Assessment of cervical cancer screening and follow-up programs

There is essentially no debate about the benefits of cervical cancer screening. The current debate centers around periodicity, the appropriate interval for repeated testing, and the age at which screening should be discontinued. As the frequency of screening is increased within a defined population, there is a gain in survival (life-years) depending upon the risk status of the population segment screened. However, each increment in survival comes at an increasingly high cost. Significant gains have been made in improving screening and detection services through widespread availability of the Papanicolaou test. However, there has been concern raised that the cost-effectiveness of cervical cancer screening has not been clearly demonstrated. This report analyzes the current status of the literature on screening for cervical cancer with a focus on cost-effectiveness and cost-benefit analyses of screening using the Pap test. A relatively small group of studies was located which directly addressed the cost-effectiveness question. All of the studies cited attempted in some manner to describe the relationship between benefits of cervical cancer screening and costs. Two studies reported a program design with net positive monetary benefits, while one estimated that the direct cost of medical care avoided through screening was approximately equal to the cost of the screening program. In general, however, screening for cervical cancer is viewed as an investment in extending life (a net cost per year of life gained). Most analysts ascribe a net monetary cost to cervical cancer screening programs. Then the question becomes one of cost-effectiveness--designing a program so as to optimize the result obtained. With respect to optimizing screening, the literature leaves no doubt of the value of cervical cancer screening in general. From a cost-effectiveness perspective, screening no more frequently than every 3-5 years appears reasonable. It is important to think in terms of a total program and how effectively the population at risk is being reached. The literature reviewed spans a period of more than twenty years and reflects studies across the globe. While the quality is uneven, from this body of work a consensus emerges: screening is effective, but the frequency of screening in the United States is probably too high. In addition, those who are most intensively screened are probably at the lowest risk. Outreach and targeting of at-risk population groups needs to be addressed in order to improve cost-effectiveness of cervical cancer screening. The effectiveness of the screening technology (the Pap test) is taken for granted, but this may be a mistake.(ABSTRACT TRUNCATED AT 400 WORDS)