George F. Sawaya

Avoiding Low-Value Care and Patient Financial Harm in Cervical Cancer Screening

Abstract The provision of low-value care remains a significant concern in healthcare. The negative impacts resulting from low-value cervical cancer screenings are extensive at the population level and can lead to harms and substantial out-of-pocket expenses for patients. Inattention to the financial implications of screening poses a serious threat to low-income populations that depend on affordable screening services, and it may exacerbate existing healthcare disparities and inequities. Identifying and implementing strategies that promote high-value care and reduce patient out-of-pocket expenses are important to ensure that all people, regardless of their socioeconomic status, have access to effective and affordable preventive care. See related article by Rockwell et al., p. 385

Primary human papillomavirus testing vs cotesting: clinical outcomes in populations with different disease prevalence

Abstract Implementation of primary human papillomavirus (HPV) testing has been slow in the United States perhaps because of concerns of decreased sensitivity compared with concurrent HPV and cytology testing (“cotesting”). We used the National Breast and Cervical Cancer Early Detection Program and the Kaiser Permanente of Northern California cohort to quantify potential trade-offs with primary HPV compared with cotesting in 4 US populations with differing precancer or cancer prevalence. In all settings, cotesting required more lab tests and more colposcopies compared with primary HPV testing. Additional cervical intraepithelial neoplasia grade 3 or cancer immediately detected from cotesting vs primary HPV decreased with decreasing population-average cervical intraepithelial neoplasia grade 3 or cancer prevalence from 71 per 100 000 screened among never or rarely screened individuals in the National Breast and Cervical Cancer Early Detection Program (prevalence = 1212 per 100 000) to 4 per 100 000 screened among individuals with prior HPV-negative results in Kaiser Permanente of Northern California (prevalence = 86 per 100 000). These data suggest that cotesting confer an unfavorable benefit-to-harm ratio over primary HPV testing.