Cervical cancer prevention for all the world's women: Genuine promise resides in skilled quality management rather than novel screening approaches

Abstract

The debate over the best route for cervical cancer prevention in developing countries may be considered part of a larger debate over whether the global health community has become enamored with the promise of new approaches at the expense of delivering available preventives today. Pap screening, which is feasible anywhere cervical screening is appropriate, is the only intervention currently available for the prevention of cervical cancer in developing countries, and the Pap test will be an essential component of future novel preventive approaches. Cervical cancer vaccination, the long-term effectiveness of which is uncertain, will not eliminate screening requirements and is currently not affordable in developing countries. Root cause analyses, which may appropriately inform the best routes for improving health in developing countries, document that failures of cervical cancer prevention efforts are not attributable to factors specific to the Pap test but to lapses in programmatic quality management to which all screening tests are vulnerable. The genuine promise of cervical cancer prevention for all the world's women therefore resides in skilled quality management rather than novel screening approaches. We propose a global consensus policy by which Pap screening services will be provided in any setting where cervical screening is appropriate but unavailable, with consideration given to novel preventive approaches as they mature. Opportunity costs, borne by the underserved, are associated with prioritizing research on new approaches in any setting where established preventives are feasible but unavailable.

Cobertura do teste de Papanicolaou e fatores associados à não-realização: um olhar sobre o Programa de Prevenção do Câncer do Colo do Útero em Pernambuco, Brasil

“…Odds ratio IC95% impactar nas taxas de incidência e mortalidade por câncer do colo do útero, freqüentemente, guardam associação com a não-garantia desses fatores 27 . Os resultados deste estudo sugerem que uma expressiva parcela das mulheres pernambucanas, entre 25-59 anos de idade, população-alvo do programa de prevenção do câncer do colo do útero, realizou o teste Papanicolaou com intervalo de tempo máximo recomendado pelo Ministério da Saúde do Brasil.…”

Implicaciones Éticas Y Sociales De La Introducción De La Vacuna Contra El Virus Del Papiloma Humano en México: Reflexiones Sobre Una Propuesta De Intervención

“…Algunos autores sugieren que -en países en vías de desarrollo-los programas de prevención de CaCU, en un escenario ideal, incluyan la vacuna contra VPH en un abordaje integral(8) y, en función de la incertidumbre existente, recomiendan que los recursos se asignen mayoritariamente a tamizaje más que a vacunación (12).…”

Test group biases and ethical concerns mar New England Journal of Medicine articles promoting HPV screening for cervical cancer in rural India

“…The paper also states that “no potential conflict of interest was reported.” However, questions have been raised in the peer-reviewed literature as to whether or not the Gates Foundation and the ACCP might have in effect “become enamored with the promise of science and new technologies at the expense of delivering available preventives today”. [5] Questions have also been raised about the partnership between AACP's coordinating organization and the HPV test manufacturer. [5–7] Similarly, the Gates Foundation was recently acknowledged as having funded a large project supporting publication of a special supplemental issue of the journal Vaccine entitled “Overview of Human Papillomavirus-Based and Other Novel Options for Cervical Cancer Screening in Developed and Developing Countries.”[8] The HPV test manufacturer is also listed as providing corporate support,[8] acknowledged as “critical for meetings and travel.” The two lead authors of the NEJM article and one of the NEJM editorial writers are specifically listed among the large number of international contributors.…”

“…[5] Questions have also been raised about the partnership between AACP's coordinating organization and the HPV test manufacturer. [5–7] Similarly, the Gates Foundation was recently acknowledged as having funded a large project supporting publication of a special supplemental issue of the journal Vaccine entitled “Overview of Human Papillomavirus-Based and Other Novel Options for Cervical Cancer Screening in Developed and Developing Countries.”[8] The HPV test manufacturer is also listed as providing corporate support,[8] acknowledged as “critical for meetings and travel.” The two lead authors of the NEJM article and one of the NEJM editorial writers are specifically listed among the large number of international contributors. The presence of not even a single cytopathologist among the very large number of contributors supported for international travel and meetings clearly suggests an anticytology bias for the proceedings, one perhaps mirrored in the NEJM .…”

“…Pap screening, when successfully implemented, reduces cervical cancer rates by 60–90% within 3 years of introduction to populations that have not been screened; these reductions in incidence and mortality are consistent and dramatic across populations. [513] Even a single round of screening with conventional cytology and limited training in rural India appears to have been remarkably effective, despite the published interpretations of study data in the NEJM . As noted by many of the same authors in their 2005 publication, “Our results clearly show that good quality cytology can be implemented even in a rural setting of a developing country with reasonable investment, while HPV testing does not give any better detection of CIN2/3 lesions, despite the higher investments.”[3] Careful reading of the 2009 publication data and assessments of the numerous internal biases suggest that the widely reported conclusions may be significantly misleading.…”