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LETTER |
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, 1200 El Camino Real, South San Francisco, CA 94080 (e-mail: eric.suba{at}kp.org).
The participants of the Viet/American Cervical Cancer Prevention Project have agreed that research on novel screening approaches in certain low-resource settings may be appropriate, provided that such research is conducted subordinate to, not instead of, the development of Papanicolaou (Pap) screening services in the same settings.1 Opportunity costs, borne by the underserved, are associated with prioritizing research on novel health interventions in any setting where established interventions are feasible but unavailable.2 The debate to which Sherris et al. appropriately refer Journal readers3,4 may be considered part of a larger debate, articulated bluntly by President Jimmy Carter, over whether the Bill & Melinda Gates Foundation has become enamored with the promise of science and novel technologies at the expense of delivering available preventives today.5 That research on novel technologies in developing countries may be more compatible with market forces than with public health goals adds additional complexity to the situation.2
It would be paradoxical to suggest that Program for Appropriate Technology in Health (PATH) is partnered with yet uninfluenced by human papillomavirus (HPV) test manufacturers. For example, PATH’s partnership with Digene Corporation (Gaithersburg, MD) presents a source of potential bias in favor of HPV screening that should be disclosed to readers of Alliance for Cervical Cancer Prevention cost-effectiveness studies.6 Because dozens of public–private partnerships have recently been established with philanthropic funding in global health,5 PATH should set a leading example by fully disclosing the terms of its public–private partnerships, including any arrangements for revenue sharing from future sales of HPV tests.
More than 7 years after the founding of the Alliance for Cervical Cancer Prevention, cytology remains the only preventive option available for public-sector cervical cancer control in developing countries.7 HPV vaccination, the long-term effectiveness of which remains uncertain, is currently unaffordable, as is HPV screening. Quality management methods are not established for visual inspection with acetic acid, which is not recommended for use outside of pilot projects and is inappropriate for postmenopausal women in any setting.7 Because cytology will be an essential triage component of future "screen and treat" or multiple-visit HPV-based or visual inspection with acetic acid programs,1,2,4 we entreat Sherris et al. to endorse, on the Web site for Alliance for Cervical Cancer Prevention, a patient-centered consensus policy whereby Pap screening will be implemented anywhere cervical screening is appropriate but unavailable, with consideration given to novel preventives as locality-specific research into novel preventives is completed.2,4 Proponents of the alternative policy—to further delay the implementation of Pap screening in some settings pending the unlikely realization of cytology-free preventive approaches with decisive advantages over approaches incorporating some cytology—are unfortunately enamored with the promise of novel approaches at the expense of delivering available preventives today.4
References
1. Suba EJ, Donnelly AD, Furia LM, Huynh MLD, Raab SS. Coming to terms with Vietnam: the Viet/American Cervical Cancer Prevention Project. Diagn Cytopathol. 2005;33:344–351.[CrossRef][Web of Science][Medline]
2. Suba EJ, Murphy SK, Donnelly AD, Furia LM, Huynh ML, Raab SS. Systems analysis of real-world obstacles to successful cervical cancer prevention in developing countries. Am J Public Health. 2006;96: 480–487.
3. Wright TC Jr, Blumenthal P, Bradley J, et al. Cervical cancer prevention for all the world’s women: new approaches offer opportunities and promise. Diagn Cytopathol. In press.
4. Suba EJ, Donnelly AD, Furia LM, Huynh MLD, Raab SS. Cervical cancer prevention for all the world’s women: genuine promise resides in skilled quality management rather than novel screening approaches. Diagn Cytopathol. In press.
5. Cohen J. The new world of global health. Science. 2006;311:162–167.
6. Suba EJ, Frable WJ, Raab SS. Cost-effectiveness of cervical-cancer screening in five developing countries [published correction appears in N Engl J Med. 2006; 355:745]. N Engl J Med. 2006;354:1535–1536.
7. 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 October 17, 2006.
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