About 5% of all Pap tests result in a diagnosis of ASCUS; however, only about 10% of women with this abnormality actually have precancer or cancer. The ASCUS and low-grade squamous intraepithelial lesions (LSIL) triage study (ALTS) was launched in the late 1990s to determine the best management strategy for women with these Pap test abnormalities that would both maximize the detection of clinically significant disease and reduce the need for unnecessary office visits and procedures. Results from ALTS, published in 2003, found that referring only those women with a positive HPV test to colposcopy was as effective at detecting cervical precancer or cancer as referring all women to colposcopy.
Shalini L. Kulasingam, Ph.D., of the Duke Center for Clinical Health Policy Research, and colleagues used data from 3488 women with ASCUS enrolled in ALTS to study the cost-effectiveness of three management strategies studied in ALTS--immediate colposcopy, HPV DNA testing, or conservative management with repeat Pap tests at 6-month intervals.
They found that the cost associated with HPV DNA testing was acceptable given the number of precancers and cancers found by this strategy. HPV DNA testing was less costly and detected more cases of precancer than immediately sending all women to receive colposcopy. The least costly strategy was a single repeat Pap test with referral to colposcopy for only those women with a high grade Pap test result; however, this option detected the fewest cases of precancer. The researchers conclude that HPV DNA testing for women with ASCUS is cost-effective and therefore, economically viable.
In an accompanying editorial, Joy Melnikow, M.D., of the University of California-Davis in Sacramento, and Stephen Birch, D.Phil, of McMaster University in Ontario, write that despite the analysis by Kulasingam, et al., HPV DNA testing for the 3 million women a year diagnosed as ASCUS would require an overall total of $250 million dollars a year. Such money, in addition to money saved by reducing overscreening for cervical cancer, could instead be used to screen for cervical cancer and precancer in underscreened populations, particularly women who have little access to health care. The authors write, "Decision makers will need to consider the value of HPV triage in relation to the expected benefits, in terms of the quality and quantity of life-years produced, and weigh these potential benefits against he substantial extra resource requirements (i.e., where will these resources be found? What are the potential benefits of using these resources for other programs?)."
- Article: Whitney L. J. Howell, Public Relations Specialist, Duke University Medical Center and Health System News Office, 919-660-1303, firstname.lastname@example.org
- Editorial: Claudia Morain, UC Davis Public Affairs, 916-734-9023, Claudia.email@example.com
- Article: Kulasingam SL, Kim JJ, Lawrence WF, Mandelblatt JS, Myers ER, Schiffman M, et al. Cost-effectiveness Analysis Based on the ASCUS and LSIL Triage Study (ALTS). J Natl Cancer Inst 2006;98:92-100.
- Editorial: Melnikow J, Birch S. Human Papillomavirus Triage of Atypical Squamous Cells of Undetermined Significance: Cost Effective, But At What Cost? J Natl Cancer Inst 2006;98:82-83
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