Advocating for patient preference in cervical cytology screening.

Cervical cytology is the prototype of a successful cancer screening test, yet debates continue as to the optimal frequency of screening and the use of new technologies. 1,2 The article by Raab et al 3 entitled " Willingness to Pay for New Papanicolaou Test Technologies " illustrates a new area of investigation for pathology. Too often in the past, pathologists have been stereotyped as preferring tissue over live patients. This study on patient preferences highlights the roles pathologists can have in test selection and even patient advocacy issues. Decisions by government and private payers on whether to cover a new test and at what rate ultimately drive the types of tests ordered by physicians and offered by laboratories. Indeed, such coverage decisions may determine the viability of a new technology. While pathologists have always been involved with influencing test selection, these discussions generally occur with other professionals or providers, not at the level of the patient. As patients become more educated about health care, they are likely to have more influence on decision making, especially in the choice of screening tests. Providers usually call for outcomes data when determining coverage policies. Cost-effectiveness studies are preferred, so payers can judge whether a new technique will save lives at a " reasonable " cost. However, " cost per life-year saved " is a crude measure; most recent studies on Papanicolaou (Pap) test cost-effectiveness do not consider indirect costs and quality-of-life issues such as morbidity, patient time spent away from work or home, convenience, and patient preference. Furthermore, there is no threshold that can be considered cost-effective, and policy decisions also should consider patient expectations and the regional standard of practice. 4 For cervical cancer screening, the goal is to detect precancerous conditions early when they can be treated. Conducting a study with no screening or intervention in the control arm is unethical. Given the success of conventional Pap smear screening, a huge study over many years would be required to demonstrate any change in cervical cancer mortality related to using a new technology. Thus, most new Pap technologies have used surrogate methods to demonstrate effectiveness, such as increased detection of precursor lesions. 5 Arguments against this approach are that many low-grade lesions will regress without therapy (meaning more sensitive tests may result in more false-positive results), and many studies do not verify either positive or negative results. Perhaps the best current proof …