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Screening all Americans for protein in the urine beginning at the age of 50 and every year after is not cost-effective, according to researchers who used a Markov decision analytic model to compare various screening strategies. It would be more cost-effective to screen only those 60 years old or older and those with high blood pressure. Protein in the urine is a sign of kidney disease, which is more easily treated if detected early.

Direct-to-consumer marketing of helical CT scans for detecting lung cancer in current and former smokers is not cost-effective, according to researchers who used computer simulation on a hypothetical group of 100,000 current or former smokers. Helical CT scans are very expensive and they may find lung abnormalities that are not cancerous. This false-positive result would lead to additional invasive tests, with no benefit to the patient.

The most cost-effective way to screen women for cervical cancer is to give them a Pap test and a human papillomavirus test every two years until the age of 65 or 70. Human papillomavirus has been linked to cervical cancer., Context: Despite quality assurance standards, Papanicolaou (Pap) test characteristics remain less than optimal. Objective: To compare the societal costs and benefits of human papillomavirus (HPV) testing, Pap testing, and their combination to screen for cervical cancer. Design, Setting, and Population: A simulation model of neoplasia natural history was used to estimate the societal costs and quality-adjusted life expectancy associated with 18 different general population screening strategies: Pap plus HPV testing, Pap testing alone, and HPV testing alone every 2 or 3 years among hypothetical longitudinal cohorts of US women beginning at age 20 years and continuing to 65 years, 75 years, or death. Main Outcome Measure: Discounted costs per quality-adjusted life-year (QALY) saved of each screening strategy. Results: Maximal savings in lives were achieved by screening every 2 years until death with combined HPV and Pap testing at an incremental cost of $76183 per QALY compared with Pap testing alone every 2 years. Stopping biennial screening with HPV and Pap testing at age 75 years captures 97.8% of the benefits of lifetime screening at a cost of $70347 per QALY. Combined biennial HPV and Pap testing to age 65 years captures 86.6% of the benefits achievable by continuing to screen until age 75 years. Human papillomavirus screening alone was equally effective as Pap testing alone at any given screening interval or age of screening cessation but was more costly and therefore was dominated. In sensitivity analyses, HPV testing would be more effective and less costly than Pap testing at a cost threshold of $5 for an HPV test. Conclusions: Screening with HPV plus Pap tests every 2 years appears to save additional years of life at reasonable costs compared with Pap testing alone. Applying age limits to screening is a viable option to maintain benefits while reducing costs.

Screening people 35 years old and older every 5 years for mild thyroid failure is as cost-effective as screening for high blood pressure. Researchers concluded this after running a hypothetical model assuming people would be screened every 5 years beginning at age 35 during their regular health examination. The cost-effectiveness was $9,223 per quality-adjusted life year (QALY) in women and $22,595 per QALY in men. Screening was more cost-effective in women because mild thyroid failure is more common in women.

There is little evidence to support giving routine Pap smears to detect vaginal cancer to women who have had a hysterectomy if the woman has no history of abnormal smears. Eighty-five percent of hysterectomies in the US are done to treat benign disease. An estimated 5.72 million Pap smears are done annually in these women, at a cost of $43.5 million to $350 million. Several studies have reported an increased risk of vaginal cancer in these women, while other studies have found no risk. Cancer originating in the vagina is very uncommon, with an incidence of 0.2 to 0.7 cases per 100,000 women. It is also not clear that early detection reduces mortality rates. The sensitivity of Pap smears in detecting early-stage vaginal cancer may be low. Consequently, the test may not pass the criteria for an effective screening test. These include proof that the test is accurate in detecting the condition and that people diagnosed early have better outcomes., Objective.--Using literature review, we assessed (1) Papanicolaou smear screening recommendations after hysterectomy for benign disease, (2) total hysterectomy for benign disease as a risk for vaginal dysplasia or carcinoma, and (3) effectiveness of screening for vaginal carcinoma after total hysterectomy for benign disease. Data Sources.--We considered (1) organizations' recommendations about screening, (2) references from major textbooks of gynecology, and (3) MEDLINE searches of English-language studies published from 1966 through 1995 using the search strategy (hysterectomy and vaginal smears) or (vaginal smears and vaginal neoplasms). Study Selection.--Published or verbal confirmations of screening recommendations were eligible. Criteria for assessing risk of vaginal dysplasia or carcinoma included original research, documented reports of hysterectomy as an exposure, and evidence of preinvasive vaginal disease or vaginal carcinoma outcomes. We sought data assessing burden of suffering, screening efficacy, and effectiveness of early detection. Data Extraction.--Descriptive and analytic data from each study were abstracted. Data Synthesis.--Screening recommendations were categorized by the organizations' positions: two opposed screening, two supported screening, and six lacked specific guidelines. Data on the risk between total hysterectomy for benign disease and subsequent vaginal carcinoma were organized by study design (three case control, two cohort, and 13 case series) and described. Data on screening effectiveness were organized to address the criteria advocated by the US Preventive Services Task Force. Conclusions.--There are conflicting guidelines on screening after hysterectomy and conflicting data on the risk of vaginal carcinoma after total hysterectomy for benign disease, though the best-designed research suggests no association. There is insufficient evidence to recommend routine vaginal smear screening in women after total hysterectomy for benign disease. (JAMA 1996;275:940-947)

A two-step process that involves pre-screening urine samples appears to be the most cost-effective means for treating chlamydial infections in adolescent males. A total of 1,000 adolescent males were screened using two protocols for chlamydial infections during routine medical check-ups. In the first protocol, first-catch urine was tested with leukocyte esterase (LE) strips. Samples with positive readings were referred for more sensitive analysis with enzyme immunoassay (EIA). In the second protocol, all urine samples were referred only for the more costly EIA testing. The LE-EIA strategy was more cost effective than EIA testing of all samples. Treatment with a single dose of azithromycin in the clinic improved cure rates from 11.2% to 16.3% depending on the screening method. The single treatment also reduced the cost of both strategies.

Computer-aided rescreening of cervical Pap smears using the PAPNET system may not identify many more cervical abnormalities and can be very expensive. Pap smears that are judged normal or benign on initial screening can be rescreened by another technologist or device to improve diagnostic accuracy. Researchers used PAPNET to screen 5,478 cervical samples that already had been screened twice by technologists. PAPNET identified 6 slides that contained atypical cervical cells. The high cost of automated rescreening was not justified by any significant improvement in cervical cancer testing., Context.-- The Food and Drug Administration has recently approved several devices that use computerized image analysis to rescreen Papanicolaou (Pap) smears that have already been examined by cytotechnologists. Physicians and laboratories must decide whether the utility of these devices justifies the cost. Objective.--To determine the effectiveness and cost of PAPNET-assisted rescreening in identifying cervical abnormalities not identified by manual rescreening. Design.--PAPNET-assisted rescreening of 5478 Pap smears obtained in 1994 and 1995 previously identified as"within normal limits" or "benign changes" on both initial and random screening. Patients.--Female service members and dependents aged 12 to 88 years. Setting.--Air Force clinics in the United States and Japan. Intervention.--Rescreening of Pap smears by PAPNET, followed by reevaluation of abnormal smears by the consensus panel, consisting of 3 cytotechnologists and 3 pathologists. Main Outcome Measures.--Proportion of Pap smears initially screened as normal identified as abnormal by both PAPNET and consensus panel; costs of rescreening. Results.--PAPNET screening identified 1614 (29%) slides requiring additional microscopic review. On further review, 448 (8% of total) had possibly abnormal cells. Ultimately, 11 of these cases were reviewed by the consensus panel for potentially atypical cells. Of these 11 cases, 5 were reclassified as atypical squamous cells of undetermined significance (ASCUS) and 1 as atypical glandular cells of undetermined significance (AGUS). No additional squamous intraepithelial neoplasia (SIL) was identified in these smears; the patient with a diagnosis of AGUS on rescreening was diagnosed as having a low-grade SIL (LSIL) on follow-up. Costs were $5825 to $33 781 for each additional ASCUS or AGUS diagnosis. A cost of $17475 to $101343 is expected for each case of LSIL identified by PAPNET-assisted rescreening and not by traditional manual rescreening. Conclusions.--PAPNET-assisted rescreening identified a few more cases of ASCUS than did manual rescreening, but at a relatively high cost. The costs of rescreening should be carefully compared with the expected efficacy in reducing cervical cancer mortality.

An annual fecal occult blood test and a sigmoidoscopy every five years beginning at age 50 followed by a colonoscopy if any abnormal polyps are found is a very effective screening method for reducing colorectal cancer mortality in men. This method reduced the incidence of colorectal cancer 60% and the mortality rate 80%.

The cost-effectiveness of screening diabetics for eye disease varies significantly depending on the age of the patient, their risk factors for eye disease, and how often they are screened. Researchers estimated the cost of screening every year, every other year, or every three years in a hypothetical group of patients. Annual screening would be beneficial in younger patients with poorly controlled blood sugar but not as beneficial in older patients. Patients at low-risk probably would not need annual screening either.

It may not be cost-effective for women over the age of 69 to get regular mammograms. Researchers analyzed the cost-effectiveness of stopping mammography at the age of 69, continuing it to age 79, or providing it to women over 69 only if they had high bone density. Women with high bone density are more likely to develop breast cancer. Continuing mammography to age 79 prevented only 1 death from breast cancer and added only 7 hours to life expectancy. Offering it only to those with high bone density saved 9 lives and added 2 days to life expectancy.

Helical CT scans for detecting lung cancer in current or former smokers is not cost-effective as of 2002. However, this could change in the future as technology improves and the scans become less expensive. If scanning also reduces mortality rates by detecting lung cancer in its early stage when it is easier to treat, it would definitely be cost-effective.

Testing samples of cervical fluid for human papillomavirus at the same time a woman has a Pap smear may be more cost-effective than a Pap smear alone, especially if it is done every three years. Women who test positive would have more frequent follow-up Pap smears than women who test negative. This virus has been linked to cervical cancer.

ABSTRACT: Two quantitative methods, Confidence Profiles and CAN * TROL, are used to analyze evidence and estimate the health and economic consequences of adding annual mammography to annual breast physical examinations in asymptomatic women aged 40 to 49 years who are at average risk for breast cancer. Such women have about a 128 in 10 000 chance of having breast cancer in the next ten years and about an 82 in 10 000 chance of dying of such a cancer. Adding annual mammograms to annual breast physical examinations each year during that age decade would reduce the probability of death to about 60 in 10 000, a reduction of about 26%. Screening would increase the expected lifetime of a woman destined to get breast cancer between ages 40 and 49 years by about 3.5 years. Ten years of screening with mammography in that age decade carries a risk of radiation-induced cancer of about one in 25 000 and a risk of a surgery recommendation for a lesion that is not cancer of about one in ten. If 25% of the women in this age group in the United States were screened every year, breast cancer mortality in the year 2000 would be decreased by about 373 deaths. In 1984 dollars, the cost of screening, workups, and continuing care in the year 2000 would be about $408 million. Treatment costs would be decreased byd about $6 million, leaving a net increase in costs in the year 2000 of approximately $402 million (1984 dollars).

The 1991 theme issue of The Journal of the American Medical Association focused on health care for the uninsured and underinsured and addressed the need for improved access to health care for all Americans; however, it failed to adequately address the issues of preventing disease and disability and promoting good health. All Americans should be extended the fundamental right to have access to quality health care at a cost they can afford. There are some anomalies in our current system of health care; we willingly pay $2,000 a day for the care of a low-birth-weight baby, yet we do not pay for prenatal care, which costs about $500 per pregnancy and can reduce the incidence of premature births. We are now experiencing an epidemic of measles; this is a consequence of failure to provide immunizations. The remedial medical and educational services required to deal with the consequences of lead poisoning in children exceed $1 billion annually; medical insurance does not even cover the cost of screening children for lead toxicity, let alone the cost of remedial care. Government and private insurance companies may pay up to $50,000 per patient to treat breast cancer, yet the cost of a screening mammogram (about $75) is usually not covered despite evidence that mammographic screening saves lives. Only a small fraction of the money spent on health care this year will be spent on prevention of disease and disability and promotion of health. Recently Blue Cross and Blue Shield took a step in the right direction by offering periodic preventive care and screening as part of their basic coverage available to healthy adults. Senator Harkin believes that disease prevention and health promotion must be part of any significant health care reform. In the US Senate, he has introduced a legislative package called 'Prevention First'. This is a series of acts that would extend preventive medicine to many Americans, address the issues of lead poisoning and breast cancer screening and appropriately change the name of the Centers for Disease Control, our main disease prevention agency, to the Centers for Disease Prevention and Control. Many of the solutions put forth to deal with the issues of the uninsured and underinsured represent another pound of cure within a system of quick fixes and inadequate remedies. It is time to put prevention first; prevent disease and disability for everyone at home, in school and at work. (Consumer Summary produced by Reliance Medical Information, Inc.)

Screening HIV-infected gay men for anal cancer and its precursor appears to be cost-effective. Researchers used a mathematical model to estimate the cost-effectiveness of screening HIV-infected gay men at various intervals. If screening began early in the disease and was done every two years, it would cost $13,000 for every quality-adjusted life year (QALY) saved. This is comparable to other preventive health programs. If screening began later, yearly screening would still be less than $25,000 per QALY saved. Screening more frequently provided little additional benefit.

It is now cost-effective to screen all sexually active young people for chlamydia infection. A 1998 Swedish study found that as the incidence of chlamydial infection decreased so too did the incidence of ectopic pregnancy. Chlamydia infection can cause many other reproductive problems, including pelvic inflammatory disease, infertility, low birth weight, and premature delivery. In the US, cities with the most active screening programs have witnessed a decline in chlamydia infections. Analysis of urine samples using the polymerase chain reaction has made the infection easy to diagnose.

Mass screening of young adults for type 2 diabetes can reduce the incidence of diabetic complications and lower the age at diagnosis. Undiagnosed diabetes, in which the blood glucose level remains high, can cause vascular disease, kidney disease, blindness, and other conditions. Researchers produced a computer model to estimate the costs associated with a population screening program. Screening adults 25 years of age and older reduces the age at diabetes diagnosis by about six years, and reduces the lifetime incidence of diabetes complications by 22-35%. Screening young adults and African Americans appears to be more cost-effective than screening older adults.