HPV Screening for Cervical Cancer in Rural India

To the Editor: Sankaranarayanan et al. (April 2 issue)1 report no significant differences in rates of detection of high-risk cervical neoplasia among women who underwent screening by cytologic testing, testing for human papillomavirus (HPV) with the Hybrid Capture II assay, or visual inspection of the cervix with acetic acid (VIA). Reductions in mortality from cervical cancer were observed only among women screened by HPV testing. The unexpected lack of a correlation between detection rates reported for the screening tests and subsequent mortality rates requires careful consideration. Sankaranarayanan et al. acknowledge that unidentified differences in followup care, rather than differences in the performance of screening tests, account for differences in mortality between women screened by VIA in their current study and women screened by VIA in an earlier study.2 The same logic, applied to the current data, suggests that unidentified differences in follow-up care, rather than nonsignificant differences among screening-test detection rates, account for differences in mortality among the groups of women who underwent screening. Within the political structures of many developing countries, there is genuine lack of support for cervical-cancer prevention efforts,3 which may be further eroded by the questionable conclusion that only an unaffordable screening option is better than none at all.1 Eric J. Suba, M.D.