U. S. Department of Heal Human Services

Since introduction of cytologic screening for cervical cancer using the Papanicolaou (Pap) test in the 1950s, the incidence of invasive cervical cancer in the United States has fallen more than 100%. No other cancer screening program has been more successful. This fall occurred despite an increase in risk factors for cervical cancer, such as younger age at initiation of sexual intercourse, more sexual partners in a lifetime, and greater prevalence of human papilloma virus (HPV) infection and cigarette smoking. Success in prevention reflects three factors: (1) progression from early cellular abnormalities, termed low-grade dysplasia, through more severe dysplasia, to carcinoma in situ and invasive cancer is generally slow, allowing time for detection; (2) associated cellular abnormalities can be identified; and (3) effective treatment is available for premalignant lesions. Consequently, invasive squamous cell carcinoma of the uterine cervix is a highly preventable disease. Introduction of screening programs in populations na ve to screening reduces cervical cancer rates by 60% to 90% within three years of implementation. This reduction of mortality and morbidity with introduction of screening with the Pap test is consistent and dramatic across populations. As a result, Pap testing is one of the few preventive interventions that has received an . A. recommendation from the US Preventive Services Task Force (USPSTF) in the absence of randomized trials demonstrating effectiveness. In the United States, approximately 12,800 new cases of cervical cancer are diagnosed and 4,800 deaths occur each year. Incidence of cervical cancer is decreasing; US rates have decreased from 14.2 new cases per 100,000 women in 1973 to 7.8 per 100,000 in 1994. For each woman with invasive disease, there will be 4 with carcinoma in situ and 10 with cervical dysplasia. Despite falling incidence, cervical cancer remains the ninth most common cause of cancer deaths. Of the cancer prevention goals established in "Healthy People 2000", including colorectal, lung, and breast cancer, cervical cancer mortality rates were the furthest off target at the mid-course review. The target for cervical cancer was reduction of mortality to 1.3 deaths per 100,000 women; the current rate remains near 2.7 deaths per 100,000, down only slightly from 2.8 per 100,000 in 1987. Detection of cervical cancer in its earliest stages is lifesaving, as survival of cancer of the cervix uteri depends heavily on stage at diagnosis. Although 91.5% of women will survive 5 years when the cancer is localized, only 12.6% will survive distant disease. Our key questions include: Key Question 1: Who should be screened for cervical cancer and how often? Specifically, we asked what are the outcomes (benefits, harms, and costs) associated with screening: 1A. Among women age 65 and older? 1B. Among women who have had a hysterectomy? Key Question 2: To what extent do new methods for preparing or evaluating cervical cytology improve diagnostic yield compared to conventional methods? At what cost (harms and economic)? Key Question 3: What is the role of HPV testing in cervical cancer screening strategies? Specifically: 3A. What are the benefits, harms, and costs of using HPV testing as a screening test, or of incorporating HPV testing at the time of the screening Pap test, compared with not testing for HPV? 3B. What are the benefits, harms, and costs of using HPV testing as part of a screening strategy to determine which women with an abnormal Pap test should receive further evaluation?

Bariatric surgery, also known as weight-loss surgery, refers to surgical procedures usually performed on people who are morbidly obese for the purpose of losing weight and to treat, as well as prevent, obesity-related comorbidities. Bariatric surgery has evolved since its introduction in the 1950s, with some procedures that were popular initially (like jejunoileal bypass) having been abandoned because of unacceptable complication rates. The types of bariatric surgery that are most commonly performed now include laparoscopic adjustable gastric banding (LAGB); Roux-en-Y gastric bypass (RYGB); biliopancreatic diversion with duodenal switch (BPD); and sleeve gastrectomy (SG), also referred to as gastric sleeve. Newer procedures-gastric sleeve with ileal interposition, duodenal-jejunal bypass, and duodenal-jejunal exclusion-are being studied outside of the United States (one study in the United States was conducted in 2008, but the results were not published). The mechanism of weight loss and metabolic impact are under investigation, but they are not regularly performed in the United States currently. Thus, they are beyond the scope of this report. Studies show that these procedures cause significant weight loss in morbidly obese patients. In addition, bariatric surgeries such as LAGB and RYGB in morbidly obese patients have been found to be far more effective than conventional nonsurgical therapy at lowering blood sugar to improve diabetes in the short term. Improvement in diabetes has been demonstrated to start rapidly after bariatric surgery, especially for patients undergoing RYGB, before significant weight loss has occurred. The mechanism of postoperative metabolic improvements has not been fully elucidated and may in part be independent from weight loss, suggesting that bariatric surgery may improve metabolic comorbidities, even for patients who are not morbidly obese. This systematic review aims to address the following Key Questions (KQs). KQ1. What does the evidence show regarding the comparative effectiveness of bariatric surgery for treating adult patients with a BMI of 30.0 to 34.9 kg/m and metabolic conditions, including diabetes? Are certain surgical procedures more effective than others (LAGB, RYGB, or SG)? KQ2. What does the evidence show regarding the comparative effectiveness of bariatric surgery versus conventional nonsurgical therapies for treating adult patients with a BMI of 30.0 to 34.9 kg/m and metabolic conditions? KQ3. What are the potential short-term adverse effects and/or complications associated with bariatric surgery for treating adult patients with a BMI of 30.0 to 34.9 kg/m who have metabolic conditions? KQ4. Does the evidence show racial and demographic disparities with regard to potential benefits and harms associated with bariatric surgery for treating adult patients with a BMI of 30.0 to 34.9 kg/m and metabolic conditions? What other patient factors (social support, counseling, preoperative weight loss, compliance with recommended treatment) are related to successful outcomes? KQ5. What does the evidence show regarding long-term benefits and harms of bariatric surgery for treating adult patients with a BMI of 30.0 to 34.9 kg/m and who have metabolic conditions? How do the long-term benefits and harms of bariatric surgery compare to short-term outcomes (within 1 year after surgery)?

Coronary artery disease (CAD), is a narrowing (stenosis) of one or more of the epicardial coronary arteries. It is most commonly due to the buildup of plaque (atherosclerosis), which impedes the ability of these blood vessels to deliver oxygenated blood to the heart muscle (myocardium). Revascularization of the stenotic vessel either by dilatation using a balloon (also known as angioplasty) or by using a bypass venous graft (also known as coronary bypass) are the most common methods to restore blood supply. Percutaneous coronary intervention (PCI) or angioplasty with stent deployment is currently the most commonly performed revascularization procedure for CAD. PCI has traditionally been based on qualitative and quantitative coronary angiography (visual inspection of the radiocontrast lumenogram and computer-based quantification, respectively), an imaging technique for visualizing the interior of blood vessels. While angiography is the standard technique for anatomic visualization of coronary arteries, it is not without limitations as it does not provide information about what is causing the narrowing or whether the narrowing seriously impedes blood flow. Several adjunctive intravascular diagnostic procedures and imaging techniques have been developed for the purpose of providing more detailed anatomic and hemodynamic information about lesions in coronary arteries. However, whether this additional information improves patient outcomes and whether this improvement outweighs any risks introduced by the additional procedure needs to be considered. Using criteria based on the AHRQ CER Methods Guide, we assessed the strength of evidence for major comparisons of interest, as follows: - There is a moderate strength of evidence (drawn from one randomized controlled trial RCT] and one nonrandomized study) that the adjunctive use of FFR during stenting, as compared with angiography alone, to decide whether an intermediate coronary lesion (50 to 70% stenosis) requires stenting, can confer a lower risk of composite endpoint of death or myocardial infarction (MI) or of major adverse cardiac event (MACE), decrease procedural costs, and lead to fewer stent implantations. However, these FFR studies also included patients with low risk lesions and lower grades of angina, and excluded left main coronary artery disease and acute MI. - There is a moderate strength of evidence (drawn from 9 RCTs and 22 nonrandomized studies) that supports no significant difference in mortality and MI, but a significant reduction in restenosis and repeat revascularizations with IVUS-guided stenting compared with stent placement guided by angiography alone. This significant reduction was observed in RCTs, but not observed in nonrandomized comparative studies. Notably, most of the RCTs were conducted before 2000 using previous generation bare-metal stents. - There is insufficient evidence concerning the use of any intravascular diagnostic techniques immediately after PCI to evaluate the success of stent placement as compared with angiography, or for direct comparisons between intravascular diagnostic techniques. - There is a moderate strength of evidence (on the basis of one large-sample-size nonrandomized study) that sex, diabetes mellitus status, lesion length and reference diameter, and interaction with IVUS- and angiography-guided stent placement did not show any significant association with individual components of death or MI or the composite outcome of MACE. - There is insufficient evidence to evaluate the comparative effect of techniques other than FFR and IVUS on outcomes. The present report describes the development of a stakeholder-prioritized list of research needs for that topic, along with a measured consideration of the advantages and disadvantages of various potential research designs, in order to help researchers and funders develop future research proposals or solicitations.