The Clinical and Economic Benefits of Co-Testing Versus Primary HPV Testing for Cervical Cancer Screening: A Modeling Analysis

An economic evaluation of two cervical screening algorithms in Belgium: HR-HPV primary compared to HR-HPV and liquid-based cytology co-testing

OBJECTIVE

To assess the costs and benefits of two algorithms for cervical cancer screening in Belgium (1) high-risk human papillomavirus (HR-HPV) primary screening and (2) HR-HPV and liquid-based cytology (LBC) co-testing.

METHODS

A decision tree was adapted from published work and parameterised using HORIZON study data and Belgian cost and population data. The theoretical model represents two different screening algorithms for a cohort of 577 846 women aged 25-64 attending routine cervical screening. Scenario analyses were used to explore the impact of including vaccinated women and alternative pricing approaches. Uncertainty analyses were conducted.

RESULTS

The cost per woman screened was €113.50 for HR-HPV primary screening and €101.70 for co-testing, representing a total cost of €65 588 573 and €58 775 083, respectively, for the cohort; a 10% difference. For one screening cycle, compared to HR-HPV primary, co-testing resulted in 13 173 more colposcopies, 67 731 more HR-HPV tests and 477 020 more LBC tests. Co-testing identified 2351 more CIN2+ cases per year (27% more than HR-HPV primary) and 1602 more CIN3+ cases (24% more than HR-HPV primary) than HR-HPV primary.

CONCLUSION

In Belgium, a co-testing algorithm could increase cervical pre-cancer detection rates compared to HR-HPV primary. Co-testing would cost less than HR-HPV primary if the cost of the HPV test and LBC were cost-neutral compared to the current cost of LBC screening but would cost more if the cost per HPV test and LBC were the same in both co-testing and HR-HPV primary strategies.

Understanding the Dynamics of Human Papillomavirus and Diagnostic Discrepancies in Cervical Pathology: A Single Center Experience

Cervical cancer (CC) is the most prevalent gynecological malignancy and a leading cause of death among women. It is primarily caused by human papillomavirus (HPV) infection, with 99.7% of cases showing high-risk HPV genotypes. This study sheds light on HPV dynamics as well as the discrepancies of different CC screening modalities results while highlighting factors that may have contributed to such a scenario. Moreover, we underscore the importance of the non-viral etiology of CC as well. We examined the current trends of HPV infection and its effects on cervical health in women treated at a tertiary care center in Belgrade, Serbia. Patients with abnormal colposcopy findings like dysplasia and re-epithelization were more likely to test negative for HPV (p < 0.001). Interestingly, women with a positive Pap smear tested HPV negative significantly more often (p = 0.041). Finally, HPV-positive individuals were more likely to have CIN I and II histologies (p < 0.001), while CIN III occurred equally in women with and without the virus. It may be inferred that inconsistencies in detecting HPV and the presence of cervical lesions may eventually result in adjustments to screening guidelines, as is crucial to adopt a meticulous approach to promote periodical CC screening, as initial samples may test negative for HPV.

Exploration of biomarkers for the diagnosis, treatment and prognosis of cervical cancer: a review

As the fourth most diagnosed cancer, cervical cancer (CC) is one of the major causes of cancer-related mortality affecting females globally, particularly when diagnosed at advanced stage. Discoveries of CC biomarkers pave the road to precision medicine for better patient outcomes. High throughput omics technologies, characterized by big data production further accelerate the process. To date, various CC biomarkers have been discovered through the advancement in technologies. Despite, very few have successfully translated into clinical practice due to the paucity of validation through large scale clinical studies. While vast amounts of data are generated by the omics technologies, challenges arise in identifying the clinically relevant data for translational research as analyses of single-level omics approaches rarely provide causal relations. Integrative multi-omics approaches across different levels of cellular function enable better comprehension of the fundamental biology of CC by highlighting the interrelationships of the involved biomolecules and their function, aiding in identification of novel integrated biomarker profile for precision medicine. Establishment of a worldwide Early Detection Research Network (EDRN) system helps accelerating the pace of biomarker translation. To fill the research gap, we review the recent research progress on CC biomarker development from the application of high throughput omics technologies with sections covering genomics, transcriptomics, proteomics, and metabolomics.

A systematic review of economic evaluations of cervical cancer screening methods

OBJECTIVE

The aims of this systematic review were to (1) identify primary- and model-based economic evaluations of cervical cancer screening methods and to (2) provide a contextual summary of valuation outcomes associated with three types of cervical cancer screening tests: visual inspection with acetic acid, human papillomavirus deoxyribonucleic acid, and Papanicolaou smear.

INTRODUCTION

Cervical cancer screening is an important public health priority with the potential to improve the detection of precancerous lesions in high-risk females for early intervention and disease prevention. Test performance and cost-effectiveness differ based on the specific screening method used across different platforms. There is a need to appraise existing economic evaluations of cervical cancer screening methods.

METHODS

This review considered primary-based and model-based full economic evaluations of cervical cancer screening methods. The evaluation methods of interest included cost-effectiveness analysis, cost-utility analysis, cost-minimization analysis, cost-benefit analysis, and cost-consequence analysis. We searched Scopus, PubMed, National Health Economic Evaluation Database (NH EED), Cochrane, and the Health Economic Evaluation Database for full economic evaluations of cancer screening methods. No formal date restrictions were applied. Model-based and primary-based full economic evaluations were included. A critical appraisal of included studies was performed by the main investigator, while a second independent reviewer assessed critical appraisal findings for any inconsistencies. Data were extracted using a standardised data extraction tool for economic evaluations. The ultimate outcomes of costs, effectiveness, benefits, and utilities of cervical cancer screening modalities were extracted from included studies, analysed, and summarised.

RESULTS

From a total of 671 screened studies, 44 studies met the study inclusion criteria. Forty-three studies were cost-effectiveness analyses, one study reported both cost-utility and cost-effectiveness outcomes, and another study reported cost utilities of cervical cancer screening methods only. Human papillomavirus (HPV) DNA testing was reported as a dominant stand-alone screening test by 14 studies, while five studies reported visual inspection with acetic acid (VIA) as a dominant stand-alone screening test. Primary HPV screening strategies were dominant in 21 studies, while three studies reported cytology-based screening strategies as the dominant screening method.

CONCLUSIONS

Existing evidence indicates that HPV-based and VIA testing strategies are cost-effective, but this is dependent on setting. Our review suggests the limited cost-effectiveness of cytology-based testing, which may be due in part to the need for specific infrastructures and human resources.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020212454 .

Pricing of HPV tests in Italian tender-based settings

BACKGROUND AND AIM

Human papillomavirus (HPV) testing has been recommended by the WHO as the first choice method in cervical cancer screening. So far, only a limited number of countries have implemented primary HPV testing, partly because of the assumed high costs of HPV testing. We assessed tender-based prices of HPV testing in Italy, where programmatic HPV-based screening has been implemented at the regional level.

MATERIALS AND METHODS

Procurement notices and awards, published between 2014 and December 2021, were retrieved from the European online platform for public procurement. The unit price per HPV test was calculated as the ratio of the contract award price and contract volume. The association between the unit price and contract volume, calendar year, number of offers, region's per capita gross domestic product and population density was assessed by linear regression. Fractional polynomials were used to describe the association between the unit price and contract volume.

RESULTS

We retrieved data from 29 procurement procedures. The median unit price per HPV test was €10.75, ranging from €4.30 to €204.80. The unit price was not higher than €5 for 6 out of 11 contract awards with a volume of at least 100,000 tests. After discarding two low-volume contracts with very high contract prices (€182.40 and €204.80), volume explained 86.5% of the variation in unit price. The unit price was not associated with other variables.

CONCLUSIONS

The Italian experience showed that the tender-based unit price of an HPV test is very low when procured at high volume, indicating that there is no reason for countries to further delay the implementation of HPV-based screening because of prohibitively high HPV testing costs.

Comparative cost analysis of cervical cancer screening programme based on molecular detection of HPV in Spain

Background

HPV cervical cancer screening (CCS) must use validated HPV tests based on the molecular detection of either viral mRNA (Aptima HPV Assay—AHPV) or DNA. AHPV has demonstrated the same cross-sectional and longitudinal sensitivity for the detection of HSIL/CIN2+ lesions but with greater specificity than HPV-DNA tests. The study aimed to estimate the total costs of a CCS with a primary HPV test based on the detection of mRNA compared to DNA in women aged 35–65 years for the National Health System.

Methods

A decision-tree-based model to estimate the cost of the CCS until the first colposcopy was designed based on Spanish CCS guidelines. The total cost (€, 2019) for CCS with AHPV or DNA tests (HC2 and Cobas) was calculated, including HPV test, liquid-based cytology (LBC) and colposcopy, for a population of 7,263,529 women aged 35–65 years (assuming 70% coverage). Clinical inputs derived from a literature review were validated by a multidisciplinary expert panel. Data from head-to-head studies between different HPV tests were selected.

Results

The use of AHPV showed reduction of 290,541 (− 35%) and 355,913 (− 40%) LBC compared to HC2 or Cobas, respectively. Furthermore, AHPV avoided 151,699 (− 47%) colposcopies versus HC2 and 151,165 (− 47%) versus Cobas. The total cost of CCS was € 282,747,877 with AHPV, € 322,587,588 with HC2 and € 324,614,490 with Cobas. Therefore, AHPV savings € − 39,839,711 versus HC2 and € − 41,866,613 versus Cobas.

Conclusions

Assuming that 70% of women from 35 to 65 years attend the CCS programme, the cost of screening up to the first colposcopy using AHPV would provide cost savings of up to € 41.9 million versus DNA tests in Spain.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12905-021-01310-8.

Multiplex Visualized Closed-Tube PCR with Hamming Distance 2 Code for 15 HPV Subtype Typing

Cervical cancer is the fourth leading cause of death in women, especially in developing countries. Specific and economic methodologies for HPV typing are crucial in cancer diagnosis and further disease control. However, routine assays based on real-time polymerase chain reaction (qPCR) or DNA-chip hybridization are either incapable of offering detailed subtype information or involve tedious open-tube operations with the risk of cross-contamination from PCR amplicons. Herein, we proposed a multiplex visualized closed-tube PCR (Multi-Vision) for HPV typing. Using gold nanoparticle probes (AuNPs) as a color change indicator combined with a Hamming distance 2 coding scheme, 13 high-risk HPVs and two subtypes associated with high-incidence benign lesions were successfully typed by performing six closed-tube PCRs. The assay demonstrates high specificity with no cross-reaction among different subtypes under several artificial sample concentrations (from 10⁰ to 10³ copies per reaction) and enables highly sensitive detection of as low as 0.5 copies/μL. Further, 105 clinical samples were successfully analyzed using our method with a high concordance rate of 99.05% (104/105) compared to a HPV typing kit. The inconsistent sample was confirmed by sequencing to be consistent with the typing results determined by our method, indicating that Multi-Vision could be a useful tool for HPV detection, especially in resource-limited regions.

Cervical Cancer Screening: Comparison of Conventional Pap Smear Test, Liquid-Based Cytology, and Human Papillomavirus Testing as Stand-alone or Cotesting Strategies

BACKGROUND

Some countries have implemented stand-alone human papillomavirus (HPV) testing while others consider cotesting for cervical cancer screening. We compared both strategies within a population-based study.

METHODS

The MARZY cohort study was conducted in Germany. Randomly selected women from population registries aged ≥30 years (n = 5,275) were invited to screening with Pap smear, liquid-based cytology (LBC, ThinPrep), and HPV testing (Hybrid Capture2, HC2). Screen-positive participants [ASC-US+ or high-risk HC2 (hrHC2)] and a random 5% sample of screen-negatives were referred to colposcopy. Post hoc HPV genotyping was conducted by GP5+/6+ PCR-EIA with reverse line blotting. Sensitivity, specificity (adjusted for verification bias), and potential harms, including number of colposcopies needed to detect 1 precancerous lesion (NNC), were calculated.

RESULTS

In 2,627 screened women, cytological sensitivities (Pap, LBC: 47%) were lower than HC2 (95%) and PCR (79%) for CIN2+. Cotesting demonstrated higher sensitivities (HC2 cotesting: 99%; PCR cotesting: 84%), but at the cost of lower specificities (92%-95%) compared with HPV stand-alone (HC2: 95%; PCR: 94%) and cytology (97% or 99%). Cotesting versus HPV stand-alone showed equivalent relative sensitivity [HC2: 1.06, 95% confidence interval (CI), 1.00-1.21; PCR: 1.07, 95% CI, 1.00-1.27]. Relative specificity of Pap cotesting with either HPV test was inferior to stand-alone HPV. LBC cotesting demonstrated equivalent specificity (both tests: 0.99, 95% CI, 0.99-1.00). NNC was highest for Pap cotesting.

CONCLUSIONS

Cotesting offers no benefit in detection over stand-alone HPV testing, resulting in more false positive results and colposcopy referrals.

IMPACT

HPV stand-alone screening offers a better balance of benefits and harms than cotesting.See related commentary by Wentzensen and Clarke, p. 432.

A hidden Markov model for population-level cervical cancer screening data

The Cancer Registry of Norway has been administrating a national cervical cancer screening program since 1992 by coordinating triennial cytology exam screenings for the female population between 25 and 69 years of age. Up to 80% of cancers are prevented through mass screening, but this comes at the expense of considerable screening activity and leads to overtreatment of clinically asymptomatic precancers. In this article, we present a continuous-time, time-inhomogeneous hidden Markov model which was developed to understand the screening process and cervical cancer carcinogenesis in detail. By leveraging 1.7 million individual's multivariate time-series of medical exams performed over a 25-year period, we simultaneously estimate all model parameters. We show that an age-dependent model reflects the Norwegian screening program by comparing empirical survival curves from observed registry data and data simulated from the proposed model. The model can be generalized to include more detailed individual-level covariates as well as new types of screening exams. By utilizing individual screening histories and covariate data, the proposed model shows potential for improving strategies for cancer screening programs by personalizing recommended screening intervals.

The Value Proposition for Pathologists: A Population Health Approach

The transition to a value-based payment system offers pathologists the opportunity to play an increased role in population health by improving outcomes and safety as well as reducing costs. Although laboratory testing itself accounts for a small portion of health-care spending, laboratory data have significant downstream effects in patient management as well as diagnosis. Pathologists currently are heavily engaged in precision medicine, use of laboratory and pathology test results (including autopsy data) to reduce diagnostic errors, and play leading roles in diagnostic management teams. Additionally, pathologists can use aggregate laboratory data to monitor the health of populations and improve health-care outcomes for both individual patients and populations. For the profession to thrive, pathologists will need to focus on extending their roles outside the laboratory beyond the traditional role in the analytic phase of testing. This should include leadership in ensuring correct ordering and interpretation of laboratory testing and leadership in population health programs. Pathologists in training will need to learn key concepts in informatics and data analytics, health-care economics, public health, implementation science, and health systems science. While these changes may reduce reimbursement for the traditional activities of pathologists, new opportunities arise for value creation and new compensation models. This report reviews these opportunities for pathologist leadership in utilization management, precision medicine, reducing diagnostic errors, and improving health-care outcomes.

The impact of recent power morcellator risk information on inpatient surgery and patient outcomes

Aim: We examine the impact of the new risk information about a surgical device on surgery and patient outcomes for hysterectomy in the inpatient setting. Methods: We utilize a difference-in-differences approach to assess the impact of new risk information on patient outcomes in the inpatient setting between 2009 and 2014. The inpatient data come from a nationally representative sample of hospitalizations in the USA. We use the likelihood of laparoscopic surgery, measures of resource use and surgical complications as outcome variables. Results: We estimate a three-percentage point decrease in the likelihood of receiving laparoscopic hysterectomy, a one-percentage point increase in the likelihood of experiencing a surgical complication and no impact on resource use, relative to pre-existing means. Conclusion: Our findings show that there was movement away from laparoscopic surgery in the months following the dissemination of new risk information. These changes had limited effect on patient outcomes.

Forgone Health and Economic Benefits Associated with Socioeconomic Differences in Organized Cervical Cancer Screening

Objective:

To describe cervical cancer screening participation among women in Taiwan under its population-based screening policy and to estimate the economic burden of disease attributable to avoidable disparities in cervical cancer (CC) screening.

Methods:

We identified a nationally-representative sample of females aged 30 years or above who were eligible for Pap smear testing in Taiwan from 1 January to 31 December 2013. An administrative database with detailed claims of health care utilization under the universal coverage health care system was used. Socioeconomic position of the female subjects was defined using the occupation classification, and two groups were specifically identified: general (O1) and low-income (O5) groups. Differences in screening rate, CC prevalence, and CC-attributable deaths were assessed between the two groups. Economic consequences as a result of screening inequalities were estimated using actual total health care spending (health care expenditure), monetary value per life-year and years of life lost for ill health and screening disparities (health as consumption good), and productivity losses alongside costs of social benefits (health as capital good).

Result:

A total of 301,057 enrolled females aged 30 years and older eligible for screening were identified. Overall, 3-year and 1-year screening rates among all subjects were 0.601 and 0.372, respectively. Impact of observed differences in screening translated to US$59,568 of health care spending in one year, 90.4% of which was specific to hospital admissions. When we viewed health as a consumption good and capital good, the impact of screening disparity on health losses through CC would be equivalent to US$78,095 and US$190,868, respectively.

Conclusion:

Forgone health and economic benefits associated with inequalities in CC screening uptake can be considerable in productive women.

Call for Systematic Population-Based Cervical Cancer Screening: Findings from Community-Based Screening Camps in Tamil Nadu, India

Background:

In India, systematic cervical cancer screening under the national programme is yet to cover the entire population and therefore opportunistic or camp based approach is commonly practiced screening mode currently. This study presents the proportion of screen-positive women [positive visual inspection of the cervix with acetic acid (VIA) and/or Papanicolaou (Pap) smear results] and its associated factors from a rural community-based cervical cancer screening conducted in a service setting.

Methods:

In this cross-sectional study involving record review, data was drawn from free screening camps conducted by a non-governmental organization in two rural districts of Tamil Nadu, India between March 2015 and March 2017. The associations were assessed using adjusted prevalence ratio with 95% confidence interval.

Results:

A total of 5,207 women were screened from 307 camps. The mean age was 39.5 years (SD: 8.6). At least one symptom was observed among 2,245 women (43.1%). Of 5,207 women, 19.4% (n=1,009, 95% CI: 18.3%, 20.5%) were screen-positive. Screen positivity in women <30 years was 19%. Age 31-45 years, age at marriage 18-21 years, age at first child birth less than 18 years and unhealthy cervix (on examination) were significantly associated with screen positivity.

Conclusion:

Reduction in the minimum age of screening from 30 to 21 years considering their marital status and parity, and intensifying awareness campaigns to attract asymptomatic women would be advantageous in early detection and prevention of cervical cancer. Service-based organizations may adopt systematic population-based screening to increase the coverage instead of camp approach.

Relative Performance of HPV and Cytology Components of Cotesting in Cervical Screening

Background

The main goal of cervical screening programs is to detect and treat precancer before cancer develops. Human papillomavirus (HPV) testing is more sensitive than cytology for detecting precancer. However, reports of rare HPV-negative, cytology-positive cancers are motivating continued use of both tests (cotesting) despite increased testing costs.

Methods

We quantified the detection of cervical precancer and cancer by cotesting compared with HPV testing alone at Kaiser Permanente Northern California (KPNC), where 1 208 710 women age 30 years and older have undergone triennial cervical cotesting since 2003. Screening histories preceding cervical cancers (n = 623) and precancers (n = 5369) were examined to assess the relative contribution of the cytology and HPV test components in identifying cases. The performances of HPV testing and cytology were compared using contingency table methods, general estimating equation models, and nonparametric statistics; all statistical tests were two-sided.

Results

HPV testing identified more women subsequently diagnosed with cancer (P < .001) and precancer (P < .001) than cytology. HPV testing was statistically significantly more likely to be positive for cancer at any time point (P < .001), except within 12 months (P = .10). HPV-negative/cytology-positive results preceded only small fractions of cases of precancer (3.5%) and cancer (5.9%); these cancers were more likely to be regional or distant stage with squamous histopathology than other cases. Given the rarity of cancers among screened women, the contribution of cytology to screening translated to earlier detection of at most five cases per million women per year. Two-thirds (67.9%) of women found to have cancer during 10 years of follow-up at KPNC were detected by the first cotest performed.

Conclusions

The added sensitivity of cotesting vs HPV alone for detection of treatable cancer affected extremely few women.

Direct costs of both inpatient and outpatient care for all type cancers: The evidence from Beijing, China

Background

Cancer is a major public health issue worldwide. The cost of cancer care imposes a substantial economic burden on society and patient, but it has not been thoroughly studied in China. This study aimed to describe direct cost and cost elements of all cancer types by different beneficial characteristics.

Methods

The research was a retrospective observational study based on inpatient and outpatient records with a primary diagnosis of cancer from 31 hospitals in 2016. Total cost and cost per time were analyzed by cancer type, sources (prescription medicines, consumables fee for diagnosis and surgery, and other health services), and beneficial characteristics (gender and age).

Results

A total of 30 224 eligible inpatient admissions and 485 391 outpatient visits were identified during the study period. Inpatient care costs account for 58.6% cancer treatment costs. Nearly 70% of the total expenditure is spent on patients aged 50‐79 years. Lung cancer had the highest economic cost (15% of overall cancer costs), followed by breast cancer (12%), and colorectal cancer (10%). Anticancer drug cost accounted a large proportion in both inpatient (37.7%) and outpatient care (64.6%). The average cost per inpatient admission was estimated to be $4590.1 (5621.9), ranging from $1157.7 (1349.8) for testis cancer to $7975 (7343.9) for stomach cancer. The regression analyses revealed that length of hospital stay, cancer type, age, payment type, and hospital level were highly correlated with the expenditure per admission (P < 0.001).

Conclusions

The cancer care cost is substantial and varies with cancer type. Our findings provide important information for health service planning, allowing more efficient allocation of health resources for the care of people with cancer.

PCR-RFLP assay as an option for primary HPV test

Persistent human papillomavirus (HPV) infection is an essential factor of cervical cancer. This study evaluated the analytical performance of restriction fragment length polymorphism polymerase chain reaction (PCR-RFLP) assay compared to PapilloCheck^® microarray to identify human papilloma virus (HPV) in cervical cells. Three hundred and twenty-five women were analyzed. One sample was used for conventional cytology and another sample was collected using BD SurePath™ kit for HPV tests. Eighty samples (24.6%) were positive for HPV gene by PCR-Multiplex and were then submitted to PCR-RFLP and PapilloCheck^® microarray. There was a genotyping agreement in 71.25% (57/80) on at least one HPV type between PCR-RFLP and PapilloCheck^® microarray. In 22 samples (27.5%), the results were discordant and those samples were additionally analyzed by DNA sequencing. HPV 16 was the most prevalent HPV type found in both methods, followed by HPVs 53, 68, 18, 39, and 66 using PCR-RFLP analysis, and HPVs 39, 53, 68, 56, 31, and 66 using PapilloCheck^® microarray. In the present study, a perfect agreement using Cohen's kappa (κ) was found in HPV 33 and 58 (κ=1), very good for HPV 51, and good for types 16, 18, 53, 59, 66, 68, 70, and 73. PCR-RFLP analysis identified only 25% (20/80) HPV coinfection, and PapilloCheck^® microarray found 62.5% (50/80). Our Cohen's kappa results indicate that our in-house HPV genotyping testing (PCR-RFLP analysis) could be applied as a primary HPV test screening, especially in low income countries. If multiple HPV types are found in this primary test, a more descriptive test, such as PapilloCheck^® microarray, could be performed.

Why does cervical cancer occur in a state-of-the-art screening program?

BACKGROUND

The goal of cervical screening is to detect and treat precancers before some become cancer. We wanted to understand why, despite state-of-the-art methods, cervical cancers occured in relationship to programmatic performance at Kaiser Permanente Northern California (KPNC), where >1,000,000 women aged ≥30years have undergone cervical cancer screening by triennial HPV and cytology cotesting since 2003.

METHODS

We reviewed clinical histories preceding cervical cancer diagnoses to assign "causes" of cancer. We calculated surrogate measures of programmatic effectiveness (precancers/(precancers and cancers)) and diagnostic yield (precancers and cancers per 1000 cotests), overall and by age at cotest (30-39, 40-49, and ≥50years).

RESULTS

Cancer was rare and found mainly in a localized (treatable) stage. Of 623 cervical cancers with at least one preceding or concurrent cotest, 360 (57.8%) were judged to be prevalent (diagnosed at a localized stage within one year or regional/distant stage within two years of the first cotest). Non-compliance with recommended screening and management preceded 9.0% of all cancers. False-negative cotests/sampling errors (HPV and cytology negative), false-negative histologic diagnoses, and treatment failures preceded 11.2%, 9.0%, and 4.3%, respectively, of all cancers. There was significant heterogeneity in the causes of cancer by histologic category (p<0.001 for all; p=0.002 excluding prevalent cases). Programmatic effectiveness (95.3%) and diagnostic yield were greater for squamous cell versus adenocarcinoma histology (p<0.0001) and both decreased with older ages (ptrend<0.0001).

CONCLUSIONS

A state-of-the-art intensive screening program results in very few cervical cancers, most of which are detected early by screening. Screening may become less efficient at older ages.

Cytology at the Time of HPV: Some Things to Think about when Discussing HPV

'In the current 28 Member States of the European Union (EU), approximately 34,000 new cases of cervical cancer and 13,000 deaths occur' [Ferlay et al.: Eur J Cancer 2014;49:1374-1403]. 'The current 10-fold gradient in the mortality rates of cervical cancer among the EU Member States largely reflects the persistent absence, or inadequate implementation of cervical cancer screening programmes more than 10 years after organized, population-based screening programmes following European quality assurance guidelines were unanimously recommended by the Health Ministers of the EU' [Council of the European Union: Off J Eur Union 2003;327:34-38]. This article will compare the strengths, weaknesses and risks of the following 4 cervical health screening strategies: HPV as a triage of cytology, cytology as a triage of HPV, cotesting (parallel) or cytology at the time of HPV (HPV-informed guided screening). 'The optimal screening strategy should identify those cervical cancer precursors likely to progress to invasive cancers (maximizing the benefits of screening) and avoid the detection and unnecessary treatment of transient HPV infection and its associated benign lesions that are not destined to become cancerous (minimizing the potential harms of screening)' [Saslow et al.: Am J Clin Pathol 2012;137:516-542].