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Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles.
By happenstance, the week after the BMJ ‘Short cuts’ (1) summarized
the paper by Sankaranarayanan et al that HPV testing can reduce cervical-
cancer mortality (RR 0.52) (2) the Lancet published its editorial on harms
from screening (3). However none of the many reviews of the study on ‘HPV-
testing’ questioned the wisdom of author’s suggestion that screening for
HPV would be an efficient way to reduce cervical cancer. We hope our
letter will redress that situation.
The problem of quoting relative risk without giving the absolute risk
has been highlighted repeatedly in the BMJ (4,5). The cervical-cancer
death-rate in the control group of the study can be used to calculate the
risk in the population without any screening program. There were 64 deaths
in 8 years in the population of 31,488 making for an absolute risk of
2.5/10,000/year. The absolute risk reduction in this case works out to be
0. 00013.
The cost of the HPV testing strategy is much higher than ‘$20 for
each woman over 30’, suggested by the authors. 10% women showed up
positive on HPV testing and they needed further investigations including
repeated PAP smear examinations and biopsies to effect this lowering of
mortality. The costs for all these procedures needs to be added up and
weighed against the ARR of 0.00013. The intangible costs of the anxiety to
10% of the population of women, who need these repeated examinations, also
need consideration.
References
1. BMJ Short Cuts HPV test is best for a single round of cervical
cancer screening in India. BMJ 2009;338:b1423
2. Sankaranarayanan R, Nene BM, Shastri SS, Jayant K, Muwonge R,
Budukh AM, Hingmire S, Malvi SG, Thorat R, Kothari A, Chinoy R, Kelkar R,
Kane S, Desai S, Keskar VR, Rajeshwarkar R, Panse N, Dinshaw KA. HPV
screening for cervical cancer in rural India. N Engl J Med. 2009;360:1385-
94.
3. Editorial. The trouble with screening Lancet 2009;373:1223
4. Campbell MJ. Resting heart rate as predictor. What about absolute
risks? BMJ. 2009;338:b1197
5. Alonso-Coello P, García-Franco AL, Guyatt G, Moynihan R. Drugs for
pre-osteoporosis: prevention or disease mongering? BMJ. 2008;336:126-9.
Understanding the Absolute Risk Reduction from HPV Screening is Crucial
By happenstance, the week after the BMJ ‘Short cuts’ (1) summarized
the paper by Sankaranarayanan et al that HPV testing can reduce cervical-
cancer mortality (RR 0.52) (2) the Lancet published its editorial on harms
from screening (3). However none of the many reviews of the study on ‘HPV-
testing’ questioned the wisdom of author’s suggestion that screening for
HPV would be an efficient way to reduce cervical cancer. We hope our
letter will redress that situation.
The problem of quoting relative risk without giving the absolute risk
has been highlighted repeatedly in the BMJ (4,5). The cervical-cancer
death-rate in the control group of the study can be used to calculate the
risk in the population without any screening program. There were 64 deaths
in 8 years in the population of 31,488 making for an absolute risk of
2.5/10,000/year. The absolute risk reduction in this case works out to be
0. 00013.
The cost of the HPV testing strategy is much higher than ‘$20 for
each woman over 30’, suggested by the authors. 10% women showed up
positive on HPV testing and they needed further investigations including
repeated PAP smear examinations and biopsies to effect this lowering of
mortality. The costs for all these procedures needs to be added up and
weighed against the ARR of 0.00013. The intangible costs of the anxiety to
10% of the population of women, who need these repeated examinations, also
need consideration.
References
1. BMJ Short Cuts HPV test is best for a single round of cervical
cancer screening in India. BMJ 2009;338:b1423
2. Sankaranarayanan R, Nene BM, Shastri SS, Jayant K, Muwonge R,
Budukh AM, Hingmire S, Malvi SG, Thorat R, Kothari A, Chinoy R, Kelkar R,
Kane S, Desai S, Keskar VR, Rajeshwarkar R, Panse N, Dinshaw KA. HPV
screening for cervical cancer in rural India. N Engl J Med. 2009;360:1385-
94.
3. Editorial. The trouble with screening Lancet 2009;373:1223
4. Campbell MJ. Resting heart rate as predictor. What about absolute
risks? BMJ. 2009;338:b1197
5. Alonso-Coello P, García-Franco AL, Guyatt G, Moynihan R. Drugs for
pre-osteoporosis: prevention or disease mongering? BMJ. 2008;336:126-9.
Competing interests:
None declared
Competing interests: No competing interests