Lifetime effects, costs, and cost effectiveness of testing for human papillomavirus to manage low grade cytological abnormalities: results of the NHS pilot studiesBMJ 2006; 332 doi: https://doi.org/10.1136/bmj.38698.458866.7C (Published 12 January 2006) Cite this as: BMJ 2006;332:79
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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
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
Former Consultant Pathologist at Prince Charles Hospital, Merthyr Tydfil. Search BMJ.Com for background information.
Competing interests: No competing interests
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. 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).  Women
with cervical infection have a three fold increased risk of anal
infection and up to 13% will be infected at both sites.  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. These
may , by inference, be the very risk factors that point to anal cancer.
HIV infection and immunosuppression further increase this risk.  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.
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: No competing interests