Correspondence
We declare that we have no competing interests.
Achim Schneider, Ulrich Petry, *Evrim Erdemoglu, Jorma Paavonen [email protected] Department of Gynecology and Gynecologic Oncology, Charite University, Berlin, Germany (AS); Department of Obstetrics and Gynaecology, Klinikum Wolfsburg, Wolfsburg, Germany (UP); Department of Gynecology and Gynecologic Oncology, Suleyman Demirel University, Isparta 32260, Turkey (EE); and Department of Obstetrics and Gynaecology Helsinki University, Helsinki, Finland (JP) 1
Ronco G, Dillner J, Elfström KM, et al. International HPV screening working group. Efficacy of HPV-based screening for prevention of invasive cervical cancer: follow-up of four European randomised controlled trials. Lancet 2014; 383: 524–32.
Authors’ reply Mario Sideri and Sarah Igidbashian note that human papillomavirus (HPV)-based screening detected fewer invasive cancers than cytology in the first screening round. This difference was not significant and virtually disappeared among women testnegative at baseline (RR 0·87, 95% CI 0·25–3·05). Thus, our study1 does not indicate which test is more sensitive for prevalent cancers. Achim Schneider and colleagues ask for more information about breakthrough cases of invasive cervical cancer in the HPV-based screening group. Of 19 invasive cervical cancers detected in the HPV group more than 2·5 years from recruitment, only eight (incidence rate of 1·9 per 10⁵ years) were in women HPV negative at baseline. All eight women also had negative baseline cytology, and five cancers were microinvasive. In four of these eight cases, the last negative HPV test was taken more than 6 years before cancer detection, so regular HPV testing every 5 years might have prevented them. The remaining 11 out of 19 (including four microinvasive) invasive cervical cancers occurred in women HPV positive at baseline. Within 2·5 years, only one of these women had a biopsy (cervical intraepithelial neoplasia grade 1 [CIN1] after 2 years, with cancer detected www.thelancet.com Vol 383 April 12, 2014
2·5 years later). One further patient became HPV negative after 1 year, and cancer was diagnosed 10·5 years later. Of the nine remaining women, five did not attend for a repeat HPV test and four should have had colposcopy but no biopsy was taken. For these four women, we do not have information on whether colposcopy was negative or not done. Thus, non-compliance to follow-up procedures (and possibly insensitivity of colposcopy) was the major reason for failure of HPV-based screening to prevent these invasive cervical cancers. Although the point estimate of the protective effect was larger in the New Technologies for Cervical Cancer screening (NTCC) study, the difference between studies was not significant.1 The difference, if any, reflected lower loss to follow-up procedures rather than a more aggressive protocol. Assuring high compliance to regular screening and high compliance and performance in subsequent diagnostic procedures are crucial with HPV-based testing, as with any screening method.2,3 Regarding optimal screening methods for HPV-vaccinated women, because vaccination prevents new infections a larger proportion of HPV-positive women will have nonvaccine HPV types with lower risk of progression to CIN and cancer4 than HPV16 and HPV18. This might allow even longer intervals between screens and older age at first screen.5 CJLM has been a member of the scientific advisory board of Qiagen, has received speaker’s fees from GlaxoSmithKline, Merck, and Roche, and is a shareholder of Self-Screen. The other authors declare that they have no competing interests.
*Guglielmo Ronco, Chris J L Meijer, Nereo Segnan, Henry Kitchener, Paolo Giorgi-Rossi, Julian Peto, Joakim Dillner [email protected] Unit of Cancer Epidemiology, Center for Cancer Epidemiology and Prevention, AO City of Health and Science, 10123 Torino, Italy (GR, NS); VU University Medical Centre, Amsterdam, Netherlands (CJLM); University of Manchester, Manchester, UK (HK); Azienda Sanitaria Locale, Reggio Emilia, Italy (PG-R); London School of Hygiene & Tropical Medicine, London, UK (JP); and Karolinska Institutet, Stockholm, Sweden (JD)
1
2
3
4
5
Ronco G, Dillner J, Elfström KM, et al. International HPV screening working group. Efficacy of HPV-based screening for prevention of invasive cervical cancer: follow-up of four European randomised controlled trials. Lancet 2014; 383: 524–32. Silfverdal L, Kemetli L, Sparen P, et al. Risk of invasive cervical cancer in relation to clinical investigation and treatment after abnormal cytology: a population-based case-control study. Int J Cancer 2011; 129: 1450–58. Zucchetto A, Ronco G, Giorgi Rossi P, et al. Screening patterns within organized programs and survival of Italian women with invasive cervical cancer. Prev Med 2013; 57: 220–26. Kjær SK, Frederiksen K, Munk C, Iftner T. Long-term absolute risk of cervical intraepithelial neoplasia grade 3 or worse following human papillomavirus infection: role of persistence. J Natl Cancer Inst 2010; 102: 1478–88. Ronco G, Giorgi-Rossi P. New paradigms in cervical cancer prevention: opportunities and risks. BMC Women’s Health 2008; 8: 23.
Steve Gschmeissner/Science Photo Library
screening programmes. How should these women be screened?
Cognitive behaviour therapy for health anxiety In their Comment (Jan 18, p 190)1 Chris Williams and Allan House suggest that the cognitive behavioural treatment shown to be successful in our trial2 was not condition-specific and therefore offered little beyond other similar treatment for anxiety disorders. We challenge this conclusion. Patients with health anxiety do not seek treatment for their anxious symptoms as those with other anxiety disorders do; they seek a solution to their anxiety by medical consultation, reassurance, and investigation, and this is counter-productive. There are also specific focused technologies of treatment as used in our study which have been shown to be more effective than a less focused and specific cognitive behaviour therapy.3 A very important part of management is the sensitive engagement of people who are at first often not willing to accept they have an anxiety problem, and that at its core is fear of disease rather than real disease. This contrasts with generic psychoeducation-based treatments, which are typically not acceptable to those with high levels 1295
Tek Image/Science Photo Library
Correspondence
For more on The Global Health Film initiative see http://www. globalhealthfilm.org
of disease conviction. We argue that the recognition of health anxiety and hypochondriasis is not just a “fashion in terminology” as Williams and House suggest, but an important and separate anxiety disorder that deserves its own classification, as indeed has happened recently with the introduction of illness anxiety as a diagnosis in DSM-5.4 The cognitive behavioural treatment of health anxiety is not just like any other, and it might be more appropriate for it to be initially given by nurses and other hospital staff in the clinics where the disorder presents rather than detected by screening or external referral, but this ultimately depends on better identification of the condition in hospital care, where much attention is needed. The disorder is not mild or trivial. It causes great suffering and tends to be persistent as well as complex,5 and the continued benefit of treatment after 2 years in our trial2 shows the value of a successful intervention, comparing very favourably with the long-term outcome of cognitive behavioural treatment for generalised anxiety disorder.6 We follow up the patients in this trial to establish whether benefits are still present 5 years after this brief form of treatment. We declare that we have no competing interests.
*Peter Tyrer, Paul Salkovskis, Helen Tyrer, Simon Dupont, David Murphy [email protected] Centre for Mental Health, Imperial College, London W6 8LN, UK (PT, HT); Department of Psychology, University of Bath, Bath, UK (PS); Greenacres Centre, Hillingdon Hospital, Pield Heath Road, Uxbridge, UK (SD); and Department of Clinical Psychology, Charing Cross Hospital, Fulham Palace Road, London, UK (DM) 1
2
3
4
1296
Williams C, House A. Cognitive behaviour therapy for health anxiety. Lancet 2014; 383: 190–91. Tyrer P, Cooper S, Salkovskis P, et al. Clinical and cost-effectiveness of cognitive behaviour therapy for health anxiety in medical patients: a multicentre randomised controlled trial. Lancet 2014; 383: 219–25. Clark DM, Salkovskis PM, Hackmann A, et al. Two psychological treatments for hypochondriasis: a randomized controlled trial. Br J Psychiatry 1998; 173: 218-25. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th edn. Washington, DC: APA, 2013: 315.
5
6
Seivewright H, Salkovskis P, Green J, et al. Prevalence and service implications of health anxiety in genitourinary medicine clinics. Int J STD AIDS 2004; 15: 519–22. Durham RC, Higgins C, Chambers JA, et al. Long-term outcome of eight clinical trials of CBT for anxiety disorders: symptom profile of sustained recovery and treatment-resistant groups. J Affect Dis 2012; 136: 875-81.
Founding of the Global Health Film initiative Film plays a unique role in today’s society. It is an art form, a language, an educational tool, a method of information delivery, and a vehicle for social marketing. Film has the power to communicate stories, to stir emotions, to inspire, to encourage action, and highlight inequities. The Global Health Film initiative is a partnership between the Bill & Melinda Gates Foundation, the Royal Society of Medicine, and the London School of Hygiene and Tropical Medicine. The primary objective of the Global Health Film initiative is to use film as a catalyst for discussion and for change in policy and practice for health worldwide. Traditionally, film has been a powerful mechanism to communicate public health messages. In the late 1920s, DM Connan, Bermondsey’s Medical Officer of Health, highlighted the importance of visual imagery and adoption of the latest technology to engage the public. Bermondsey Borough Council pioneered public health cinema to communicate messages on health and disease in one of London’s most deprived areas.1 Our activities will include the establishment of an annual Global Health Film Festival from 2015, based at the Royal Society of Medicine in London with satellite screenings. The Lancet will be offering a prize for best documentary in global health and for best young filmmaker. A film workshop will also bring together filmmakers, journalists, scientists, doctors, public health
advocates, and those interested in film and in global health to combine the skills and the language of filmmaking with the technical knowledge of public health sciences and critical appraisal. We hope that this innovative approach will bring together some leading minds to better communicate the advances and challenges in global health to the public, health professionals, and policy makers. In concert with the open access movement in medical publishing, we aspire for documentary film to join the open-access movement. The Global Health Film initiative will work with sector-leading organisations, film production companies, and funders to develop an online platform to share high quality documentary film on global health. We urge the public health community to support the initiative by contacting the secretariat with nominations for the film festival and suggesting collaborative centres for satellite screenings. Exposure to public health information in the media has the potential to educate, empower, and inspire individuals to live healthier lives.2 JRF is director of the Global Health Film initiative. LB is coordinator of the Global Health Film initiative. We declare that we have no competing interests.
*Joseph R Fitchett, Lalitha Bhagavatheeswaran, Maysoon Dahab, Andy P Haines, W John Edmunds, on behalf of the Global Health Film initiative joseph@filminitiative.org Department of Infectious Diseases, King’s College London, London SE1 9RT, UK (JRF); Royal Society of Medicine, London, UK (LB, MD); Department of Population Health and Department of Social and Environmental Health, London School of Hygiene & Tropical Medicine, London, UK (APH); and Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK (WJE) 1
2
Wellcome Collection. Here Comes Good Health! London: Wellcome Trust. http://www. wellcomecollection.org/whats-on/exhibitions/ here-comes-good-health.aspx (accessed March 17, 2014). Wakefield MA, Loken B, Hornik RC. Use of mass media campaigns to change health behaviour. Lancet 2010; 376: 1261–71.
www.thelancet.com Vol 383 April 12, 2014
We declare that we have no competing interests.
Achim Schneider, Ulrich Petry, *Evrim Erdemoglu, Jorma Paavonen [email protected] Department of Gynecology and Gynecologic Oncology, Charite University, Berlin, Germany (AS); Department of Obstetrics and Gynaecology, Klinikum Wolfsburg, Wolfsburg, Germany (UP); Department of Gynecology and Gynecologic Oncology, Suleyman Demirel University, Isparta 32260, Turkey (EE); and Department of Obstetrics and Gynaecology Helsinki University, Helsinki, Finland (JP) 1
Ronco G, Dillner J, Elfström KM, et al. International HPV screening working group. Efficacy of HPV-based screening for prevention of invasive cervical cancer: follow-up of four European randomised controlled trials. Lancet 2014; 383: 524–32.
Authors’ reply Mario Sideri and Sarah Igidbashian note that human papillomavirus (HPV)-based screening detected fewer invasive cancers than cytology in the first screening round. This difference was not significant and virtually disappeared among women testnegative at baseline (RR 0·87, 95% CI 0·25–3·05). Thus, our study1 does not indicate which test is more sensitive for prevalent cancers. Achim Schneider and colleagues ask for more information about breakthrough cases of invasive cervical cancer in the HPV-based screening group. Of 19 invasive cervical cancers detected in the HPV group more than 2·5 years from recruitment, only eight (incidence rate of 1·9 per 10⁵ years) were in women HPV negative at baseline. All eight women also had negative baseline cytology, and five cancers were microinvasive. In four of these eight cases, the last negative HPV test was taken more than 6 years before cancer detection, so regular HPV testing every 5 years might have prevented them. The remaining 11 out of 19 (including four microinvasive) invasive cervical cancers occurred in women HPV positive at baseline. Within 2·5 years, only one of these women had a biopsy (cervical intraepithelial neoplasia grade 1 [CIN1] after 2 years, with cancer detected www.thelancet.com Vol 383 April 12, 2014
2·5 years later). One further patient became HPV negative after 1 year, and cancer was diagnosed 10·5 years later. Of the nine remaining women, five did not attend for a repeat HPV test and four should have had colposcopy but no biopsy was taken. For these four women, we do not have information on whether colposcopy was negative or not done. Thus, non-compliance to follow-up procedures (and possibly insensitivity of colposcopy) was the major reason for failure of HPV-based screening to prevent these invasive cervical cancers. Although the point estimate of the protective effect was larger in the New Technologies for Cervical Cancer screening (NTCC) study, the difference between studies was not significant.1 The difference, if any, reflected lower loss to follow-up procedures rather than a more aggressive protocol. Assuring high compliance to regular screening and high compliance and performance in subsequent diagnostic procedures are crucial with HPV-based testing, as with any screening method.2,3 Regarding optimal screening methods for HPV-vaccinated women, because vaccination prevents new infections a larger proportion of HPV-positive women will have nonvaccine HPV types with lower risk of progression to CIN and cancer4 than HPV16 and HPV18. This might allow even longer intervals between screens and older age at first screen.5 CJLM has been a member of the scientific advisory board of Qiagen, has received speaker’s fees from GlaxoSmithKline, Merck, and Roche, and is a shareholder of Self-Screen. The other authors declare that they have no competing interests.
*Guglielmo Ronco, Chris J L Meijer, Nereo Segnan, Henry Kitchener, Paolo Giorgi-Rossi, Julian Peto, Joakim Dillner [email protected] Unit of Cancer Epidemiology, Center for Cancer Epidemiology and Prevention, AO City of Health and Science, 10123 Torino, Italy (GR, NS); VU University Medical Centre, Amsterdam, Netherlands (CJLM); University of Manchester, Manchester, UK (HK); Azienda Sanitaria Locale, Reggio Emilia, Italy (PG-R); London School of Hygiene & Tropical Medicine, London, UK (JP); and Karolinska Institutet, Stockholm, Sweden (JD)
1
2
3
4
5
Ronco G, Dillner J, Elfström KM, et al. International HPV screening working group. Efficacy of HPV-based screening for prevention of invasive cervical cancer: follow-up of four European randomised controlled trials. Lancet 2014; 383: 524–32. Silfverdal L, Kemetli L, Sparen P, et al. Risk of invasive cervical cancer in relation to clinical investigation and treatment after abnormal cytology: a population-based case-control study. Int J Cancer 2011; 129: 1450–58. Zucchetto A, Ronco G, Giorgi Rossi P, et al. Screening patterns within organized programs and survival of Italian women with invasive cervical cancer. Prev Med 2013; 57: 220–26. Kjær SK, Frederiksen K, Munk C, Iftner T. Long-term absolute risk of cervical intraepithelial neoplasia grade 3 or worse following human papillomavirus infection: role of persistence. J Natl Cancer Inst 2010; 102: 1478–88. Ronco G, Giorgi-Rossi P. New paradigms in cervical cancer prevention: opportunities and risks. BMC Women’s Health 2008; 8: 23.
Steve Gschmeissner/Science Photo Library
screening programmes. How should these women be screened?
Cognitive behaviour therapy for health anxiety In their Comment (Jan 18, p 190)1 Chris Williams and Allan House suggest that the cognitive behavioural treatment shown to be successful in our trial2 was not condition-specific and therefore offered little beyond other similar treatment for anxiety disorders. We challenge this conclusion. Patients with health anxiety do not seek treatment for their anxious symptoms as those with other anxiety disorders do; they seek a solution to their anxiety by medical consultation, reassurance, and investigation, and this is counter-productive. There are also specific focused technologies of treatment as used in our study which have been shown to be more effective than a less focused and specific cognitive behaviour therapy.3 A very important part of management is the sensitive engagement of people who are at first often not willing to accept they have an anxiety problem, and that at its core is fear of disease rather than real disease. This contrasts with generic psychoeducation-based treatments, which are typically not acceptable to those with high levels 1295
Tek Image/Science Photo Library
Correspondence
For more on The Global Health Film initiative see http://www. globalhealthfilm.org
of disease conviction. We argue that the recognition of health anxiety and hypochondriasis is not just a “fashion in terminology” as Williams and House suggest, but an important and separate anxiety disorder that deserves its own classification, as indeed has happened recently with the introduction of illness anxiety as a diagnosis in DSM-5.4 The cognitive behavioural treatment of health anxiety is not just like any other, and it might be more appropriate for it to be initially given by nurses and other hospital staff in the clinics where the disorder presents rather than detected by screening or external referral, but this ultimately depends on better identification of the condition in hospital care, where much attention is needed. The disorder is not mild or trivial. It causes great suffering and tends to be persistent as well as complex,5 and the continued benefit of treatment after 2 years in our trial2 shows the value of a successful intervention, comparing very favourably with the long-term outcome of cognitive behavioural treatment for generalised anxiety disorder.6 We follow up the patients in this trial to establish whether benefits are still present 5 years after this brief form of treatment. We declare that we have no competing interests.
*Peter Tyrer, Paul Salkovskis, Helen Tyrer, Simon Dupont, David Murphy [email protected] Centre for Mental Health, Imperial College, London W6 8LN, UK (PT, HT); Department of Psychology, University of Bath, Bath, UK (PS); Greenacres Centre, Hillingdon Hospital, Pield Heath Road, Uxbridge, UK (SD); and Department of Clinical Psychology, Charing Cross Hospital, Fulham Palace Road, London, UK (DM) 1
2
3
4
1296
Williams C, House A. Cognitive behaviour therapy for health anxiety. Lancet 2014; 383: 190–91. Tyrer P, Cooper S, Salkovskis P, et al. Clinical and cost-effectiveness of cognitive behaviour therapy for health anxiety in medical patients: a multicentre randomised controlled trial. Lancet 2014; 383: 219–25. Clark DM, Salkovskis PM, Hackmann A, et al. Two psychological treatments for hypochondriasis: a randomized controlled trial. Br J Psychiatry 1998; 173: 218-25. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th edn. Washington, DC: APA, 2013: 315.
5
6
Seivewright H, Salkovskis P, Green J, et al. Prevalence and service implications of health anxiety in genitourinary medicine clinics. Int J STD AIDS 2004; 15: 519–22. Durham RC, Higgins C, Chambers JA, et al. Long-term outcome of eight clinical trials of CBT for anxiety disorders: symptom profile of sustained recovery and treatment-resistant groups. J Affect Dis 2012; 136: 875-81.
Founding of the Global Health Film initiative Film plays a unique role in today’s society. It is an art form, a language, an educational tool, a method of information delivery, and a vehicle for social marketing. Film has the power to communicate stories, to stir emotions, to inspire, to encourage action, and highlight inequities. The Global Health Film initiative is a partnership between the Bill & Melinda Gates Foundation, the Royal Society of Medicine, and the London School of Hygiene and Tropical Medicine. The primary objective of the Global Health Film initiative is to use film as a catalyst for discussion and for change in policy and practice for health worldwide. Traditionally, film has been a powerful mechanism to communicate public health messages. In the late 1920s, DM Connan, Bermondsey’s Medical Officer of Health, highlighted the importance of visual imagery and adoption of the latest technology to engage the public. Bermondsey Borough Council pioneered public health cinema to communicate messages on health and disease in one of London’s most deprived areas.1 Our activities will include the establishment of an annual Global Health Film Festival from 2015, based at the Royal Society of Medicine in London with satellite screenings. The Lancet will be offering a prize for best documentary in global health and for best young filmmaker. A film workshop will also bring together filmmakers, journalists, scientists, doctors, public health
advocates, and those interested in film and in global health to combine the skills and the language of filmmaking with the technical knowledge of public health sciences and critical appraisal. We hope that this innovative approach will bring together some leading minds to better communicate the advances and challenges in global health to the public, health professionals, and policy makers. In concert with the open access movement in medical publishing, we aspire for documentary film to join the open-access movement. The Global Health Film initiative will work with sector-leading organisations, film production companies, and funders to develop an online platform to share high quality documentary film on global health. We urge the public health community to support the initiative by contacting the secretariat with nominations for the film festival and suggesting collaborative centres for satellite screenings. Exposure to public health information in the media has the potential to educate, empower, and inspire individuals to live healthier lives.2 JRF is director of the Global Health Film initiative. LB is coordinator of the Global Health Film initiative. We declare that we have no competing interests.
*Joseph R Fitchett, Lalitha Bhagavatheeswaran, Maysoon Dahab, Andy P Haines, W John Edmunds, on behalf of the Global Health Film initiative joseph@filminitiative.org Department of Infectious Diseases, King’s College London, London SE1 9RT, UK (JRF); Royal Society of Medicine, London, UK (LB, MD); Department of Population Health and Department of Social and Environmental Health, London School of Hygiene & Tropical Medicine, London, UK (APH); and Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK (WJE) 1
2
Wellcome Collection. Here Comes Good Health! London: Wellcome Trust. http://www. wellcomecollection.org/whats-on/exhibitions/ here-comes-good-health.aspx (accessed March 17, 2014). Wakefield MA, Loken B, Hornik RC. Use of mass media campaigns to change health behaviour. Lancet 2010; 376: 1261–71.
www.thelancet.com Vol 383 April 12, 2014
