Published 6 August 2009, doi:10.1136/bmj.b3186
Cite this as: BMJ 2009;339:b3186

Editor's Choice

An embarrassment of riches

¹ BMJ

At what age should women start having cervical screening? In England screening begins at 25, but elsewhere in the United Kingdom it’s offered from the age of 20. Campaigners have questioned this since the death in February from cervical cancer of the reality television star Jade Goody, who was 27, and at last month’s BMA annual conference 68% of voters called to lower the screening age in England.

Now a large population based study across the UK has provided compelling evidence to support the English stance (doi:10.1136/bmj.b2968). Peter Sasieni and colleagues found that although screening was associated with a 60% reduction of cancers in women aged 40, increasing to 80% at age 64, there was no evidence that screening women aged 22-24 reduced the incidence of cervical cancer over the next five years. While 73 women in this youngest group had cervical cancers, only five could be attributed to lack of screening. As vaccination against human papillomavirus (HPV) gains ground among teenagers, say the authors, the risk of cancer under 25 will almost certainly make screening at such an age unjustifiable.

Would it be better to screen women using HPV testing? Not yet because, although the sensitivity and reliability are greater than for cytology, the specificity and predictive value are still too low and a single test can’t completely define risk or provide reassurance. Now Philip E Castle and colleagues have shown that, among women whose HPV infections don’t resolve within a year, the risk of developing high grade cervical intraepithelial neoplasia in the next three to five years is greatly increased (doi:10.1136/bmj.b2569). They propose repeated testing for the two most carcinogenic HPV types, 16 and 18, starting at age 25.

"More is known about the course of cervical neoplasia than for any other cancer . . . [thus] it might seem that identifying precancerous cervical lesions and establishing the threshold for management and treatment should no longer be a matter of debate," muses Eduardo L Franco, but there’s still the problem of what to do with a cytological result that’s borderline or shows low grade abnormality (doi:10.1136/bmj.b3014). Providing what Professor Franco calls an embarrassment of riches, a trio of UK based studies compares the clinical and economic merits of conservative versus aggressive treatment policies in such cases (doi:10.1136/bmj.b2546, doi:10.1136/bmj.b2548, and doi:10.1136/bmj.b2549). These landmark studies conclude that any benefits of more aggressive treatments are offset by adverse effects, overtreatment, and complications.

These studies’ authors also provide another landmark, by producing the first print issue to carry an entire Research section in the BMJ pico format. We’ve been piloting this way of abridging research articles for the print BMJ, with positive support from readers and authors, and we’re now adopting it fully for new papers (doi:10.1136/bmj.b3168).

And I can’t end without a message for new junior doctors as they start work: you will survive—particularly if you download the free e-book with that title from doc2doc, the BMJ Group’s professional networking site (http://doc2doc.bmj.com).

Cite this as: BMJ 2009;339:b3186

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