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Improving cervical screening by involving general practitioners
699
precise molecular (often genetic) diagnosis, elucidation of pathogenesis, formulation of new treatments to be tested by clinical trial, to promotion of any successful treatment. Your editorial seems only in the first and last part of the cycle, neglecting that part capable of providing precision rather than guesswork. Medicine is becoming a precise science and paediatrics in the UK to believe
should take part in that revolution. Your editorial would appear to argue against this.
Data from the Leiden region for the new system are fully comparable with those for the old system. All histological data were retraced by the laboratory; as were those cases referred to the gynaecologists with a cytological diagnosis of mild-to-moderate dysplasia. Postal codes were used to check data for any possible bias due to urbanisation. The cytological and histological rates per 1000 screenees were higher under the new system for all diagnoses. The
change in policy increased screening efficiency.
ROLAND LEVINSKY MARCUS PEMBREY
Institute of Child Health, London WC1 N 1EH, UK
Becoming a doctor in China SIR,-As a Chinese-qualified doctor on clinical attachment in the UK I would add my
comments to
those of Dr Chen and Dr
Godfrey (July 20, p 169). They clearly demonstrate the striking improvement
in life
expectancy and infant mortality achieved in China in comparison with other nations (table n). It should be noted, however, that the improvement has been in communicable diseases, which are susceptible to relatively cheap public health measures. The pattern of disease is now changing to the chronic degenerative illnesses familiar in the western world. This will require additional resources not only in hospital beds, but also in advanced western medical
experience. Although English texts form part of the medical curriculum, an adequate working knowledge of the language is not enough for complete understanding. Furthermore, western textbooks are usually out of date by the time they are translated into Chinese. China has been encouraging some of its doctors to obtain experience in western countries. However, many of them are too senior to be of interest to institutions, and Chinese doctors would be unable to afford the foreign travel on their own funding (their salary is only C20 per month), as well as follow the complicated application
procedure. Because of the language barrier, even when foreign doctors visit cities in China, translation is sometimes done by commercial interpreters unversed in medical terminology. Many of the senior doctors in China cannot read foreign language textbooks or papers in their own subject. This lack of exposure to world publications means that many clinical research programmes do nothing more than duplicate work already done abroad. Index Medicus, for example, tends to gather dust in the library rather than being consulted, especially since few articles written by Chinese doctors appear there. Since China is the most populous country in the world and copes with a changing demography and disease pattern, its doctors will need to participate in the interchange of medical knowledge and skills. It is thus to be hoped that not only will foreign medical teachers and medical techniques be welcomed into China, but that many more Chinese doctors will have the opportunity to sharpen their clinical skills abroad. I thank Dr B. J. M. Jones, Dr W. R. Price, Dr A. N. Hamlyn, and Mrs M. Littlewood for their helpful comments.
Department of Gastroenterology, Russells Hall Hospital, Dudley DY1 2HQ, UK
Y. C. ZHANG, Attending Doctor, Fu Shan Hospital, Tsingtao, PR China.
CtS=carcmoma-!n-s!tu
In the
had noticed that the efficiency of "opportunistic" taking in general practice was better than population screening in health-care centres.3 The doctor has an active role in the selection process which allows him to influence efficacy; thus we cannot speak of a Hawthorne effect. However, in both the old and the new national screening programme, the screenee "selected" herself for screening having received an invitation. So the general practitioner could not directly influence the selection. The setting therefore differs fundamentally from
1970s,
we
smear
opportunistic smear taking. To explain our findings we looked closely at compliance
rates:
under the new system this was around 40% but in the old system it was much the same’ However, in the old system, the compliance rate of the married women was twice that of divorced women4 diminishing efficiency because divorced women are a high-risk group for smear positivity. In the new system the compliance rates of these two groups were equal, indicating that divorcees were no longer shunning screening. As expected4 in the new system the divorcees scored higher (x 3-0) than the married women for (pre)neoplastic cervical lesions. To explain the high detection rates for cervical (pre)neoplasia it must be assumed that high-risk groups other than divorcees-groups that are more difficult for us to identify-participated in large numbers in the new system. The involvement of general practitioners in cervical screening programmes ought to be encouraged in the UK.5 Leiden Cytology and Pathology Laboratory, PO Box 16084, 2301 GB Leiden, Netherlands
1. Boon
MATHILDE E. BOON SAMUEL BECK
ME, de Graaff Guilloud JC, Kok LP, Olthof PM, van Erp EJM. Efficacy of
cervical squamous and adenocarcinoma: the Dutch experience. Cancer 1987; 59: 862-66. 2. EVAC. Population sceening for cervical cancer in The Netherlands. Int J Epidemiol
screening for
1989; 18: 775-81. 3. Kirk RS, Boon ME. A comparison of the efficiency of diagnosis of early cervical carcinoma by general practitioners and cytology screening programs in the Netherlands. Acta Cytol 1981; 25: 259-62. 4. Boon ME, de Graaff Guilloud JC, Rietveld WJ, Wijsman-Grootendorst A. Effect of regular 3-yearly screening on the incidence of cervical smears: the Leiden
experience. Cytopathology 1990; 1: 201-10. screening performance in general practice: an evaluation in a single health district. Cytopathology 1990; 1: 59-64.
5. Havelock GM. Cervical
Improving cervical screening by involving general practitioners SIR,-In the Netherlands, the nationwide cervical screening of aged 35-54 has changed lately. Between 1976 and 1989 the smears of canvassed women were taken in health-care centres by specially trained smear takers; in the new system, the canvassed women are referred to their own general practitioners for smear taking. In this experiment, only the circumstances under which the smear was done and the person doing the procedure were changed. Everything else-including the canvassing system run by the local authorities, the age group, reporting, and follow-up system--
women
remained the same.2 .2
Cost-effectiveness in
advertising
SIR,-I read with some concern your Aug 17 (p 416) editorial which referred to a recent cost-effectiveness study Brocades Pharma had commissioned on ’De-Nol’ (colloidal bismuth subcitrate). You question the legitimacy of cost-savings as a basis for advertising, making the point that advertisements must be consistent with the data sheet and the product licence. The insert in question makes no claims for de-no that are in any way inconsistent with the data sheet. Since the price of a product is an integral part of
precise molecular (often genetic) diagnosis, elucidation of pathogenesis, formulation of new treatments to be tested by clinical trial, to promotion of any successful treatment. Your editorial seems only in the first and last part of the cycle, neglecting that part capable of providing precision rather than guesswork. Medicine is becoming a precise science and paediatrics in the UK to believe
should take part in that revolution. Your editorial would appear to argue against this.
Data from the Leiden region for the new system are fully comparable with those for the old system. All histological data were retraced by the laboratory; as were those cases referred to the gynaecologists with a cytological diagnosis of mild-to-moderate dysplasia. Postal codes were used to check data for any possible bias due to urbanisation. The cytological and histological rates per 1000 screenees were higher under the new system for all diagnoses. The
change in policy increased screening efficiency.
ROLAND LEVINSKY MARCUS PEMBREY
Institute of Child Health, London WC1 N 1EH, UK
Becoming a doctor in China SIR,-As a Chinese-qualified doctor on clinical attachment in the UK I would add my
comments to
those of Dr Chen and Dr
Godfrey (July 20, p 169). They clearly demonstrate the striking improvement
in life
expectancy and infant mortality achieved in China in comparison with other nations (table n). It should be noted, however, that the improvement has been in communicable diseases, which are susceptible to relatively cheap public health measures. The pattern of disease is now changing to the chronic degenerative illnesses familiar in the western world. This will require additional resources not only in hospital beds, but also in advanced western medical
experience. Although English texts form part of the medical curriculum, an adequate working knowledge of the language is not enough for complete understanding. Furthermore, western textbooks are usually out of date by the time they are translated into Chinese. China has been encouraging some of its doctors to obtain experience in western countries. However, many of them are too senior to be of interest to institutions, and Chinese doctors would be unable to afford the foreign travel on their own funding (their salary is only C20 per month), as well as follow the complicated application
procedure. Because of the language barrier, even when foreign doctors visit cities in China, translation is sometimes done by commercial interpreters unversed in medical terminology. Many of the senior doctors in China cannot read foreign language textbooks or papers in their own subject. This lack of exposure to world publications means that many clinical research programmes do nothing more than duplicate work already done abroad. Index Medicus, for example, tends to gather dust in the library rather than being consulted, especially since few articles written by Chinese doctors appear there. Since China is the most populous country in the world and copes with a changing demography and disease pattern, its doctors will need to participate in the interchange of medical knowledge and skills. It is thus to be hoped that not only will foreign medical teachers and medical techniques be welcomed into China, but that many more Chinese doctors will have the opportunity to sharpen their clinical skills abroad. I thank Dr B. J. M. Jones, Dr W. R. Price, Dr A. N. Hamlyn, and Mrs M. Littlewood for their helpful comments.
Department of Gastroenterology, Russells Hall Hospital, Dudley DY1 2HQ, UK
Y. C. ZHANG, Attending Doctor, Fu Shan Hospital, Tsingtao, PR China.
CtS=carcmoma-!n-s!tu
In the
had noticed that the efficiency of "opportunistic" taking in general practice was better than population screening in health-care centres.3 The doctor has an active role in the selection process which allows him to influence efficacy; thus we cannot speak of a Hawthorne effect. However, in both the old and the new national screening programme, the screenee "selected" herself for screening having received an invitation. So the general practitioner could not directly influence the selection. The setting therefore differs fundamentally from
1970s,
we
smear
opportunistic smear taking. To explain our findings we looked closely at compliance
rates:
under the new system this was around 40% but in the old system it was much the same’ However, in the old system, the compliance rate of the married women was twice that of divorced women4 diminishing efficiency because divorced women are a high-risk group for smear positivity. In the new system the compliance rates of these two groups were equal, indicating that divorcees were no longer shunning screening. As expected4 in the new system the divorcees scored higher (x 3-0) than the married women for (pre)neoplastic cervical lesions. To explain the high detection rates for cervical (pre)neoplasia it must be assumed that high-risk groups other than divorcees-groups that are more difficult for us to identify-participated in large numbers in the new system. The involvement of general practitioners in cervical screening programmes ought to be encouraged in the UK.5 Leiden Cytology and Pathology Laboratory, PO Box 16084, 2301 GB Leiden, Netherlands
1. Boon
MATHILDE E. BOON SAMUEL BECK
ME, de Graaff Guilloud JC, Kok LP, Olthof PM, van Erp EJM. Efficacy of
cervical squamous and adenocarcinoma: the Dutch experience. Cancer 1987; 59: 862-66. 2. EVAC. Population sceening for cervical cancer in The Netherlands. Int J Epidemiol
screening for
1989; 18: 775-81. 3. Kirk RS, Boon ME. A comparison of the efficiency of diagnosis of early cervical carcinoma by general practitioners and cytology screening programs in the Netherlands. Acta Cytol 1981; 25: 259-62. 4. Boon ME, de Graaff Guilloud JC, Rietveld WJ, Wijsman-Grootendorst A. Effect of regular 3-yearly screening on the incidence of cervical smears: the Leiden
experience. Cytopathology 1990; 1: 201-10. screening performance in general practice: an evaluation in a single health district. Cytopathology 1990; 1: 59-64.
5. Havelock GM. Cervical
Improving cervical screening by involving general practitioners SIR,-In the Netherlands, the nationwide cervical screening of aged 35-54 has changed lately. Between 1976 and 1989 the smears of canvassed women were taken in health-care centres by specially trained smear takers; in the new system, the canvassed women are referred to their own general practitioners for smear taking. In this experiment, only the circumstances under which the smear was done and the person doing the procedure were changed. Everything else-including the canvassing system run by the local authorities, the age group, reporting, and follow-up system--
women
remained the same.2 .2
Cost-effectiveness in
advertising
SIR,-I read with some concern your Aug 17 (p 416) editorial which referred to a recent cost-effectiveness study Brocades Pharma had commissioned on ’De-Nol’ (colloidal bismuth subcitrate). You question the legitimacy of cost-savings as a basis for advertising, making the point that advertisements must be consistent with the data sheet and the product licence. The insert in question makes no claims for de-no that are in any way inconsistent with the data sheet. Since the price of a product is an integral part of