Costs and benefits of cervical screening IV: valuation by women of the cervical screening programme

OBJECTIVES: To assess the value of the cervical smear test to women, taking account of the positive and negative aspects of the cervical screening service. DESIGN: A postal survey. SETTING: Tayside Health Board region of Scotland. PARTICIPANTS: A sample of 2000 women aged 20-59. MAIN OUTCOME MEASURES: Maximum willingness to pay (WTP) for a cervical smear test. RESULTS: Women were prepared to pay 50.20 British pounds per smear on a 3-yearly basis. Willingness to pay was positively related to income, but unrelated to age and whether or not the respondent had previously had a smear. CONCLUSIONS: Previous studies have estimated the cost per screen or cost per life year saved by cervical screening. This study used the economic instrument of WTP to take account of other potential (dis)benefits to women. The value women place on having a smear was more than the cost to the National Health Service (NHS) of providing the service. The output of a WTP study is potentially useful at the policy level. Future work should explore both the value of alternative approaches to cervical screening, and the value of competing health care interventions.     

Should the laboratory assess the sampling adequacy of cervical smears?

Should the laboratory assess the sampling adequacy of cervical smears? The results of a questionnaire answered by 14 out of the 18 NHS laboratories in Scotland reporting cervical smears showed that, since the publication of Guidelines for Judging the Adequacy of a Cervical Smear, by the British Society for Clinical Cytology (BSCC), rates of unsatisfactory smears had risen from a mean of 3.3% to 6.5%, with some laboratories reporting rates of over 10%. Four laboratories followed the guidelines closely in requiring the presence of two indicators of sampling of the transformation zone, i.e. endocervical cells, metaplastic cells or endocervical mucus. Seven laboratories required one indicator either in all smears or in a subset, whilst three did not require any indicator at all. The laboratories observing the guidelines closely had a higher mean unsatisfactory rate than those partially observing them. The main impediment to the full implementation of the BSCC guidelines appeared to be fear of an unmanageably high unsatisfactory smear rate. The accuracy of the assessment of adequacy is questioned, as is the cost effectiveness of doing so.     

Effect of regular 3-yearly screening on the incidence of cervical smears: the Leiden experience

The effect of regular 3-yearly screening over a period of 12 years, on the incidence of cervical cancer in 25,000 women aged 35-54 years, is examined. The rate of squamous cell carcinoma decreased from 0.38 per 1000 women in the first round to zero in the fourth round. Similarly, the rate of carcinoma in situ declined from 1.69 per 1000 women in the first round to 0.35 per 1000 in the fourth round. The rates of severe dysplasia showed no decline. Cytologic under diagnosis of carcinoma-in-situ and cervical carcinoma increased with each round. Widowed and divorced women and those living in urban areas were identified as high risk groups.     

Rapid pre-screening of cervical smears as a method of internal quality control in a cervical screening programme

Objective:  To evaluate the performance of rapid pre-screening (RPS) as a method of internal quality control in the cytopathological examination of cervical smears for cervical cancer screening.
Methods:  The sample consisted of 6135 cervical smears submitted to RPS and routine screening (RS) methods. The smears classified as negative in RPS and RS were considered final diagnoses, and were not, therefore, submitted to any additional review. The smears identified as suspect or unsatisfactory according to RPS were analysed separately by two different cytologists irrespective of the diagnosis reached in RS. Smears considered abnormal or unsatisfactory at RS were also reviewed. When both cytologists issued concordant diagnoses, this was considered the final diagnosis. Discordant results were analysed by a third cytologist and a consensus meeting was held to define the final diagnosis.
Results:  Taking abnormalities detected by RS as the denominator, RPS had a sensitivity of 63.0% for the detection of all abnormal smears and 96.7% for high grade squamous intraepithelial lesion (HSIL). When compared with the final diagnosis, sensitivity of RPS for all abnormal smears was 74.9% and for HSIL 95.0%. Of the 529 abnormal smears confirmed in the final diagnosis, 2.15% were detected only by the RPS.
Conclusion:  RPS is an effective alternative method of internal quality control with high sensitivity for the detection of more severe lesions. It also permits monitoring of the laboratory rate of false-negative results, and allows constant evaluation of the performance both of the pre-screening and RS cytologists.     

Rapid rescreening of cervical smears as a quality control method in a high-risk population

OBJECTIVE: Cancer of the cervix is one of the commonest cancers in South Africa. Accurate cytological diagnosis is one of the prerequisites for an effective cervical screening programme and requires the implementation of appropriate quality assurance modalities. This study was undertaken to determine if rapid review of reportedly negative cervical smears is a useful internal quality assurance modality in an unscreened population with very high rates of cervical carcinoma. METHOD: Approximately 26% of all cervical smears received at the study institution between 1 January 1998 and 31 December 2003, and initially reported as negative or inadequate, underwent rapid review. RESULTS: A total of 62,866 (26%) cervical smears out of 241,796 reportedly negative or inadequate cervical smears underwent rapid review. An amended report was sent out in 373 (0.59%) of these 62,866 cervical smears. This included 101 cases of high-grade squamous intraepithelial lesion (HSIL) and high-grade atypical squamous cells (ASC-H), 143 low-grade squamous intraepithelial lesions, 54 atypical squamous cells of undetermined significance (ASC-US) and 33 atypical glandular cells that were not reported initially. The false-negative proportion for HSIL and ASC-H (combined) in this study was 5.76%. No squamous cell carcinomas were diagnosed on rapid review but one patient with HSIL/ASC-H on review had squamous cell carcinoma on biopsy. Three cytotechnologists had a lower sensitivity of primary screening and required retraining. CONCLUSIONS: Rapid review is beneficial as an internal quality assurance modality in an unscreened high-risk population and increases the detection of women with significant cervical lesions requiring treatment. The relatively low cost of rapid review compared with other rescreening modalities makes this an attractive option in low resource settings.     

Review of negative and low‐grade cervical smears in women with invasive cervical cancer after the first 3 years of the national cervical screening programme in Slovenia

A. Repše‐Fokter, A. Pogačnik, V. Snoj, M. Primic‐Žakelj and M. S. Fležar
Review of negative and low‐grade cervical smears in women with invasive cervical cancer after the first 3 years of the national cervical screening programme in Slovenia Objective: The purpose of the study was to perform a national review of negative, low‐grade and inadequate smears reported during the latest screening period before cervical cancer diagnosis in 2006, after the first 3 years of the screening programme. Methods: Among 162 new cervical cancer cases there were 47 (29%) without previous cytology, 47 (29%) with one high‐grade smear prior to diagnosis and 68 (42.0%) with at least one previous negative, low‐grade, atypical or inadequate smear 1–40 months before diagnosis. Of the latter 68 cases, 37 patients with 59 smears (together with 118 control slides) were included in the review as 31 had smears reported at laboratories no longer operating. Findings were related to the last cytology report before diagnosis as well as to histological type and stage of the cancer. Results: In our study group, 19 (51%) of 37 patients had squamous cell carcinoma, 15 (41%) adenocarcinoma and 3 (8%) adenosquamous carcinoma, compared with 121 (75%), 26 (16%), 12 (7%), respectively, and 3 (2%) other types, for all carcinomas. Twenty‐one of 37 women also had high‐grade cytology prior to diagnosis of cancer. Women with previous cytology (with or without recent high‐grade smears) were more likely to have stage I cancers than those without cytology (P < 0.0001). The expert group upgraded 17/33 smears in the patients with squamous carcinomas, which was more than in those with adeno‐ and adenosquamous carcinomas (5/24, P < 0.05). Conclusion: As expected, a higher proportion of smears preceding adenocarcinomas were true negative. Under‐diagnosed smears were not related to cancer stage or last cytology report before diagnosis.     

Personal view. Is it reality or an illusion that liquid‐based cytology is better than conventional cervical smears?

Liquid-based cytology (LBC) has been heralded as the way forward for cervical screening, and as the answer to many of its problems. It is already used as a sole method of cell preparation in many private clinics in the UK. It is being used for colposcopy smears in many NHS clinics and is now being piloted for primary screening in three screening centres in England, as well as one in Scotland and one in Wales. LBC has been welcomed as a new technology because it deals with the problem of specimen adequacy at source, removing responsibility for slide preparation and fixation from the clinician or nurse. It provides uniformly well-fixed preparations that are free of inflammatory exudate and blood, and seem easier to screen than conventional smears. There are many articles in the world literature suggesting that LBC is more accurate than conventional screening, and it is thought likely to reduce the number of false negative tests. The main reasons for piloting LBC in the NHS Cervical Screening Programme (NHSCSP) lie in its potential for reducing screening times and for reducing the numbers of repeats for inadequate tests. LBC is expensive in terms of equipment, capital costs, maintenance, consumables, training, technical preparation time, transportation and disposal of liquid media. Its costs could be justified if they were offset by the money saved from reduced screening time and repeat tests, but only if its accuracy in terms of sensitivity and specificity were proven to be equal to or better than conventional cytology. Although that is generally held to be true by the public and medical profession alike, there is very little hard evidence to support it.     

Evaluation of 100% rapid rescreening of negative cervical smears as a quality assurance measure

OBJECTIVE: The objective of this study was to compare the performance of 100% rapid rescreening, 10% random rescreening and the review of smears selected on the basis of clinical criteria, as a method of internal quality control of cervical smears classified as negative during routine screening. METHODS: A total of 3149 smears were analysed, 173 of which were classified as positive and 2887 as negative, while 89 smears were considered unsatisfactory. The smears classified as negative were submitted to 100% rapid rescreening, 10% random rescreening, and rescreening based on clinical criteria. The rescreening stages were blinded and results were classified according to the Bethesda 2001 terminology. Six cytologists participated in this study, two of whom were responsible for routine screening while the other four alternated in carrying out rescreening so that no individual reviewed the same slide more than once. RESULTS: The 100% rapid rescreening method identified 92 suspect smears, of which 42 were considered positive at final diagnosis. Of the 289 smears submitted to the 10% rescreening method, four were considered abnormal but only one was confirmed positive in the final diagnosis. Of the 690 smears rescreened on the basis of clinical criteria, 10 were considered abnormal and eight received a positive final diagnosis. CONCLUSIONS: The 100% rapid rescreening method is more efficient at detecting false-negative results than 10% random rescreening or rescreening on the basis of clinical criteria, and is recommended as an internal quality control method.     

Quality grading for cervical smears

Three thousand five hundred and eighty cervical smears were taken in 1990–1992 at a Genitourinary Medicine Clinic with various spatula or spatula brush combinations. the unsatisfactory rate and the detection of cellular abnormalities showed some relation to spatula type. However, the satisfactory smears screened in the laboratory are routinely assigned a quality grade-good, fair or poor. Analysis shows higher rate of detection of cellular abnormalities in good quality smears, the detection of dyskaryosis being twice as high, in contrast to the fair or poor quality smears. It is suggested that quality grade is a better way of classifying smear quality in the cervical screening programmes rather than the presence or absence of endocervical and/or metaplastic cells.     

武汉市农地非市场价值评估

估算农地资源的非市场价值,将其纳入资源成本核算体系,不仅能够弥补市场机制作用不足给农地城市流转决策带来的影响,而且通过提高土地资源农业利用的比较效益,能够起到缓解农地流失的作用。运用条件价值评估法对武汉市不同类型农地的非市场价值进行估算,在对471份有效问卷进行统计分析后的研究表明：（1）随着农地保护意识的增强,武汉居民已经意识到农地资源非市场价值的存在,83．65％的受访居民对农地保护有正的支付意愿;（2）从居民参与农地保护的支付意愿（Willingness to pay,WTP）出发,全市居民每年保护农地的支付意愿总价值为30．0035×10^8元,折合单位hm^2农地的非市场价值为116154元;（3）从农民作为农地保护执行主体参与农地保护、接受政府补偿（willingness to accept,WTA）的角度出发,农地非市场价值16447．57元／hm^2,是目前国家鼓励农民种植粮食作物发放补贴（中稻225元／（hm^2·a^-1）,折合无限年期价值4978元／hm^2）的3．30倍;（4）从城市居民作为农地保护的间接受益者,假设城市周边农地被城市建设用地征收后带来环境损失,城市居民为接受征地计划、家庭每年愿意接受政府补偿（willingness to accept,WTA）的角度出发,平均每户家庭年均需要接受政府补偿8612元,按当前城市居民户数计算,全市城市居民每年对农地损失的受偿接受金额为109．5685×10^8元,折合单位hm^2农地非市场价值42．42×10^4元。     

Atypical glandular cells in cervical smears: histological correlation and a suggested plan of management based on age of the patient in a low-resource setting

Objectives:  To perform an audit of all smears reported as atypical glandular cells (AGC) using the Bethesda system (TBS) 2001.
Methods:  A total of 18 376 cervical smears were screened from January 2005 to June 2007, of which 65 cases were reported as AGC. Follow-up histology was available in 31 cases (47.7%), in whom a detailed cytological/histological correlation was carried out.
Results:  AGC constituted 0.35% of all Pap smears. Follow-up histology was normal or benign in 20 cases, whereas a squamous or glandular abnormality was seen in 11 cases. Squamous abnormalities included one case each of cervical intraepithelial neoplasia (CIN)1, CIN2 and CIN3 and five cases of squamous cell carcinoma. All glandular epithelial abnormalities were endometrial in origin and included two endometrial adenocarcinomas and one uterine serous carcinoma. Neither in situ nor invasive adenocarcinoma of the endocervix was observed. Review of smears and reclassification as AGC, not otherwise specified and favour neoplasia revealed a higher proportion of abnormality in the latter group, reaffirming the utility of subtyping. The median age of women with AGC was 41 years. The outcome was analysed with respect to the median age. In women aged equal or more than 40 years, AGC reflected a high-grade squamous or glandular epithelial abnormality in 50% of cases compared with none in those less than 40 years old ( P  = 0.010).
Conclusion:  The age of the woman as well as the subtype of atypical glandular cells influences outcome and hence must be taken into consideration while formulating an acceptable management strategy in these women in a low-resource setting.     

Nuclear grooves in intermediate cells in cervical smears

One thousand cervical smears from women who took part in a hospital-based screening programme for early detection of cervical cancer were studied for the presence of nuclear grooves. Grooved nuclei were frequently detected in intermediate cells in all phases of the menstrual cycle, although their frequency of occurrence was slightly lower in the luteal and premenstrual phases. The mean number of nuclear grooves varied from 3.6 to 4.2 in different phases of the menstrual cycle. The differences, however, were not statistically significant. The presence of nuclear grooves in cervical cells appears to be a nonspecific finding at present.     

应用条件价值评估法对无锡市五里湖综合治理的评价

在政府环境审计项目中,政府审计机关面临着对环境改善效益进行评估的需要。由于环境资源不具有市场价值,目前条件价值评估方法是唯一能对环境物品进行评估的技术方法。首先对条件价值评估方法及其步骤进行了分析,然后将其应用于实际的审计案例,验证其可行性和有效性。案例研究把江苏省无锡市五里湖作为假想市场,以元锡市当地居民和来此旅游的游客为调查对象,利用问卷调查方式针对五里湖环境改善前后公众的满意度、受访者的旅游支付意愿以及对综合整治工程的资助意愿进行调查分析。对452位受访者调查结果显示,受访者对于五里湖环境改善后的满意度确有显著提高;在环境改善后受访者的旅游支付意愿为89．1元（总支付金额22275万元）,与改善前的支付意愿22．6元（总支付金额5650万元）相比有较大提高;对综合整治工程的资助意愿为平均每人140．2元（总支付金额62063万元）;然后从受访者不同的社会经济属性及对自然生态的认识与态度等各种因素,对受访者的支付意愿进行分析显示,对公众满意度影响最显著的因素是家庭年收入和职业,对五里湖综合整治工程的资助意愿影响最显著的因素是家庭年收入和教育程度,而所在地域、性别、年龄及是否参加环保社团对支付意愿无显著性影响。     

Costs and benefits of cervical screening. I. The costs of the cervical screening programme

In 1991, the average total Health Service cost of a cervical smear, including follow up at the colposcopy clinic, was almost £22.70 in the Perth and Kinross district of Scotland. The average cost per colposcopy clinic visit was £30. The main cost elements were in general practice (55% of total) and the laboratory (33%), and most of the cost was for staff time.     

条件价值评估法在非市场价值评估中的应用

条件价值评估法（CVM）是非市场价值评估技术中最为重要、应用最为广泛的一种方法。从生态系统服务功能评估的角度出发,在CVM的基础理论和大量国内外研究案例的基础上,总结出CVM国内外研究各自的特点,并比较了二者的异同之处。CVM国内外研究案例主要在研究领域、研究重点、研究结果、引导工具及调查方式五大方面有所不同,而在总体趋势等方面具有共同的特征。最后针对我国国情,对CVM的实际操作提出改进方向。     

Fluorescent studies directed towards the location of abnormal epithelial cells in cervical smears

Cervical screening is concerned with the search for abnormal epithelial cells in smears prepared from scrapings from the uterine cervix. It is a highly skilled labour intensive operation and automated methods of detecting dyskariotic cells in cervical smears would be helpful. We report a fluorescence method of detecting abnormal cervical cells in smears and biopsies using a probe for guanidinobenzoatase. This approach has the potential for automation.     

Inadequate cervical smears: results of an educational slide exchange scheme

Fifty-six slides, predominantly inadequate and of varying difficulty, were circulated to 12 laboratories as an educationally based slide exchange scheme. Three slides failed to achieve an agreed majority consensus opinion. Seventy percent of participants agreed with the consensus opinion in 80% of slides. Of the slides originally reported as inadequate, the consensus diagnosis was inadequate in 78%, negative in 12% and abnormal in 10%. The latter included two cases of high-grade dyskaryosis. There was good agreement for the two most frequent causes of inadequacy in submitted slides (obscured and poor cellularity). There was poor consistency in reporting the presence or absence of endocervical and immature squamous metaplastic cells, to an extent that questions their use in the assessment of smear adequacy. Three inadequate slides on consensus opinion were associated with subsequent cervical intraepithelial neoplasia (grade III) or invasive squamous cell carcinoma. In the latter case, the slide had originally been reported as negative by the submitting laboratory.     

基于CVM的太湖湿地生态功能恢复居民支付能力与支付意愿相关研究

采用意愿调查价值评估法(CVM)法定量评估湿地生态功能修复保护非使用价值,力图探讨支付能力与支付意愿的相关机理.研究结果显示:(1)支付意愿调研综合置信度为2.652,处于可信程度较高的范畴,3个调研区的集中度均呈现不规则偏正态分布,WTP中位数与平均数重现性良好,中支付区域集中度达86％,符合经济学原理,说明WTP结果可信度较高.(2)公务员、教师、律师、高薪企业工人、部分高收入农民、军人支付意愿较高,两者的相关性高达0.937以上.(3)按CVM法计算,当地居民对世行工程的平均支付意愿为户均支付19.19元/月,产生区域支付差异的原因主要在于不同区域随机被访者职业构成和收入构成存在差异.(4)在估算湿地生态功能恢复项目支付意愿时CVM法是可靠的基本方法,支付能力是支付意愿的重要制约因素,中等支付能力者支付金额最高,支付能力与支付意愿之间存在不仅仅是正相关而是复杂的关联性.     

Aylesbury and cervitula spatulas: a comparative study to assess the adequacy of cervical smears

OBJECTIVE: To assess whether the Aylesbury (Pharmaceutical Enterprises Ltd., Pinelands, Capetown, South Africa) or Cervitula spatula (Harwill Medical, Capetown, South Africa) is more effective for adequate cervical smears in obstetric and gynecology patients. STUDY DESIGN: The Cervitula spatula was compared with the Aylesbury spatula by taking a total of 160 smears, which were examined cytologically. This consisted of 40 obstetric and 40 gynecology patients. The sequence in which the spatiulas were used was determined by computer randomization. Our main outcome criterion was whether both ectocervical and endocervical cells were present, thus making the smear adequate. Our numbers were too small to draw conclusions on the cytologic abnormalities detected between the two spatulas. RESULTS: The Cervitula was more effective for the identification of endocervical cells in obstetric patients (P = .0008). When combining the obstetric and gynecology groups, the Cervitula was also better in obtaining endocervical cells, but this did not reach statistical significance (P = .016). CONCLUSION: Pap smear sampling with the Cervitula reduces the number of cases without endocervical cells, which would constitute an inadequate smear, requiring unnecessary recall of patients for repeat smears.