PART THREE
Special Techniques in Cytology
T a b le 3 4 .5 G yn e co lo g ic C yto lo g yR eim b urse m e n t: C enters fo r M edicare
and M edicaid Services N ational L im ita tio n A m o u n ts
CPT C o d e 0
A m o u n t (US$)
C on ve n tion a l
88164
14.76
88147
15.90
88148
21.23
Liquid-based
88142
28.31
88174
29.85
88175
37.01
Table 34.5 shows current Centers for Medicare and Medicaid Services national
limitation rates of reimbursement for various gynecologic cytology current
procedural terminology code procedures. Although individual insurers can
reimburse at any level above these figures, the Centers for Medicare and Medicaid
Services national limitation rates set a lower limit for all payers.
“88164/88142, manual screening of conventional/liquid-based cervical cytology
specimens; 88147/88174, automated screening of conventional/liquid-based
cervical cytology specimen with no manual review; 88148/88175, automated
screening of conventional/liquid-based cervical cytology specimen with manual
review.
in to h u m a n w o rk reductions o f up to one-q uarter o f the to ta l
screening w o rk o f the laboratory. Use o f the T hinP re p Im aging
System can add p ro d u c tivity at an even greater level, w ith stud-
ies show ing up to o n e -h a lf o f screening w o rklo a d savings. H o w
m uch overall savings accrues fro m th is increased p rod u c tivity
w ill depend on the cost o f the in stru m e n ta tio n . A t present, m ost
anecdotal in fo rm a tio n indicates th a t the cost fro m these tw o
devices can add between US$5 and U S$20 per case depending
o n lab o rato ry volum e. Finally, reim b ursem ent, a lthoug h n o t a
fo rm a l piece o f th e cost-effectiveness m od el equation, is im p o r-
ta n t in d eterm in in g i f these technologies can be successfully
em ployed in the laboratory. A lth o u g h reim b ursem ent is h ig h ly
variable am ong private insurers and regions, one starting p o in t
fo r com parison are the current Centers fo r M edicare and M edic-
aid Services n a tio n a l lim ita tio n am ounts used fo r US M edicare/
M edicaid reim b ursem ent, as show n in Table 3 4.5 . Reim burse-
m ents und er th is system are ab out d ouble fo r use o f liquid-based
cytology com pared w ith c onventional smears (U S$14.76 versus
US$28.31, respectively), and adding com puterized scanning to
liquid-based cytology adds an a d d itio na l US$8.70. A lth o u g h
n o t counted in the cost-effectiveness m odels, reim bursem ents at
such levels have m ade it possible fo r laboratories in the U n ite d
States to u tiliz e these technologies o n a widespread basis.
A com prehensive review article discussing cost-effectiveness
data fro m m an y p rio r studies is available.115 M o d e lin g studies
th a t have actually attem pted to incorp orate m a n y o f the quan-
tifia b le param eters discussed above have concluded th a t use
o f these new technologies require m od ifica tio n s in screening
strategies in ord er to achieve cost-effectiveness. For instance,
screening b y con ve n tio na l cytology at 3- to 5-year intervals
yield s cost-effectiveness ratios o f U S $ 6 8 0 0 -2 5 600 per life year
saved (LYS). Increasing screening frequency to 2-year intervals,
again w ith c onventional cytology, increases the cost-effective-
ness ra tio to U S$34 5 0 0 -5 6 400 per LYS, and p e rform in g liq -
uid-based cytology screening at 2-year intervals fu rth e r increases
the cost-effectiveness ra tio to U S$174 2 0 0 -4 5 2 600 per LYS.
U sing liquid-based preparations o n an annual basis yet again
increases th is cost-effectiveness ra tio to > US$1 m illio n per LYS.
For the annual and 2-year strategies cited, regardless o f te ch no l-
ogy u tilize d , the red uction in cervical cancer hovers at ab out
the 90% m ark. For the 3- to 5-year con ve n tio na l sm ear strat-
egy, the red uction is in th e 7 0 -8 0 % range. T h is compares w ith
a strategy o f H P V testing alone p erform ed three tim es over a
life tim e , w h ic h has a cost-effectiveness ra tio sig n ific an tly less, at
U S $ 5 9 0 -2 5 0 0 per LYS, and a red uction in cervical cancer m o r-
ta lity in the 5 0 -6 0 % range (Fig. 3 4.2 2 ) . Clearly, decisions to
u tiliz e new technologies w ill require changes in th in k in g ab out
screening intervals, the use o f c om b in atio ns o f technologies,
and decisions ab out w here to spend funds given the tradeoffs
required. Strategies developed in countries having adequate
resources fo r com prehensive screening program s m ay decide
th a t the costs are w ith in reach, whereas countries w ith m ore
lim ite d resources and o th e r healthcare issues (e.g. m alaria,
tuberculosis, and h u m a n im m un od e ficien cy viru s) m ay decide
on e n tire ly d iffe re n t strategies.
Concluding Remarks
In 2008, cervical cytolog y is at a crossroads regarding its future.
F ifty years o f stud y and practice experience have b ro u g h t the
fie ld to its present state, in w h ic h specim ens have been stand-
ardized in an o p tim a l fa sh io n fo r analysis and com p uterized
devices have been approved and entered in to c o m m o n usage.
B oth o f these technolog ic advances have been p ositive fo r the
field , y ie ld in g im p ro ve m e n ts in accuracy and p rod u c tivity, in
a system th a t has already been sho w n to be th e m o st effec-
tive cancer screening program ever devised. However, 2006
b ro u g h t th e b rea kth ro ug h o f the firs t cancer vaccine— targeting
cervical cancer th ro u g h a causative epitope, th e HPV. T he fu tu re
hold s p rom ise fo r sig n ific an t re d u c tio n in disease due to th is
advance, and as authors have p o in ted o ut, resu ltan t reductions
in cancer and high-grade precursors w ill necessarily reduce the
s e n s itiv ity o f cervical cytolog y screening program s, regardless
o f th e te ch no log y u tiliz e d , because o f decreased disease preva-
lence.116 It is u n lik e ly that, in such an e n v iro n m e n t, investiga-
tors and m anufacturers w ill spend sig n ific an t d evelop m ent
fund s o n fu rth e r im p ro ve m e n ts and refinem ents in th e current
m orp holog y-b ased system. Therefore it is h ig h ly lik e ly th a t we
have n o w seen th e z e n ith fo r te chnolog y d ire c tly related to the
current practice o f cervical cytology. T h a t being said, there s till
are areas in w h ic h te ch no log y m ay s till a llo w fo r m ore e ffi-
cient practice. T he c o m b in a tio n o f liq uid -b ased p rep aration,
autom ated screening, and Internet-based telecytolog y is one
such current te ch no log y in te g ra tio n th a t m ay a llo w fo r c ytol-
ogy specim ens to be processed and scanned rem otely, w ith the
cognitive skills o f in te rp re ta tio n being centralized fo r m a xim a l
efficiency (Fig. 3 4 .2 3 ) .117
However, aside fro m refinem ents o f the c urrently extant tech-
nologies, it makes the m ost sense th a t fu tu re advances in the
fie ld o f cervical cancer detection and p revention w ill take place
in the realm o f m olec ular biology. Studies are already beg inning
to emerge th a t u tiliz e m olec ular events to predict the presence
o f high-grade cervical preneoplastic processes. H ig h -risk H P V
testing was a start, b u t m ore specific m arkers o f H P V integra-
tio n , cell cycle d ysfunction m arkers, and chrom osom al ab nor-
m alitie s are b eg inning to emerge th a t w ill becom e m ainstays in
o u r fu tu re screening and evaluation program s (Fig. 3 4.2 4 ) .118-120
U n til such tests becom e m ainstream , the b urden o f o u r current
screening program s w ill be anchored b y the cytology a u to m a tio n
1038
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