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RESEARCH: Rosa Legood, Alastair Gray, Jane Wolstenholme, and Sue Moss Lifetime effects, costs, and cost effectiveness of testing for human papillomavirus to manage low grade cytological abnormalities: results of the NHS pilot studies BMJ 2006; 332: 79-85 [Abstract] [Full text]

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Take this opportunity to screen for anal cancer too.

Awori J Hayanga   (15 January 2006)

Does this Study model the current Cytology Screening Programme?

Bernard J Charnley   (23 January 2006)

Take this opportunity to screen for anal cancer too. 15 January 2006
Awori J Hayanga, General Surgery Resident University of Michigan Health Systems Send response to journal: Re: Take this opportunity to screen for anal cancer too.	The impact that HPV screening has had on the rates of cervical intraepithelial neoplasia (CIN) is a topical issue and Legood et al pay much needed attention to this subject. The introduction of routine cytological screening has significantly reduced the incidence of cervical cancer. It is opportune therefore, to discuss within the same context, an embryological and pathological correlate namely the anal canal ( with its transitional epithelium and columnar - squamous junction) and anal intraepithelial neoplasia (AIN) respectively. Despite obvious similarities, anal cancer has not benefited from the same level of attention. There are currently no existing guidelines regarding screening of this very similar and more rapidly growing pathological entity. The incidence of anal cancer has increased by almost 40 per cent in females.[2] There is a 26% genotypic concordance among concurrent Human Papilloma Virus ( HPV) infections of the cervical and anal canals, indicating a common source of infection such as vaginal and anal intercourse with the same infected partner(s). [3] Women with cervical infection have a three fold increased risk of anal infection and up to 13% will be infected at both sites. [3] There is, however, a predominance of nononcogenic strains in the anus , HPV strain 84, for example, compared with cervical cancer. This may explain the lower prevalence of anal compared with cervical cancers. This, however, does not detract from the fact that young healthy women , infected with HPV 16 and 18, with a regular consumption of alcohol, a history of chlamydial infection, early age of sexual intercourse and several lifetime sexual partners are at risk for cervical infection.[3] These may , by inference, be the very risk factors that point to anal cancer. HIV infection and immunosuppression further increase this risk. [2] It may be prudent to use these in establishing guidelines for anal cancer screening, particularly with the growing indication that the two entities may share a common aetiology and so prevent us from having to reinvent the wheel in the establishment of new guidelines. REFERENCES 1 Legood R , Gray A , Wolstenholme J , Moss S. Lifetime effects, costs, and cost effectiveness of testing for human papillomavirus to manage low grade cytological abnormalities: modelling study. BMJ. 2006 Jan 6; [Epub ahead of print] 2 Chang GJ, Berry M, Jay N, Palefsky, JM, Welton ML. Surgical treatment of high-grade anal squamous intraepithelial lesions: a prospective study. Dis Colon Rectum. 2002 Apr;45(4):453-8 3 Hernandez B , McDuffie K, Zhu X , Wilkens LR , Killeen J, Kesse B , Wakabayashi MT , Bertram CC, Easa D , Ning L , Boyd J, Sunoo C, Kamemoto L, Goodman MT. Anal human papillomavirus infection in women and its relationship with cervical infection. Cancer Epidemiol Biomarkers Prev. 2005 Nov;14(11 Pt 1):2550-6. Competing interests: None declared
Does this Study model the current Cytology Screening Programme? 23 January 2006
Bernard J Charnley, The Old Vicarage, Defynnog, Brecon, Powys LD3 8SB Send response to journal: Re: Does this Study model the current Cytology Screening Programme?	The model does not reflect the current cytology screening programme in Wales, and may not be valid beyond the centres studied. The Strategy A should approximate to the extant programme if the predictions of the model are to be used as a prediction of effects. This strategy is allocated 9.4 routine smears and 0.21 colposcopies averaged over a participating lifetime. Policy in Wales is three yearly screening from 20 to 64 which allocates 14.7 routine smears to a woman/lifetime of 44 years and about 518,228 Women participate. There were at least 16,363 colposcopies in Wales in 2004/5, of which 82% (13,418) are directly generated by the screening programme suggesting a lifetime colposcopy use of 1.14. In the population of about 22,000 women screened by the Prince Charles Hospital laboratory in Merthyr Tydfil, 381 women were directly referred for colposcopy by the programme and they received about 1,000 colposcopy examinations suggesting the current lifetime colposcopy use rate is 2.00. Merthyr is on course for near total population referral without the use of any additional test. Can the model be modified to suggest what will happen and what the costs will be if the test is implemented in Merthyr and Wales? The costings as published cannot be generalised to other sites and may need considerable modification to reflect the real world. I am concerned the current costing of Colposcopy services may be out by an order of magnitude, and levels of tests used may be much higher than anticipated away from the pilot sites studied. Reference: KC53/61/65 Statistical Report 2004/05 Cervical Screening Wales, Cardiff. July 2005 Competing interests: Former Consultant Pathologist at Prince Charles Hospital, Merthyr Tydfil. Search BMJ.Com for background information.