NEW YORK (Reuters Health) – More frequent cervical cancer screening starting at younger ages is associated with lower rates of cervical cancer and cervical cancer death, but with more preterm births and more neonatal deaths and higher medical costs, according to a decision and cost-effectiveness analysis.
Treating high-grade precancerous cervical lesions identified during cervical cancer screening and biopsy, using large loop excision of the transformation zone (LLETZ), has been associated with an increased risk of preterm birth. Whether this fact should affect cervical cancer screening strategies is unclear.
Dr. Esme I. Kamphuis from VU University Medical Center, Amsterdam, the Netherlands, and colleagues used micro-simulation screening analysis to assess the effect of age at initiation and interval of various cytology-based cervical cancer screening programs on the risk of future preterm birth, maternal life-years gained, and costs of both screening and preterm birth. Findings were published online November 3 in Obstetrics and Gynecology.
In their model, based on Dutch demographic data, the researchers compared eight scenarios that varied in women’s screening-initiation times from ages 21 to 30 and that compared screening intervals of 3 versus 5 years. The model assumed that all women diagnosed with cervical intraepithelial neoplasia (CIN) 2 or 3 and 25% of women diagnosed with CIN 1 were treated with LLETZ.
The number of LLETZs per 100,000 women varied from 9,612 with the most-intensive screening (every 3 years starting at age 21) to 4,646 with the least-intensive screening (every 5 years starting at age 30). The most-intensive scenario resulted in 52 cervical cancer cases and 4 cervical cancer deaths, compared with 158 cancer cases and 16 deaths for the least-intensive scenario.
The number of life-years gained varied from 10,728 with the most-intensive screening to 9,809 for screening every 5 years starting at age 24. This measure was consistently lower for screening every 5 years rather than every 3 years.
In contrast, the estimated number of additional preterm births per 100,000 women caused by LLETZ conducted within the screening program ranged from 45 with the least-intensive screening to 158 with the most-intensive screening. These additional preterm births were associated, respectively, with 4 and 13 neonatal cases of morbidity and with 1 and 4 neonatal deaths.
The number of maternal life-years gained per additional preterm birth varied from 68 with the most-intensive screening to 258 with the least-intensive screening.
Compared with the least-intensive screening, the most-intensive screening reduced cervical cancer cases by 67% and maternal deaths by 75% at the expense of 250% more preterm births and 320% more neonatal deaths, while increasing total costs by $55 million (from $23 million to $77 million).
Screening women from age 21 at 5-year rather than 3-year intervals would lead to 119% more cervical cancer cases and 150% more maternal deaths while reducing preterm births by 23% and neonatal deaths by 25%, thereby lowering total costs by $30 million (from $77 million to $47 million).
“Screening decisions should ideally be individualized, taking into account a woman’s expected harm-benefit ratio of screening,” the researchers conclude. “Although screening may be more harmful to women with a reproductive life plan, it may be more beneficial to those with young age at first intercourse, high parity, long-term use of oral contraceptives, and smoking behavior.”
“We recognize that perinatal adverse effects may also be limited by taking a more restrictive approach to immediate treatment, offering monitoring instead,” they note. “However, lesions may still progress during follow-up, and knowledge of having CIN 2 or worse may be burdensome for women. We therefore plead for more research to estimate the effects of delaying treatment.”
Dr. Kamphuis did not respond to a request for comment.
SOURCE: http://bit.ly/2zjb8ln
Obstet Gynecol 2017.
Tidak ada komentar:
Posting Komentar