with cytology-based screening needs to be compensated for
by a longer screening interval to become cost-effective.
Prevalence of disease, availability of resources in terms
of staff and technology, expectations and acceptability by
the population, and ﬁnancial costs of an intervention largely
differ between countries and regions. Therefore, the results
of population-based evaluations in one region can therefore
never be translated as such to a different region, but studies
(depending on which aspects are different) will have to be
Screening strategies are often introduced into clinical
practice without proper evaluation. We have proposed
a stepwise framework to evaluate new screening strategies,
in which an increasing level of evidence is gath ered but re-
quire progressively more stringent and expensive studies.
Regional, national, or international authorities should im-
pose requirements for testing and implementing new
screening strategies, as currently has been done in a number
of countries. Together with other recently published crite-
ria, our framework may be helpful in deﬁning such require-
ments, which should lead toward a net beneﬁt in general
health of the individual at an acceptable cost for society.
All authors contributed substantially to conception and
design, revised the artic le critically for important intellec-
tual content, and gave ﬁnal approval of the version to be
Special thanks should be given to the the Belgian Foun-
dation Against Cancer (Brussels, Belgium) for providing
the ﬁnancial means.
M.A. received ﬁnancial support from the Belgian Foun-
dation Against Cancer (Brussels, Belgium), the Interna-
tional Agency for Research on Cancer (IARC, Lyon,
France), the 7th Framework Programme of DG Research
of the European Commission through the PREHDICT
project (grant no. 242061, coordinated by the Vrije Univer-
siteit Amsterdam, the Netherlands), and the Gynaecological
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