screening Human Papillomavirus (HPV) DNA testing has been accepted as an adjunct to cytology for primary cervical screening in women over 30 years of age. 1,2 The combination of HPV testing and cervical cytology is more sensitive in detecting cervical intraepithelial neoplasia (CIN) lesions with risk for progression to invasive cancer than either method alone, with extremely high negative predictive values. [3][4][5] Several studies have evaluated the economic impact of cervical screening with and without HPV testing, but have reported variable results. [6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22] Possible reasons for discrepancies include different modeling methodologies, use of surrogate endpoints and use of input data based on clinical studies that may not have been representative of the population as a whole. However, most modeling studies have consistently found similar reductions of the cumulative lifetime risk of invasive cervical cancer as a result of cytology and HPV DNA screening. 6,11,12,19,[23][24][25] State transition models are used in more than 85% of all costeffectiveness analyses and several cervical cancer state transition models have been reported previously. 26,27 The long-term effects and cost of cytology and HPV screening cannot be captured in clinical trials, where all studies have used surrogate endpoints, such as CIN grade 2 or 3 (CIN2-3). ...

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“…In general, elderly patients are reluctant to accept a gynecologic examination as long as they are asymptomatic [30,31], and therefore, are more likely to present with advanced stage disease. Additionally, since cervical cancer screening causes a stage shift towards an earlier stage [32,33], a higher ratio of early to advanced stage disease would be expected in well screened populations than in less screened one. Consequently, the higher proportion of advanced stage cervical cancer in the elderly, as observed in our study, seems to be consistent with this notion.…”

Section: Discussionmentioning

confidence: 99%