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To the Editor: Dr Wright and colleagues1 report that human papillomavirus (HPV) testing of self-collected vaginal swabs is as sensitive as Papanicolaou tests for detecting high-grade cervical cancer in women aged 35 to 65 years. However, the results may have been influenced by verification bias. Because only women with a positive HPV result were referred for the criterion standard of colposcopy and biopsy, unbiased estimates of true-positive rates of each test cannot be computed. These rates are relative, and subsequent estimates of sensitivity and specificity are prevalence-dependent and can only apply to the sampled population.2 This bias is particularly important to extrapolating these results to a lower-risk population, such as older women in the United States.
Wright et al conclude that the sensitivity of self-collected samples is lower than that of clinician-obtained samples. However, clinician-collected samples were analyzed in a different country than patient-collected samples. Furthermore, it is unclear from the data whether all women whose self-collected sample tested positive underwent colposcopy to define their disease status.
In clinical settings where cytological screening is not available routinely, self-collected samples for HPV DNA could be used to identify older women at high risk of cervical disease. Results from a recent study in the similarly high-risk country of Zimbabwe showed that the majority of women with high-grade lesions associated with HPV DNA were younger than 35 years.3 It is therefore unfortunate that the study by Wright et al did not include younger women to maximize the benefits of screening in this region. If the authors wish to address the issue of underscreening in the United States, it would seem more sensible to study that particular group and to assess the acceptability of self-testing among those women.
Women with HPV who seroconvert,4 who are infected with human immunodeficiency virus,3 and in whom HPV persists5 are more likely to have cervical lesions associated with detection of HPV DNA. These factors could be useful for determination of the frequency of repeating the screening procedure and to refine criteria for referral for colposcopy.
Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature
Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal
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