To the Editor: I read with interest the article on cervical screening by Dickinson.1 Cervical screening has been the most successful public health measure introduced for the prevention of cancer, and the Pap test has been highly effective in reducing cervical cancer mortality and morbidity.

In New South Wales, between 1972 and 1999, the age-standardised incidence and mortality of cervical cancer fell by 49% and 66.6%, respectively.2 The overseas experience is similar, with the best screening programs reporting a 70% reduction in mortality rates, with slight annual mortality increases since 1986.3

That women continue to die from this potentially preventable disease emphasises the limitations of the current screening method and highlights the need for new directions. The conventional Pap test is "yesterday's tool for today's world", let alone tomorrow's! The Pap test is prone to errors at all levels, but, most importantly, at specimen collection and cytological interpretation. Consequently, relatively high numbers of false negative results are associated with the test. Further, the Pap test is only partially successful in predicting the biological behaviour of the cytological abnormality.

As Dickinson states, minor abnormalities that come and go are unimportant, and can cause unnecessary alarm. These minor and transient abnormalities often lead to colposcopy, biopsy, surgical treatment and subsequent cytological and clinical or colposcopic follow-up, at a considerable cost to individual women, the screening program and taxpayers.4

Recent developments in cervical cytology and molecular biology have opened up new horizons.5 Liquid-based cytology, human papillomavirus (HPV) DNA testing and new molecular markers will help us to accurately select the patients who are likely to have biologically aggressive disease with a high probability of progression.4,5 With refinements, these new technologies will not only dramatically reduce the frequency of Pap test screening, but they may postpone the age for starting screening from 18 years to perhaps 25 or even 30 years.

These new technologies come at a price. Liquid-based cytology costs about $30 and HPV DNA testing is about $90, and no Medicare rebates are currently available for these tests.

The additional cost of these new technologies should be considered in the context of the cost of diagnosis, treatment and subsequent cytological and clinical follow-up of biologically insignificant disease. The money saved from improved patient selection for treatment and reduced frequency and late commencement of screening would allow more resources to be allocated to enrolling women (who are currently underscreened) and to funding these new technologies.