Showing papers by "Stephen S. Raab published in 2001"

De novo establishment and cost-effectiveness of Papanicolaou cytology screening services in the Socialist Republic of Vietnam.

Abstract: BACKGROUND Cervical carcinoma is the leading cause of cancer-related death among women in the developing world. The absence of cervical screening in Vietnam and other developing countries is due in large part to the perceived expense of implementing Papanicolaou cytology screening services, although, to the authors' knowledge, the cost-effectiveness of establishing such services has never been studied in a developing country. METHODS Using decision analytic methods, the authors assessed cost-effectiveness of Pap screening from a societal perspective in Vietnam, the world's 9th most populous developing country (estimated 1999 population, 79 million). Outcomes measured included life expectancy, cervical carcinoma incidence, cost per woman, and cost-effectiveness. RESULTS Total costs to establish a nationwide 5-year interval Pap screening program in Vietnam will average less than $148,400 annually during the 10-year time period assumed necessary to develop the program and may be considerably lower if only high risk geographic areas are targeted. Maintenance costs will average less than $0.092 annually per woman in the target screening population. Assuming 70% program participation, cervical carcinoma incidence will decrease from 26 in 100,000 to 14.8 in 100,000, and cost-effectiveness will be $725 per discounted life-year. Several assumptions used in this analysis constitute biases against the effectiveness of Pap screening, which in reality may be significantly more cost-effective than reported here. CONCLUSIONS Contrary to widespread belief, Pap screening in developing countries such as Vietnam is extraordinarily inexpensive and appears to be cost-effective. Because prospects are uncertain regarding useful alternatives to the Pap test, the evidence-based argument for establishing conventional Pap screening services in developing countries such as Vietnam is compelling. Population-based conventional Pap screening services have been established de novo in Vietnam and are now operational. Cancer 2001;91:928–39. © 2001 American Cancer Society.

Fine-needle aspiration for the diagnosis of primary epithelial tumors of the lacrimal gland and ocular adnexa.

Abstract: Results of fine-needle aspiration (FNA) of solid-tissue neoplasms arising in the periocular glands are infrequently reported in the literature. To our knowledge, no previous series relating to this topic exist. Neoplastic processes that arise in the semiconfined area of the orbit behave as space-occupying lesions. Such lesions can exert significant pressure on the globe, be responsible for altered vision, and result in proptosis. When noninvasive techniques fail to confirm or rule out the suspicion of a neoplastic lacrimal or adnexal lesion, FNA may be of use in establishing a diagnosis in an efficient, reliable, timely, cost-effective, and safe manner. During the 14-yr interval from 1986-1999, 77 orbital/ ocular needle aspiration biopsies were conducted by staff ophthalmologists at Allegheny General Hospital (Pittsburgh, PA). Review of the diagnoses for these specimens revealed seven primary solid-tissue lesions of the lacrimal gland and other adnexal glands, all arising in adult patients (age range, 45-92 yr; mean age, 74 yr). Primary lacrimal and adnexal gland neoplasms were found to represent ∼9% of orbital fine-needle aspirations (7/79). The 7 cases included 3 lacrimal gland lesions diagnosed as benign mixed tumors, 3 lesions diagnosed as adenoid cystic carcinoma of the lacrimal gland, and 1 tumor diagnosed as sebaceous carcinoma of the meibomian holocrine glands. Cytologic diagnoses were rendered using standard criteria for salivary gland-type tumors. Tissue confirmation was available from surgical follow-up in 4 of the 7 cases, with 100% correlation. Although primary neoplasms of the lacrimal gland and glands of the eyelids are rare, accurate diagnoses of such lesions may be established with minimally invasive aspiration techniques. Preoperative aspiration biopsy diagnoses provide a great advantage to ophthalmic surgeons who routinely operate in a conservative fashion in an area of the body requiring great attention to cosmesis. Our experience indicates that FNA is a reliable and effective tool in the diagnosis and management of primary lacrimal and ocular adnexal tumors.

Subcategorization of Papanicolaou Tests Diagnosed as Atypical Squamous Cells of Undetermined Significance

Abstract: In this issue of the Journal, Renshaw et al1 address the issue of subcategorizing Papanicolaou (Pap) tests diagnosed as atypical squamous cells of undetermined significance (ASCUS) I would like to make several comments about this article in light of the recommendations presented on the Web site of the 2001 Bethesda System Conference2 and in light of ancillary studies, such as human papillomavirus (HPV) testing One of the recommendations from the 2001 Bethesda System Conference is for changing the terminology of Pap tests formerly called ASCUS (using the 1991 Bethesda System terminology)2,3 The 1991 Bethesda Committee recommended that ASCUS Pap tests could be subclassified as favor reactive or favor dysplasia (favor low-grade squamous intraepithelial lesion [SIL]), and if neither of these categories seemed to fit, then the Pap test could be diagnosed simply as ASCUS (which some prefer to term the not otherwise specified [NOS] category)3 The 2001 Bethesda Committee recommended eschewing previous ASCUS terms for the term atypical squamous cells (ASC); all Pap tests then should be subclassified as either atypical squamous cells– undetermined significance (ASC-US) or atypical squamous cells–high-grade dysplasia not excluded (ASC-H)2 Note the differences in the 1991 and the 2001 Bethesda Systems categories of ASCUS It was argued that the ASCUS, favor reactive category be eliminated from the 2001 schema because follow-up reveals that the majority of women with this diagnosis do not have a high-grade dysplasia but have a benign lesion2 The ASCUS, NOS and ASCUS, favor dysplasia categories were collapsed into 1 category because it was thought that both categories included women with a significant risk of having dysplasia (mostly low grade) on follow-up Although the risk of dysplasia associated with the categories of ASCUS, NOS and ASCUS, favor dysplasia are different, this difference in risk was not considered disparate enough to warrant 2 categories Followup data for women with ASC-H show that the risk of having dysplasia, and particularly high-grade dysplasia, is significantly higher than for women with ASC-US2 Atypical cells classified as ASC-H usually are metaplastic, and it is interesting to note that the 1991 Bethesda Committee recognized these cells as potentially representing a high-grade dysplasia3 As a result of these recommendations, the 1991 Bethesda System category of ASCUS morphed from 3 categories to 2 categories, one predominantly a risk category for low-grade dysplasia and the other predominantly a risk category for high-grade dysplasia The ASCUS categories examined by Renshaw et al1 are a hybrid of the 1991 and the 2001 Bethesda categories The 1991 ASCUS, favor reactive category is maintained; the 1991 ASCUS, favor dysplasia and ASCUS, NOS categories are not collapsed; and the 2001 ASC-H category is added Using receiver operating characteristic curve analysis, Renshaw et al1 argued that the sensitivity of the Pap test is lowered if any ASCUS subset is eliminated Does this mean that the 2001 Bethesda Committee is mistaken in eliminating ASCUS, favor reactive and in collapsing ASCUS, NOS and ASCUS, favor dysplasia? I believe that the 2001 Bethesda Committee is justified in its recommendations, although I agree with Renshaw et al1 that removal of ASCUS subcategories decreases Pap test sensitivity Before discussing these points further, the data and methods of Renshaw et al1 first deserve some comment The data used in their analysis suffer from sample bias The

Clinical perception of disease probability associated with Bethesda System diagnoses.

Abstract: The degree to which clinical perceptions of Papanicolaou smear sensitivity contribute to patient mismanagement is uncertain. A voluntary, anonymous questionnaire was mailed to 350 obstetricians/gynecologists (OGYNs) and 350 other primary care providers (PCPs) located in Pennsylvania or Ohio. The clinicians estimated the probability of no disease, dysplasia, and invasive carcinoma for 1 of 7 Bethesda System diagnoses. Differences in probability estimates between provider types and between the clinicians and medical literature data were measured. The response rate was 22.7%. Compared with published values, clinicians estimated similar disease probabilities for many diagnoses. However, for some diagnoses, the probability estimates differed considerably from published values (eg, overestimation of dysplasia and invasive carcinoma for benign diagnoses and underestimation of dysplasia for some dysplasia diagnoses), and such errors could contribute to patient mismanagement. OGYNs generally were more accurate in probability estimates than PCPs. Methods to convey more accurately these diagnostic disease probabilities should be examined.