Costs and benefits of different strategies to screen for cervical cancer in less-developed countries.

BACKGROUND: About 80% of cervical cancers occur in less-developed countries. This disproportionate burden of cervical cancer in such countries is due mainly to the lack of well-organized screening programs. Several cervical cancer screening strategies have been proposed as more cost-effective than cytology screening. We compared the costs and benefits of different strategies and their effectiveness in saving lives in a less-developed country. METHODS: We used a population-based simulation model to evaluate the incremental societal costs and benefits in Thailand of seven screening techniques, including visual inspection of the cervix after applying acetic acid (VIA), human papillomavirus (HPV) testing, Pap smear, and combinations of screening tests, and examined the discounted costs per year of life saved (LYS). RESULTS: Compared with no (i.e., not well-organized) screening, all strategies saved lives, at costs ranging from 121 US dollars to 6720 US dollars per LYS, and reduced mortality, by up to 58%. Comparing each strategy with the next least expensive alternative, VIA performed at 5-year intervals in women of ages 35-55 with immediate treatment if abnormalities are found was the least expensive option and saved the greatest number of lives, with a cost of 517 US dollars per LYS. HPV screening resulted in similar costs and benefits, if the test cost is 5 US dollars and if 90% of women undergo follow-up after an abnormal screen. Cytology (Pap smear) was a reasonable alternative if sensitivity exceeds 80% and if 90% of women undergo follow-up. Compared with no screening, use of a combination of Pap smear and HPV testing at 5-year intervals in women of ages 20-70 could achieve greater than 90% reduction in cervical cancer mortality at a cost of 1683 US dollars per LYS, and VIA could achieve 83% reduction at 524 US dollars per LYS. CONCLUSIONS: Well-organized screening programs can reduce cervical cancer mortality in less-developed countries at low costs. These cost-effectiveness data can enhance decision-making about optimal policies for a given setting.

Induced abortion in Thailand: current situation in public hospitals and legal perspectives.

Abortion is illegal in Thailand unless the woman's health is at risk or pregnancy is due to rape. This study, carried out in 1999 in 787 government hospitals, examined the magnitude and profile of abortion in Thailand, using data collected prospectively through a review of 45,990 case records (of which 28.5% were classified as induced and 71.5% as spontaneous abortions) and face-to-face interviews with a sub-set of 1854 women patients. The estimated induced abortion ratio was 19.5 per 1000 live births. Almost half the induced abortions were in young women under 25 years of age, many of whom had little or no access to contraception. Socio-economic reasons accounted for 60.2% of abortions. Serious complications were observed in almost a third of cases, especially following abortions performed by non-health personnel. Government physicians' current provision of induced abortion went beyond the provisions of the law in almost half of cases, most commonly for intrauterine death and for congenital anomalies. The paper proposes a framework for policy discussions of the grey areas of maternal and fetal indications leading to legal reform, in order to facilitate safe abortion. A recommendation to amend the abortion law has been proposed to the Ministry of Public Health and the Thai Medical Council.

A new approach for the detection of cervical cancer in Thai women.

OBJECTIVES: The objective was to screen cervical cell samples of Thai women by using the Fourier-transform infrared (FTIR) spectrophotometry technique; the results were compared to the histologic diagnosis (gold standard). METHODS: FTIR spectrophotometry is a new technology for cervical cancer screening. Instead of detecting the morphological changes as used in Pap smear test, this technique detects, at the molecular level, structural changes of functional groups through the changes of the infrared absorption spectrum. When the infrared light is passed through a cervical cell sample, a molecule absorbs infrared radiation of the appropriate frequency which excites it from one vibrational or rotational level to another. A graph of energy absorbed versus frequency is the absorption spectrum of the sample. The FTIR spectra can be interpreted as normal and abnormal results. First, significant changes in the intensity ratios and, second, significant shifts of the peak frequencies were detected. Two hundred seventy-five cervical cell specimens were received from patients undergoing hysterectomy at the Department of Obstetrics and Gynecology, Faculty of Medicine, Chulalongkorn University Hospital. Samples were collected, prepared, and analyzed by FTIR spectroscopy. RESULTS: Histological examinations showed 108 abnormal cases and 167 normal cases. FTIR results versus histology showed sensitivity of 96.3% and specificity of 96.4%. False-negative and false-positive rates were 3.7 and 3.6%, respectively. CONCLUSIONS: FTIR showed high sensitivity and yielded a good false-negative rate. Besides the cervical cancer detection, the FTIR spectroscopy technique can also elicit positive results from adenocarcinoma of the endometrium, sarcoma of the uterus, and ovarian malignancies.