Excess Cost of Cervical Cancer Screening Beyond Recommended Screening Ages or After Hysterectomy in a Single Institution.

OBJECTIVE: The aim of the study was to estimate the excess cost of guideline nonadherent cervical cancer screening in women beyond the recommended screening ages or posthysterectomy in a single healthcare system. MATERIALS AND METHODS: All Pap tests performed between September 1, 2012, and August 31, 2014, in women younger than 21 years, older than 65 years, or after hysterectomy, were coded as guideline adherent or nonadherent per the 2012 America Society of Colposcopy and Clinical Pathology guidelines. We assumed management of abnormal results per the 2013 America Society of Colposcopy and Clinical Pathology management guidelines. Costs were obtained from a literature review and Center for Medicare and Medicaid Services data and applied to nonadherent screening and subsequent diagnostic tests. RESULTS: During this period, 1,398 guideline nonadherent Pap tests were performed (257 in women <21 years, 536 in women >65 years, and 605 after hysterectomy), with 88 abnormal results: 35 (13.5%) in women younger than 21 years, 14 (2.6%) in women older than 65 years, and 39 (6.5%) in women after hysterectomy. The excess cost for initial screening, diagnostic tests, and follow-up was US $35,337 for 2 years in women younger than 21 years, US $54,378 for 5 years in women older than 65 years, and US $77,340 for 5 years in women after hysterectomy, resulting in a total excess cost of US $166,100 for 5 years. Of the 1,398 women who underwent guideline nonadherent screening, there were only 2 (0.1%) diagnoses of high-grade dysplasia (VaIN3). CONCLUSIONS: Guideline nonadherent cervical cancer screening in women beyond the recommended screening ages and posthysterectomy resulted in costs exceeding US $160,000 for screening, diagnostic tests, and follow-up with minimal improvement in detection of high-grade dysplasia.

Propensity-Weighted Comparison of Long-Term Risk of Urinary Adverse Events in Elderly Women Treated For Cervical Cancer.

PURPOSE: Cervical cancer treatment is associated with a risk of urinary adverse events (UAEs) such as ureteral stricture and vesicovaginal fistula. We sought to measure the long-term UAE risk after surgery and radiation therapy (RT), with confounding controlled through propensity-weighted models. METHODS AND MATERIALS: From the Surveillance, Epidemiology, and End Results (SEER)-Medicare database, we identified women ≥66 years old with nonmetastatic cervical cancer treated with simple surgery (SS), radical hysterectomy (RH), external beam RT plus brachytherapy (EBRT+BT), or RT+surgery. We matched them to noncancer controls 1:3. Differences in demographic and cancer characteristics were balanced by propensity weighting. Grade 3 to 4 UAEs were identified by diagnosis codes plus treatment codes. Cumulative incidence was measured using Kaplan-Meier methods. The hazard associated with different cancer treatments was compared using Cox models. RESULTS: UAEs occurred in 272 of 1808 cases (17%) and 222 of 5424 (4%) controls; most (62%) were ureteral strictures. The raw cumulative incidence of UAEs was highest in advanced cancers. UAEs occurred in 31% of patients after EBRT+BT, 25% of patients after RT+surgery, and 15% of patients after RH; however, after propensity weighting, the incidence was similar. In adjusted Cox models (reference = controls), the UAE risk was highest after RT+surgery (hazard ratio [HR], 5.07; 95% confidence interval [CI], 2.32-11.07), followed by EBRT+BT (HR, 3.33; 95% CI, 1.45-7.65), RH (HR, 3.65; 95% CI, 1.41-9.46) and SS (HR, 0.99; 95% CI, 0.32-3.01). The higher risk after RT+surgery versus EBRT+BT was statistically significant, whereas, EBRT+BT and RH were not significantly different from each other. CONCLUSIONS: UAEs are common after cervical cancer treatment, particularly in patients with advanced cancers. UAEs are more common after RT, but these women tend to have the advanced cancers. After propensity weighting, the risk after RT was similar to that after surgery.

American Cancer Society, American Society for Colposcopy and Cervical Pathology, and American Society for Clinical Pathology screening guidelines for the prevention and early detection of cervical cancer.

An update to the American Cancer Society (ACS) guideline regarding screening for the early detection of cervical precancerous lesions and cancer is presented. The guidelines are based on a systematic evidence review, contributions from six working groups, and a recent symposium co-sponsored by the ACS, American Society for Colposcopy and Cervical Pathology (ASCCP), and American Society for Clinical Pathology (ASCP), which was attended by 25 organizations. The new screening recommendations address age-appropriate screening strategies, including the use of cytology and high-risk human papillomavirus (HPV) testing, follow-up (e.g., management of screen positives and screening interval for screen negatives) of women after screening, age at which to exit screening, future considerations regarding HPV testing alone as a primary screening approach, and screening strategies for women vaccinated against HPV16/18 infections.

Longitudinal assessment of bone loss from diagnostic computed tomography scans in gynecologic cancer patients treated with chemotherapy and radiation.

OBJECTIVE: The objective of the study was to measure the volumetric bone mineral density (vBMD) using diagnostic computed tomography scans in gynecologic oncology patients. STUDY DESIGN: In a retrospective study, spine and femoral neck (FN) vBMD was measured for 1 year in 40 patients receiving chemotherapy or radiation. RESULTS: There is significant bone loss after chemotherapy, radiation, and a combination of radiation and chemotherapy (P = .0211). In 1 year, the percent reduction in vBMD (±SE) at L1-L2 spine and the FN was a 15.9% (±5.67) and 10.4% (±4.06) in chemotherapy; 11% (±5.68) and 15.8% (±2.56) in radiation; and 21.0% (±7.03) and 3.6% (±3.3.7) in the combined therapy group. Bone loss was evident immediately after treatment and persisted or worsened in most women. CONCLUSION: Gynecologic cancer patients treated with chemotherapy or radiation experience immediate and prolonged bone loss; thus, pre- and posttreatment monitoring of bone loss is important in these patients.

Optimization of primary and secondary cervical cancer prevention strategies in an era of cervical cancer vaccination: a multi-regional health economic analysis.

With the recent advent of cervical cancer vaccines, many questions relating to the best overall prevention methods for cervical disease are beginning to arise. A Markov model was used across five geographic regions (Canada, The Netherlands, Taiwan, UK, US) to examine the clinical benefits and cost-effectiveness of: (1) vaccination combined with screening, considering changes to screening-related parameters and (2) vaccination combined with screening, considering changes to screening policy. Given the assumptions used in this analysis, adding vaccination to current screening is likely to be cost-effective in the regions studied. When considering vaccination with several plausible changes to screening programmes, locations with the most frequent Papanicolaou smear testing may achieve the most efficiency gains by adopting a less frequent screening interval or incorporating HPV testing into their screening practices. Although it may be beneficial to change screening to maximize efficiency, the most cost-effective strategies for vaccination and screening combinations may not lead to the greatest reductions in cervical cancer; therefore such policy decisions may vary depending on region-specific goals. Finally, new screening paradigms such as primary HPV testing should be considered in future analyses.

The disparity of cervical cancer in diverse populations.

Significant disparities in cervical cancer incidence and mortality rates among minority groups have been documented in the United States, despite an overall decline in these rates for the population as a whole. Differences in cervical cancer screening practices have been suggested as an explanation for these disparities, as have differences in treatment among various racial and ethnic groups. A number of factors are attributed to these observed differences. As minority populations continue to grow in size over the next 50 years, persistent disparities will place an ever increasing burden on these populations and on the national healthcare system. Strategies to reduce cervical cancer disparities need to be employed in order to reverse these trends.