Rescreening of Cervical Papanicolaou Smears Using PAPNET—Reply

In Reply.— Dr Greenberg suggests that the traditional Pap smear should be supplemented with HPV testing when ASCUS, AGUS, or LSIL is encountered. Since our study did not address HPV testing, we cannot address the cost-effectiveness of this strategy, but observe that routine Pap smear testing as infrequently as every 3 years can reduce the incidence of invasive cervical cancer by up to 90%.¹

Dr Koss, Drs Mango and Radensky, and Dr Schechter would have preferred we perform a traditional cost-effectiveness analysis of PAPNET, rather than compare this relatively expensive rescreening strategy with the less expensive manual alternative. We wanted to find out how expensive it is to use PAPNET to find abnormal Pap smears that would be missed by manual rescreening. Cost-effectiveness analyses that ignore the existence of a less expensive alternative tend to make the proposed intervention look better than it really is; this is unquestionably the case with both the study by Schechter² and the study by Radensky and Mango.³ These analyses are further limited by the use of pooled data³ and do not appear to address either interlaboratory variation or uncertainties in the rate of progression of premalignant lesions; these factors are considered more effectively by Raab.⁴