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Zee (2009) evaluated which imaging modality would be most useful for cervical cancer screening in older women (age 50-64) compared with younger women. This is a potential market that is presently underserved. She noted that older women are likely to have smaller and more numerous cervical lesions than younger women, and that human papillomavirus (HPV) testing can also identify older women with abnormal cervical findings. The mean age of women seeking cervical cancer screening is 51 years. However, women seeking primary cervical cancer screening have a mean age of 49 years and are 30 years younger than women with an average risk of developing cervical cancer, which is 50-65 years. About 10% of U.S. women older than 65 years have had at least one birth and are considered to be at increased risk of cervical neoplasia. The authors placed a particular emphasis on the cost-effectiveness of adding either high-resolution anoscopy (HSIL) or VIA to the testing protocol, noting that the initial costs of either method would be offset by their reduced downstream costs. The initial cost for HPV testing is the same for either VIA or HSIL and for VIA or HSIL comparisons was more cost-effective for HPV testing than for VIA. The authors reported that the sensitivity of HSIL was 0.64 compared with 0.86 of VIA, and 0.62 compared with 0.62 for HPV testing. The specificity was 0.85 for HSIL compared with 0.98 for VIA, and 0.91 for HPV compared with 0.95 for VIA. Although ‘expenditure-to-revenue ratios’ for the various options were all positive, the authors indicated that their cost analysis does not take into account the increased efficacy of HPV-based screening based on the age and HPV status of the population being screened. Finally, compared with HSIL, VIA was less discriminatory than HPV testing. Zee and colleagues concluded that HPV testing remains the most cost-effective strategy as multiple initial rounds of screening followed by a positive (or removal) test (in which the results of the first round are used to predict the presence of disease with repeat testing at intervals) are necessary to screen all women. This approach also has the potential for a high level of specificity. d2c66b5586
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