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This Article Extract Full Text (PDF) All Versions of this Article: AJPH.2006.102962v1 97/2/199-a    most recent Submit a response View Shopping Cart Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services Similar articles in this journal Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Suba, E. J. Search for Related Content PubMed Articles by Suba, E. J. Related Collections Global Health Screening Cancer Women's Health

Eric J. Suba, MD

The author is with the Viet/American Cervical Cancer Prevention Project, San Francisco, Calif, and with Kaiser Permanente Medical Center, San Francisco.

Correspondence: Requests for reprints should be sent to Eric J. Suba, MD, Kaiser Permanente Medical Center, 1200 El Camino Real, South San Francisco, CA 94080 (e-mail: eric.suba{at}kp.org).

"Feasibility" refers to that which is possible, in addition to that which is operational, successful, or sustained. Papanicolaou screening is feasible anywhere cervical screening is appropriate, because it is not appropriate to screen for cancer among communities without access to curative treatment services, and because communities with access to curative treatment will also have access to cytology laboratories. Papanicolaou screening is the only preventive option currently available for public sector control of cervical cancer in developing countries.¹ Because future screening programs based on alternative screening tests will require cytology as an essential triage component, visual inspection with acetic acid (VIA), human papillomavirus, and cytology tests may be appropriately regarded as complementary rather than competitive.²

Research on alternative screening tests in developing countries has unfortunately been justified by incorrect assumptions that Papanicolaou screening is not feasible in low-resource settings where screening is appropriate. Because these incorrect assumptions undermine progressive public health leaders and empower apologists for the status quo, nongovernmental organizations and investigators distracted by fundraising obligations disconnected from public health goals engender significant obstacles to successful cervical cancer prevention in developing countries. Tsu does not specify why management procedures used for follow-up in research settings cannot be used in real-world settings.

We regret any confusion caused by the inference that "abnormal" rates of 20% to 39%, added to "atypical" rates of 37% to 49%,³ suggest a test-positive rate of 71% for VIA. VIA remains a feasible screening test for premenopausal but not postmenopausal women.¹ Because individuals with positive screening tests understandably desire to know whether they truly have cancer, the implementation of VIA in real-world settings will require confirmatory testing, such as the biopsies suggested by Tsu, that will in turn require cytologic triage. Screening strategies—including VIA "screen and treat"—that do not provide required confirmatory testing should be considered obsolete.

Foege et al.⁴ have observed that a lack of management skills appears to be the single most important obstacle to improving health throughout the world.⁴ Our findings corroborate their observation in the context of cervical cancer prevention in developing countries, where critical real-world obstacles involve people far more than technology, and where skilled program managers are therefore critical for success. Failures of cervical cancer prevention efforts are not attributable to factors specific to the Papanicolaou test, but to lapses of political will and programmatic quality management to which all screening tests are vulnerable. The use of alternative screening tests may reinforce, rather than overcome, critical real-world obstacles.

References

1. World Health Organization. Comprehensive cervical cancer control: a guide to essential practice. Available at: http://www.who.int/reproductive-health/publications/cervical_cancer_gep/index.htm. Accessed September 25, 2006.

2. Suba EJ, Frable WJ, Raab SS. Cost-effectiveness of cervical-cancer screening in developing countries [published correction appears in N Engl J Med. 2006;355: 745]. N Engl J Med. 2006;354:1535–1536.[Free Full Text]

3. University of Zimbabwe/JHPIEGO Cervical Cancer Project. Visual inspection with acetic acid for cervical cancer screening: test qualities in a primary care setting. Lancet. 1999;353:869–873.[CrossRef][Web of Science][Medline]

4. Foege WH, Daulaire NMP, Black RE, Pearson CE, eds. Global Health Leadership and Management. San Francisco, Calif: Jossey-Bass; 2005.

This Article Extract Full Text (PDF) All Versions of this Article: AJPH.2006.102962v1 97/2/199-a    most recent Submit a response View Shopping Cart Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services Similar articles in this journal Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Suba, E. J. Search for Related Content PubMed Articles by Suba, E. J. Related Collections Global Health Screening Cancer Women's Health