Cross-Country Study on Cervical Cancer Screening
Cervical cancer screening guidelines were recently published by the USPSTF and ACS/ASCCP/ASCP. The guidelines, published after evidence-based review, suggested that less screening was more effective in certain groups of women. The recommendations considered "…both the benefits and harms…, and an assessment of the balance."
In a recent article published in the March issue of the Milbank Quarterly, a multidisciplinary journal of population health and health policy, a comparative study of cervical cancer screening suggests that the United States cancer preventive services are not as cost-effective as international public screening services in the Netherlands. This article is well worth the read and has abundant useful information. This cross-country study evaluated the estimated number of Pap tests performed and cervical cancer mortality rate from 1950 to 2007. Although women in the United States ( NCI SEER registries) undergo far more Pap testing than their counterparts in the Netherlands (Netherlands Cancer Registry 2010), they have similar death rates from cervical cancer.
This information is likely to prove important when taking into consideration the U.S. Patient Protection and Affordable Care Act of 2010 which requires the coverage of preventive services by new private health insurance plans and Medicare, without co-payments or deductibles. Although preventive services are usually cost-effective, implementation methods may affect the real cost savings. Actual practice patterns may not match recently updated guidelines, and could dramatically affect the cost borne by the US taxpayer. The pattern observed in this comparative study likely reflects the differences between the public health model vs medical services model for cervical cancer screening.
In a recent interview conducted by Medscape Medical News, the lead author Martin L. Brown, PhD, concluded the following:
"The cervical cancer screening system in the Netherlands seems to have been as effective as the American system but used much less screening," … "I knew we probably had a lot more overuse here than in the Netherlands, but I guess my expectation was that we'd have better outcomes," ... "As it turned out, the level of use here was much higher and the outcomes were identical."
The Milbank study further concluded that "…adequate coverage of the female population at risk seems to be of central importance."
Policy Analysis and Clinical Guidelines
In the US, there have been few analyses of policy on Pap smear usage. The studies performed have had limited influence on clinical guideline recommendations for cervical cancer screening, although they have shown a very high cost per short screening interval, and a low benefit per cost.
An interesting commentary in the article describes a 2007 U.S. physician survey which ranked in order of influence ("very influential") the pap test screening guidelines prepared by ACOG (PCP-57%,OB-GYN-88%), ACS (PCP-55%, OB-GYN-48%), and USPSTF (PCP-45%, OB-GYN-24%). Of note, only the USPSTF guidelines use an "...evidence-based and transparent process".
The latest USPSTF and ACS/ASCCP/ASCP guidelines recommend against screening women younger than 21 years, and against screening women older than 65 who have had adequate previous screening and are not otherwise at high risk for cervical cancer. Recommendations include Pap testing alone every 3 years for women 21-29, with HPV testing only performed after an abnormal result; and for women 30 to 65 years of age who prefer a longer screening interval, combined cytology and human papillomavirus (HPV) testing every 5 years.
Physician Practices and Attitudes
It will be interesting to see what effect the new guidelines will have on physician practices and attitudes. In the same 2007 survey mentioned above, the group of physicians most inconsistent with the cervical cancer screening guidelines were OB-GYN's followed by primary care physicians…the end result of course being over-utilization of screening.
Although the Milbank article did not specifically study HPV-DNA testing, they do reference recent cervical cancer screening recommendations by the Dutch Health Council, which included replacement of the Pap test with HPV-DNA testing. Current U.S. guidelines, similar to Pap testing guidelines, show much variation in practice compared to guideline recommendation, as suggested in two recent surveys, one discussed in the Milbank article by Saraiya, et. al, and the other from the CAP Supplemental Questionnaire Survey for 2006, by Moriarty, et. al.
The Milbank article has several graphs which are much more detailed than the examples I have provided here. obtained this data directly from the SEER data from the NCI website, and from the Netherlands Cancer Registry. If you want to explore the statistics, I suggest reading the article, as well as visiting the websites online.
Conclusions-Less is More
The conclusions drawn from the Milbank analysis is that when you look at mortality, both prevention programs have demonstrated a reduction in cervical cancer mortality that is similar in both countries, although at dramatically different rates of Pap smear testing and usage. The dramatically lower number of Pap tests performed in the Netherlands, compared to the U. S., emphasizes a more efficient and cost-effective screening process using the public health approach. It does suggest that
screening results in more benefit overall; however, the study did find a potential gap for women over the age of 65, and in women > 30 who had their last pap more than the recommended 5 years. Data also suggests that our medical services model produces significant "clinical waste" associated with cervical cancer screening and prevention in the range of $630 million to $4 billion annually. The authors estimate that the total yearly cost for cervical cancer screening in 2002 dollars is $2.3 billion to $3.8 billion. Estimated savings in 2002 dollars if two-thirds of this cost could be cut are in the range of $1.5 billion to $2.5 billion (or $2 billion to $3.4 billion in 2010 dollars). These potential savings could be better spent by assisting the CDC's National Breast and Cervical Cancer Early Detection Program for cervical cancer screening for low-income women…a program that now only reaches 7% of eligible women in the U.S.
So it seems, that for cervical cancer screening in the U.S., less is more.