Volume 197, Issue 4 , Pages 337-339, October 2007
The evolution of cost-effective screening and prevention of cervical carcinoma: implications of the 2006 consensus guidelines and human papillomavirus vaccination
Article Outline
Cervical cancer accounts for more gynecology-related deaths worldwide than any other malady, thus making it the most important preventable disease in woman’s health today. Although likely an underestimate, Parkin et al1 reported that cervical cancer affected 493,243 women worldwide in 2002, which makes it the second most common female cancer and the third most common cause of female cancer death, with 273,505 deaths reported. Another way to analyze the importance of cervical cancer to society is to evaluate the years of life lost by young and middle-aged women (25-64 years old). On a global basis, cancer of the cervix is responsible for approximately 2% of the total (weighted) years of life lost.2 However, it is the most important cause of years of life lost in Latin America and the Caribbean. Cervical cancer also contributes the largest portion to years of life lost from cancer in the populous regions of Sub-Saharan Africa and South-Central Asia, where the actual risk of loss of life from this cause is even higher, although it is somewhat overshadowed by deaths from noncancerous causes, such as acquired immunodeficiency disease and tuberculosis.
See related articles, pages 340 and 346
In the developed world in general and the United States specifically, cervical cancer incidence and mortality rates have declined approximately 75% over the past 3 decades. Still, the disease remains a serious health threat, with an estimated incidence and mortality rate of 11,150 and 3670 in 2007, respectively.3 Incidence rates for Hispanic and Asian, especially Vietnamese, women are higher than those for non-Hispanic non-Asian American women. In addition, the African American mortality rate continues to be more than double that of white women, even though the mortality rate for African American women has declined more rapidly than the rate for white women.
Cervical cancer is preventable and generally curable if detected early. Important strategies to reduce the risk of cervical cancer include screening through the use of the Papanicolaou test, human papillomavirus (HPV) testing, and prophylactic HPV vaccination. Researchers have identified HPV, which is transmitted through sexual contact, as the main cause of cervical cancer. Although the exact financial burden of HPV is unknown, it is estimated that the annual direct medical costs that are associated with cervical cancer treatment in the United States range between 300 and 400 million US dollars and that the annual direct medical costs that are associated with cervical intraepithelial neoplasia (CIN) in the United States range between 700 million and 2.3 billion US dollars.4
So, what is the most cost-effective and efficient method to reduce the incidence and death from cervical cancer? Clearly, widespread HPV vaccination is the most promising approach.5 Using noninfectious virus-like particles, HPV vaccination has been shown to be virtually 100% effective in preventing persistent type-specific HPV infections and their neoplastic sequelae.6 Fortunately, idiosyncratic toxicities have not been reported with HPV vaccination, although the durability of the vaccine induced immunity is unknown.
The 2006 Consensus Guidelines for the Management of Women with Abnormal Cervical Cancer Screening Tests7 and The 2006 Consensus Guidelines for the Management of Women with Cervical Intraepithelial Neoplasia or Adenocarcinoma in-situ,8 published in this issue of the Journal, provide clinicians with cost-effective recommendations for managing abnormal Papanicolaou test results and treatment of precancerous cervical lesions. The 146 experts, who included representatives from 29 professional organizations, federal agencies, and national and international health organizations, are to be commended for proposing the best clinical practices for cervical cancer control. Importantly, these guidelines were formulated within a framework of uncertainty and incomplete data and were derived from many sources, considering multifaceted epidemiologic, economic, social, political, and cultural factors. These revised treatment guidelines from the American Society for Colposcopy and Cervical Pathology join the screening recommendations from the American College of Obstetricians and Gynecologists, the American Cancer Society, as well as the US Preventive Services Task Force in an attempt to standardize cervical cancer prevention practices in the United States.9
These undated consensus guidelines incorporate some of the significant advances in our understanding of the natural history of HPV infections and CIN. In addition, the guidelines emphasize the extremely small chance of a serious lesion in lieu of a biopsy specimen that shows CIN I with a preceding low-grade Papanicolaou test result, even if the colposcopic examination is unsatisfactory. Finally, more emphasis is placed on immediate “screen and treat” approaches when treating women with high-grade Papanicolaou test results. HPV DNA testing is also incorporated into the treatment of women with Papanicolaou test results that show atypical glandular cells after their initial evaluation with colposcopy and endometrial sampling.
The guidelines are a product of a comprehensive and strenuous review process by cervical health experts; nonetheless, there are some notable limitations, largely because of the paucity of data from sufficiently powered studies, especially in the area of surveillance intervals and the negative predictive value of colposcopy. Concern exists therefore for the impact of false-negative colposcopy results in patients who will undergo lengthened screening intervals. In addition, the small risk of missing an occult cancer is obvious when CIN 2 or 3 are managed conservatively. Finally, the guidelines make no mention of HPV vaccination, nor do they consider future revisions in existing screening recommendations. Clearly, revisions in our approach to cervical cancer screening and prevention are needed as our understanding of the complex epidemiology of HPV and cervical cancer evolves and HPV vaccination becomes more widespread. Further study and careful modeling in this area are needed desperately.
To achieve cost-effective reductions in the cervical cancer burden, prevention initiatives must consider screening and immunization as integrated and organized entities (Figure). Alternative screening approaches that capitalize on advances in molecular genetics will likely be adopted in the future. Some experts currently would advocate for potentially leveraging HPV testing as a primary screening test, followed by triage with Papanicolaou cytologic findings.10 This alternative strategy would have the added benefit of providing immunosurveillance in vaccinated populations.
FIGURE.
Cost-effective screening and prevention of cervical carcinoma
Cost-effective screening and prevention of cervical carcinoma will require cooperation and integration of recommendations from organizations (1) that create guidelines for the management of abnormal Papanicolaou test results, such as the American Society for Colposcopy and Cervical Pathology7, 8; (2) that make recommendations for cervical cancer screening, such as the American College of Obstetricians and Gynecologists, the American Cancer Society, and the US Preventive Services Task Force; and (3) that provide advice and guidance to the Centers for Disease Control and Prevention on the control of vaccine-preventable diseases like human papillomavirus, such as the Advisory Committee on Immunization Practices.
Monk. The evolution of cost-effective screening and prevention of cervical carcinoma. AJOG 2007.
Further study of alternative screening models is needed to develop a system that can realize the cost savings in screening that is necessary to offset the added cost of universal HPV vaccination. The current guidelines are a short step toward this end; unfortunately, their net effect will likely not realize this necessary and worthy goal. Finally, although universal vaccination of teenagers and young women is a desirable policy, ethical and cultural barriers must be conquered before HPV vaccination is adopted widely across all sectors.11
References
- . Global cancer statistics, 2002. CA Cancer J Clin. 2005;55:74–108
- . Cervical cancer as a priority for prevention in different world regions: an evaluation using years of life lost. Int J Cancer. 2004;109:418–424
- Cancer Facts and Figures 2007. American Cancer Society; 2007;
- . Assessing the annual economic burden of preventing and treating anogenital human papillomavirus-related disease in the US: analytic framework and review of the literature. Pharmacoeconomics. 2005;23:1107–1122
- . Vaccines against human papillomavirus and cervical cancer: promises and challenges. Oncologist. 2005;10:528–538
- . Human papillomavirus vaccine: a new chance to prevent cervical cancer. Recent Results Cancer Res. 2007;174:81–90
- The 2006 consensus guidelines for the management of women with abnormal cervical cancer screening tests. Am J Obstet Gynecol. 2007;197:346–355
- The 2006 consensus guidelines for the management of women with cervical intraepithelial neoplasia or adenocarcinoma in-situ. Am J Obstet Gynecol. 2007;197:340–345
- . Cervical cancer screening. Curr Oncol Rep. 2004;6:497–506
- . Cervical cancer screening following the implementation of prophylactic human papillomavirus vaccination. Future Oncol. 2007;3:319–327
- . Will widespread human papillomavirus prophylactic vaccination change sexual practices of adolescent and young adult women in America?. Obstet Gynecol. 2006;108:420–424
PII: S0002-9378(07)00996-9
doi:10.1016/j.ajog.2007.08.030
© 2007 Mosby, Inc. All rights reserved.
Refers to article:
- 2006 consensus guidelines for the management of women with cervical intraepithelial neoplasia or adenocarcinoma in situ
- 2006 consensus guidelines for the management of women with abnormal cervical cancer screening tests
Volume 197, Issue 4 , Pages 337-339, October 2007
