Cervical Cancer Screening: More Is Not Always Better

Megan Brooks

March 22, 2012

March 22, 2012 — Women in the United States undergo far more Pap testing than their peers in the Netherlands, yet have similar death rates from cervical cancer. A comparative analysis suggests that cancer prevention services in the United States are not as cost effective as international, publicly run services.

Dr. Martin Brown

"The cervical cancer screening system in the Netherlands seems to have been as effective as the American system but used much less screening," lead author Martin L. Brown, PhD, from the Health Services and Economics Branch at the National Cancer Institute in Bethesda, Maryland, and colleagues from the Erasmus MC University Medical Center in Rotterdam, the Netherlands, conclude.

Their report appears in the March issue of the Milbank Quarterly, a multidisciplinary journal of population health and health policy.

In an interview with Medscape Medical News, Dr. Brown admitted that he was "a little bit surprised" by the data.

"I knew we probably had a lot more overuse here than in the Netherlands, but I guess my expectation was that we'd have better outcomes," Dr. Brown said. "As it turned out, the level of use here was much higher and the outcomes were identical."

A Tale of 2 Countries

The researchers used nationally representative data sources in the United States and the Netherlands to estimate the number of Pap tests conducted and the cervical cancer morality rate since 1950. They discovered that over a period of 3 decades, American women underwent 3 to 4 times as many Pap tests as their Dutch counterparts.

In the Netherlands, after a gradual increase in the 1970s, the rate of Pap testing reached a high of about 120 tests per year per 1000 women in the early 1980s, and dropped to 100 per year per 1000 women in the late 1990s.

In the United States, the rate of Pap testing rose "dramatically" during the late 1950s, reaching a rate above 300 per year per 1000 women in the early 1970s. From 1970 to 2007, the rate of Pap testing ranged from 300 and 450 per year per 1000 women, the data indicate.

Despite the vastly different screening rates, the overall mortality data suggest no substantially different trends between the 2 countries.

Age-Specific Pap Testing and Mortality

Dr. Brown and his colleagues report that the 5-year coverage rates for women 30 to 64 years of age were comparable in the 2 countries, at 80% to 90%. However, because screening in the Netherlands was limited to women 30 to 60 years of age, screening rates for women younger than 30 and older than 60 were much higher in the United States. These differences had consequences for age-specific mortality trends, the researchers note.

Both countries achieved steady declines in the mortality rate of women 30 to 64 years after 1970. Both countries achieved a comparable reduction in mortality in women 64 years and older.

The researchers say that this suggests that the Dutch program could have benefited from the provision of "catch-up" Pap testing for women older than the upper age of the screening recommendation (initially 53 years and later 59 years) and who had never had a Pap test before the initiation of the national screening program. "Conversely, this comparison indicates that the American pattern of often continuing regular Pap testing for women well beyond the age of 60 is unlikely to have been efficient," they write.

On March 14, the US Preventive Services Task Force (USPSTF) issued recommendations for cervical cancer screening, as reported by Medscape Medical News. These advise against screening women older than 65 who have had adequate previous screening and are not otherwise at high risk for cervical cancer, and against screening women younger than 21 years.

The USPSTF recommends cytology every 3 years or, for women 30 to 65 years of age who prefer a longer screening interval, a combination of cytology and human papillomavirus (HPV) testing every 5 years.

Asked for her thoughts on the comparative study, USPSTF chair Virginia Moyer, MD, MPH, from Baylor Medical College in Houston, Texas, said: "It's very interesting reading and it certainly provides support for the longer screening intervals that the USPSTF, [the American Cancer Society], [the American Society for Colposcopy and Cervical Pathology], and [the American Society for Clinical Pathology] now all agree are appropriate."

Macro-Level Approach

In a statement, Dr. Brown noted that "since 2010, new laws in the United States require private health insurance plans and Medicare to cover preventive services with no deductibles or copayments. Preventive medicine is seen as being cost effective, compared to the costs sustained through illness. However, practical cost saving depends on how the preventive services are implemented."

Although both the United States and the Netherlands have a "policy cycle" involving evidence review, surveillance of screening practices and outcomes, clinical guidelines, and reimbursement policies, the components of this cycle are "more systematically linked and implemented nationwide" in the Netherlands, the researchers point out. "To a large extent, this was facilitated by a public health model of screening in the Netherlands, rather than a medical services model," they say.

Dr. Brown made the point that the Netherlands takes a "macro-level approach to screening; they consider it a public health service. In the United States, while we have a lot of public health involvement, it still comes down to being a medical service.... Individual physicians often screen more frequently than even the most aggressive guidelines recommend."

Overall, Dr. Brown and colleagues say their findings are "consistent with the historical evidence that the decentralized and nonintegrated approach to cervical cancer screening in the United States produces substantial clinical waste compared with the centralized, integrated, and organized system of the Netherlands."

"Regrettably," Dr. Moyer told Medscape Medical News, "I think the authors probably have it right. A combination of inertia (doing what we have always done), a persisting belief that there is no harm in screening more often (a belief contradicted by evidence), a lack of recognition of the natural history of this particular cancer, and the lack of any real 'system' to healthcare in this country all contribute to the extraordinary difficulty in making changes to routine healthcare practices — this one included."

"The result is unnecessary suffering and expenditure of precious resources for no additional benefit," Dr. Moyer said.

Dr. Brown noted that he's "worried, as are a lot of people" about the possibility of overuse of the HPV vaccine and HPV DNA testing now coming into use. "Will [these technologies] be used effectively and efficiently? I am a little worried, given what we showed in this study, that they won't be initially."

Milbank Q. 2012;90:5-37. Abstract


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