Comparison of pain and proper sample status according to usage of tenaculum and analgesia: a randomized clinical trial

Objective

Colposcopic biopsy is a discomfortable procedure. Additionally, it creates negative influence on sexuality. This study aimed to investigate the relationships among tenaculum, pain perception, and biopsy size during colposcopy.

Methods

In total, 228 patients who underwent colposcopy-directed biopsy were included, and randomized into 4 groups based on whether analgesic and tenaculum were used and replaced (tenaculum with n=58/without analgesic n=56, no tenaculum replacement with n=57/without analgesic n=57). Lidocaine hydrochloride (40 mg) plus adrenaline (0.025 mg) was administered in the analgesic groups. The pain was assessed using a linear visual analog scale. The biopsy specimen size was measured in millimeters.

Results

The mean age of the patients was 42.85±8.88 years. The most frequent colposcopy indications were atypical squamous cells of undetermined significance and human papilloma virus-positive results on cervical cytology (30.2%; n=69). Low- and high-grade intraepithelial lesions were noted in 14.91% (n=34) and 10.96% (n=25) women through colposcopy-directed biopsy results, respectively. Tenaculum replacement increased pain perception in the without analgesic group; however, no statistically significant differences were noted between of the groups with and without tenaculum replacement with analgesic. The size and number of biopsy specimens were not associated with tenaculum replacement and analgesic use.

Conclusion

Administration of analgesics decreased discomfort and pain in patients. Tenaculum replacement aided colposcopists in manipulating the cervix. Additionally, administration of analgesics relieved pain in the tenaculum replacement group.

Trial Registration

ClinicalTrials.gov Identifier: NCT03279666

Short-term clinical and immunologic effects of poly-gamma-glutamic acid (γ-PGA) in women with cervical intraepithelial neoplasia 1 (CIN 1): A multicenter, randomized, double blind, phase II trial

OBJECTIVE

The aim of this study was to investigate the short-term efficacy and safety of Poly-gamma-glutamic acid (γ-PGA) and the immunologic changes in patients with CIN 1.

METHODS

Participants were randomly assigned to one of two groups and orally treated with placebo or 1,500 mg of γ-PGA for 4 weeks. The primary endpoint of the study was histologic regression rate of CIN 1 at 12 weeks between γ-PGA and control groups. The secondary endpoints were HPV clearance and change in immune responses.

RESULT

From April 2013 to December 2015, 195 patients participated in the study. In the intention-to-treat analysis, 42 (42.4%) of the women who received γ-PGA experienced histologic remission versus 26 (27.1%) in the control group, with a statistically significant difference (p = 0.018). In the γ-PGA group, HPV clearance was found in 37 (43.5%) of 85 patients infected with high-risk HPV, showing a significant difference compared to the control group, in which 20 (26.7%) of 75 patients exhibited HPV clearance (p = 0.026). However, there was no significant difference between the two groups in the change of NK cell activity, major histocompatibility complex (MHC) class II CD8 count, and CD56 count.

CONCLUSION

γ-PGA showed a short-term therapeutic effect on CIN 1 and high-risk HPV infection. It is a non-invasive, promising oral medication for women with these conditions.

TRIAL REGISTRATION

Clinical Trials NCT01826045.

Women's experiences of abnormal Pap smear results - A qualitative study

OBJECTIVES

To describe women's experiences of abnormal Pap smear result.

METHODS

Ten women were recruited from a women's health clinic. Qualitative interviews based on six open-ended questions were conducted, transcribed verbatim, and analyzed by content analysis.

RESULTS

The women believed that their abnormal Pap smear result was indicative of having cancer. This created anxiety in the women, which resulted in the need for emotional support and information. Testing positive with human papillomavirus (HPV) also meant consequences for the relatives as well as concerns about the sexually transmitted nature of the virus. Finally, the women had a need to be treated with respect by the healthcare professionals in order to reduce feelings of being abused.

CONCLUSIONS

In general, women have a low level of awareness of HPV and its relation to abnormal Pap smear results. Women who receive abnormal Pap smear results need oral information, based on the individual women's situation, and delivered at the time the women receive the test result. It is also essential that a good emotional contact be established between the women and the healthcare professionals.

The use of mobile technology in waiting rooms to leverage women's empowerment: A conceptual context

This article focuses on a conceptual framework that can be applied to the use of mobile technology in the waiting room with the goal of empowering women recently diagnosed with abnormal Pap test results. It further describes trends which indicate a need for improved and timely information dissemination. Genecology practice outpatients report a predominant feeling of worry on receipt of abnormal medical test results, along with a clearly expressed wish for additional information. This research suggests that there is room for improvement in existing processes through use of mobile technology with carefully vetted materials which indicate a doctor is interested in the patient's well-being.

Psychological impact of positive cervical cancer screening results among Japanese women

BACKGROUND

While cervical cancer screening is useful for detecting and then treating the disease at an early stage, most women with screen-positive results are free from cervical cancer but nevertheless subject to the unnecessary worry entailed in receiving such results. The purpose of this study was to examine whether receiving a screen-positive result was actually related to psychological distress among Japanese women who underwent cervical cancer screening.

METHODS

We conducted a questionnaire survey at health facilities in a semiurban city of Ibaraki prefecture, involving 1744 women who underwent cervical cancer screening and 72 who received screen-positive results and then underwent further testing. We used the K6 scale to assess their psychological distress (K6 score ≥5) and performed multiple logistic regression analyses to estimate the relative effect of receiving screen-positive results on psychological distress.

RESULTS

Psychological distress was more prevalent among women with screen-positive results (OR 2.22; 95 % CI 1.32-3.74), while it was also related to history of mental health consultation (OR 2.26; 95 % CI 1.69-3.01) and marital status (OR 1.32; 95 % CI 1.02-1.70).

CONCLUSIONS

Receiving a positive cervical cancer screening result was associated with psychological distress. To alleviate this psychological impact, the current form of communicating the screening results should be reconsidered.

Trends in, and predictors of, anxiety and specific worries following colposcopy: a 12-month longitudinal study

OBJECTIVE

Little is known about which women are at greatest risk of adverse psychological after-effects following colposcopy. This study examined time trends in, and identified predictors of, anxiety and specific worries over 12 months.

METHODS

Women attending two hospital-based colposcopy clinics for abnormal cervical cytology were invited to complete psychosocial questionnaires at 4, 8 and 12 months following colposcopy. General anxiety and screening-specific worries (about cervical cancer, having sex and future fertility) were measured. Generalised estimating equations were used to assess associations between socio-demographic, lifestyle and clinical variables and risk of psychological outcomes.

RESULTS

Of 584 women initially recruited, 429, 343 and 303 completed questionnaires at 4, 8 and 12 months, respectively. Screening-specific worries declined significantly over time but were still relatively high at 12 months: 23%, 39% and 18% for worries about cervical cancer, fertility and having sex, respectively. Anxiety remained stable (20%) over time. Risks of cervical cancer worry and anxiety were both almost double in women without private health insurance (cervical cancer worry: OR = 1.80, 95% CI 1.25-2.61; anxiety: OR = 1.84, 95% CI 1.20-2.84). Younger women (<40 years) had higher risk of fertility worries. Non-Irish women had higher risk of anxiety (OR = 2.13, 95% CI 1.13-4.01).

CONCLUSIONS

Screening-specific worries declined over time but anxiety remained stable. Notable proportions of women still reported adverse outcomes 12 months following colposcopy, with predictors varying between outcomes. Women in socio-demographically vulnerable groups were at greatest risk of adverse psychological outcomes. This information could inform development of interventions to alleviate psychological distress post-colposcopy.

Cervical screening program and the psychological impact of an abnormal Pap smear: a self-assessment questionnaire study of 590 patients

PURPOSE

Invasive cervical cancer is today the fourth most common cancer of women in western civilization. Screening programs have led to a continuously decrease. Nevertheless, both screening and a positive test result are known to be associated with a negative psychological impact. Screening programs in European countries differ and thus psychological impact might as well. The aim of this study was to evaluate the psychological impact of women with an abnormal Pap smear in a German cohort.

METHODS

Between July 2013 and May 2014, a self-assessment questionnaire was distributed to 595 patients that were referred to a special clinic for cervical dysplasia for further evaluation of an abnormal Pap smear. Patients were recruited in five different centers.

RESULTS

Most patients (45.9 %) were informed about the test result via phone call by their doctor. 68.8 % of the patients felt anxious and 26.3 % even felt panic. After having talked to their physician, 51.4 % of our cohort still felt worried and only 24.4 % felt reassured. Concerning disease management, 48.4 % underwent a control Pap smear in 6 months. The preferred information source was the physician (63.9 %). Compared to the results in other European countries, our study cohort showed differences concerning age distribution, patients living in a partnership, number of children and especially disease management.

CONCLUSION

Cancer screening itself and abnormal test results have an impact on patient's feelings. To reduce the psychological impact, patients need to be better informed about the risks and benefits of cancer screening programs and in case of cervical cancer screening about the meaning of an abnormal test result. Our results underline the importance of a trustful physician-patient relationship in that matter.

Experiences and unmet needs of women undergoing Pap smear cervical cancer screening: impact on uptake of cervical cancer screening in south eastern Nigeria

The burden of cervical cancer is on the increase in sub-Saharan Africa mainly due to inadequate provision and utilisation of cervical cancer prevention services. Several evidence-based strategies have been deployed to improve cervical cancer screening uptake without much success. However, patients' experiences and satisfaction with service provision has not been adequately studied. Inefficiencies in service delivery and less fulfilling experiences by women who attend cervical cancer screening could have considerable impact in future voluntary uptake of cervical cancer screening. Six hundred and eighty women who underwent Pap smear screening in three health care facilities in two states in south eastern Nigeria were interviewed to evaluate their satisfaction, willingness to undertake future voluntary screening, unmet needs and correlation between satisfaction level and willingness to undergo future screening. Satisfaction with Pap smear screening correlated positively with willingness to undertake future voluntary screening (Pearson's correlation coefficient = 0.78, P = 0.001). The mean satisfaction score was significantly higher among participants handled by nurses than those handled by the physicians (3.16 ± 0.94 vs 2.52 ± 0.77, P = 0.001). 'Scrapping discomfort' of the spatula was reported as the most dissatisfying aspect of Pap smear experience. The need for less invasive screening procedures was the most unmet need. It was concluded that improving the Pap smear screening experience of women and providing less invasive methods of cervical cancer screening with immediate results could improve uptake of cervical cancer screening in south eastern Nigeria.

Primary care provider practices and beliefs related to cervical cancer screening with the HPV test in Federally Qualified Health Centers

OBJECTIVE

Cervical cancer screening using the human papillomavirus (HPV) test and Pap test together (co-testing) is an option for average-risk women ≥ 30 years of age. With normal co-test results, screening intervals can be extended. The study objective is to assess primary care provider practices, beliefs, facilitators and barriers to using the co-test and extending screening intervals among low-income women.

METHOD

Data were collected from 98 providers in 15 Federally Qualified Health Center (FQHC) clinics in Illinois between August 2009 and March 2010 using a cross-sectional survey.

RESULTS

39% of providers reported using the co-test, and 25% would recommend a three-year screening interval for women with normal co-test results. Providers perceived greater encouragement for co-testing than for extending screening intervals with a normal co-test result. Barriers to extending screening intervals included concerns about patients not returning annually for other screening tests (77%), patient concerns about missing cancer (62%), and liability (52%).

CONCLUSION

Among FQHC providers in Illinois, few administered the co-test for screening and recommended appropriate intervals, possibly due to concerns over loss to follow-up and liability. Education regarding harms of too-frequent screening and false positives may be necessary to balance barriers to extending screening intervals.

[Perception and psychological impact of an abnormal Pap smear. Results of a comparative European survey]

OBJECTIVES

The availability of information on HPV and Pap tests has increased dramatically with the introduction of national HPV vaccination programs. But data on the effectiveness of this information is limited. However, our desire is to reduce patient anxiety and promote better delivery of information.

PATIENTS AND METHODS

Therefore a questionnaire-based cohort study was conducted to investigate women's experience with the announcement of an abnormal Pap smear result, then the ensuing events, as well as their practitioner's management. This article focuses on the French experience, underpinned by comparative data with Spain and Portugal.

RESULTS

It shows that, face with stress reactions and patient's anxiety, the level of information from the medical profession is still seen as inadequate, while the Internet as an information source has its limitations and dangers. The close entourage is most relied on, which supports the need for better public information.

DISCUSSION AND CONCLUSION

Uniformity and standardization of information strategies is not yet on European time.

Factors associated with psychological distress following colposcopy among women with low-grade abnormal cervical cytology: a prospective study within the Trial Of Management of Borderline and Other Low-grade Abnormal smears (TOMBOLA)

BACKGROUND

Little is known about psychological after-effects of colposcopy and associated investigations and treatment in women with low-grade abnormal cervical cytology. We investigated psychological distress following colposcopy and related procedures.

METHODS

Nine hundred and eighty-nine women aged 20-59 years with routine cytology showing low-grade abnormalities were recruited to the Trial of Management of Borderline and other Low-grade Abnormal smears and attended colposcopy. If the cervical transformation zone (TZ) was colposcopically abnormal, women had immediate loop excision or diagnostic punch biopsies, with treatment if these showed cervical intraepithelial neoplasia grade 2/3 (CIN2/3). Women completed socio-demographic and psychosocial questionnaires at recruitment and before colposcopy. Six weeks after their last procedure, women completed the Impact of Event Scale (IES). Logistic regression was used to determine factors associated with significant psychological distress (IES ≥ 9). Analyses were stratified by colposcopic impression.

RESULTS

The response rate was 74%. Six weeks after the last procedure, 86 (21%) of 391 women with a normal TZ had significant distress compared with 144 (42%) of 337 with an abnormal TZ. In both groups, significant distress was associated with anxiety pre-colposcopy and pain or discharge afterwards. Additional variables predicting distress in women with a normal TZ were worries about having sex and dissatisfaction with support from others. In women with an abnormal TZ, additional predictors of distress were younger age, CIN2/3, bleeding following colposcopy and worries about having cancer.

CONCLUSIONS

Substantial proportions of women experience psychological distress after colposcopy and related procedures, even when the colposcopy is normal. This is an important cost of cervical screening. Interventions to alleviate these adverse psychological effects are required.

Gynaecological symptoms reported by young women: examining the potential for earlier diagnosis of cervical cancer

BACKGROUND

Cervical cancer occurs at a younger age than most adult cancers. A pre-malignant stage can be identified at screening and treated. Screening begins at the age of 25 years in England, so in women younger than this, and in those who decline screening, cervical cancer can only be identified with symptoms. Aim. To identify the frequency of attendance for gynaecological conditions by young English women.

DESIGN

Historical cohort study using electronic primary care records.

METHODS

A cohort of English women aged 15-29 years was prepared from the General Practice Research Database. All gynaecological consultations were identified and collated. Frequencies of gynaecological consultation were analysed in three age bands: 15-19, 20-24 and 25-29 years and by calendar year.

RESULTS

The number of women available for study for each year ranged from 32 968 to 45 807. The percentage of women having any gynaecological consultation increased from 17.7% to 33.3% over the 7 years. If contraception is excluded, the percentages are 11.3% in 2003, rising to 20.1% in 2009. The rise in consultations occurred in all age bands and across most symptom categories. Post-coital bleeding and inter-menstrual bleeding-the two classic presentations of cervical cancer-were reported by 0.5% and 1.6% of women in 2009.

CONCLUSIONS

Gynaecological complaints are frequent in primary care, though the symptoms of possible cervical cancer only represent a small minority of the total. Although the chance of cancer in young women with abnormal vaginal bleeding is very small, visualization of the cervix is appropriate.

False-positive Human Papillomavirus DNA tests in cervical screening: it is all in a definition

AIM

Based on data from randomised controlled trials (RCT) on primary cervical screening, it has been reported that the problem of more frequent false-positive tests in Human Papillomavirus (HPV) DNA screening compared to cytology could be overcome. However, these reports predominantly operated with a narrow definition of a (false-)positive test. The aim of this paper was to illustrate how the narrow definition affected the measured adverse effects of HPV DNA screening compared with cytology screening.

METHODS

In the European RCT data, we measured the impact of the narrow definition of a positive screening test on the published relative positive predictive values (PPV), an indicator of the relative frequency of false-positive screening tests.

RESULTS

Using the trialists' definitions of positive screening tests, HPV screening combined with cytology triage had relative PPVs of 0.87 (95% confidence interval (CI): 0.60-1.26) for ≥ CIN3 based on Swedish RCT data, and 0.78 (0.52-1.16) for ≥ CIN2 in the Italian Phase 1 RCT (25-34 years). These PPVs changed to 0.44 (0.30-0.64) and 0.51 (0.33-0.79), respectively, when all positive HPV or cytology screening tests were accounted for. In the Finnish RCT data, HPV screening using the cut-off point of ≥ 10 pg/ml had a relative PPV of 0.27 (0.15-0.50) for ≥ CIN3, which changed to 1.84 (0.99-3.41).

CONCLUSION

The relative PPV was incorrectly estimated in six out of seven studies. In three of those six studies, the relative PPV changed significantly after inclusion of the previously erroneously excluded false-positive HPV or cytology tests.

Correlation between immunocytochemistry of human papilloma virus L1 capsid protein and behavior of low-grade cervical cytology in Korean women

AIM

The aim of this study was to evaluate the behavior of low-grade squamous intraepithelial lesion (LSIL) in Korean women infected with human papillomavirus (HPV) in relation to the immunocytochemical detection of the HPV L1 capsid protein.

MATERIAL AND METHODS

From January 2006 to December 2007, a total of 353 immunocytochemistry tests were performed on specimens from HPV-infected patients with LSIL. Due to exclusions, the study population was reduced to 318. Subjects were monitored at 4-6 month intervals. The regression, persistence, and progression of the cytologic abnormalities of the 318 cases were compared with the results of HPV L1 capsid protein immunocytochemical detection.

RESULTS

Of the 137 patients negative for the HPV L1 capsid protein, 38 (27.7%) showed progression to high-grade lesions, 50 (36.5%) showed persistence, and 49 (35.8%) showed regression to normal cytological features. In contrast, of the remaining 181 patients positive for the HPV L1 capsid protein, 15 (8.3%) showed progression to high-grade lesions, 74 (40.9%) showed persistence, and 92 (50.8%) showed regression. The results of immunocytochemical testing for the HPV L1 capsid protein show a linear association with the progression or regression behavior of low-grade cervical cytology in patients infected with HPV (linear by linear association test, P<0.05).

CONCLUSION

Immunocytochemical detection of HPV L1 was significantly related with the biological patterns of LSIL in Korean women. Hence, immunocytochemistry for the detection of HPV L1 is beneficial in providing further information for LSIL.

Developing a measure of health-related quality of life for women with cervical dysplasia resulting from human papillomavirus infection

Human papillomavirus (HPV) infection is the most common sexually transmitted infection in the USA, and has major physical and psychological consequences including fear, anxiety and stigma. To date, there is no measure of health-related quality of life specifically designed to assess symptoms and functioning for people with cervical dysplasia resulting from HPV infection. In the present study, we set out to develop a disease-specific measure of health-related quality of life among women with low-grade cervical dysplasia. We conducted literature reviews, open-ended interviews with patients, clinician surveys and cognitive interviews which guided item development. The result is a preliminary 36-item measure, the Functional Assessment of Chronic Illness Therapy-Cervical Dysplasia (FACIT-CD), which sets out to assess the physical and psychological health-related quality-of-life aspects of cervical dysplasia and will be validated in an upcoming study.

Qualitative study of women's anxiety and information needs after a diagnosis of cervical dysplasia

AIM: Each year almost 15,000 Danish women are diagnosed with cervical dysplasia, a precursor to cervical cancer. The period of medical follow-up, or 'watchful waiting', to monitor for regression or progression of the lesion before deciding if treatment by conisation is necessary can be long. The aim of this study was to examine the experiences of women with different stages of cervical dysplasia and to examine whether their knowledge of human papillomavirus (HPV) as the cause of cervical dysplasia influenced their perception of their disease. SUBJECT AND METHODS: We used focus group and individual interviews with 12 women diagnosed with different stages of cervical dysplasia-women who had and had not been conised. Interview guides were prepared on the basis of a literature review that identified important issues and questions for the participants. RESULTS: The participants considered cervical dysplasia to be a highly distressing condition and experienced monitoring as a worrying delay before regression of the lesions or treatment could be initiated. Women expressed a fear of cancer that was not proportional to the stage of their dysplasia, but was determined by their degree of knowledge about their condition. Unlike other sexually transmitted diseases, information about HPV did not result in stigmatisation as the perception of this disease was dominated by cancer. CONCLUSION: This study showed that it is extremely important to address women's fears, their need for information and to ensure better communication with medical practitioners about cervical dysplasia immediately after diagnosis, irrespective of the disease stage.

Anxiety and borderline PAP smear results

PURPOSE

Low-grade abnormalities after cervical cancer screening, i.e. borderline (Pap 2) or mildly (Pap 3a1) dyskaryotic (BMD) smear results, are found in considerable numbers of women annually. We compared quality of life and anxiety in women with BMD and a reference group of screening participants who were awaiting smear taking.

METHODS

Five hundred and fifty women with BMD in the preceding 6-24 months, identified through a regional screening organisation, were sent a questionnaire addressing generic quality of life (12-item Short-Form Health Survey [SF-12], EuroQol classification [EQ-5D]), generic anxiety (STAI-6) and screen-specific anxiety (Psychological Consequences Questionnaire [PCQ]).

RESULTS

After adjustment for differences in background characteristics, women with BMD (n=270) reported more generic anxiety (44.4 versus 32.6) and screen-specific anxiety (5.0 versus 1.4) than the reference group (n=352). The differences indicated statistical (p<0.001) and clinical significance. High anxiety (STAI-6>44) was reported by 49% of the BMD group. Mental quality of life was worse in the BMD than in the reference group (44.2 versus 52.0, p<0.001). The BMD group considered screening more often frightening (27% versus 10%) and reported 'fear for cervical cancer' more frequently as their reason for having a (repeat) smear taken (62/270, 23% versus 12/346, 4%).

CONCLUSION/DISCUSSION

BMD smears were consistently associated with considerable excess anxiety in the period of 6-24 months after the original BMD Pap smears had been taken.

Quality of life and self-esteem of long-term survivors of invasive and noninvasive cervical cancer

OBJECTIVE

We compared long-term survivors of invasive and noninvasive cervical cancer (1) to determine if there are differences in the quality of life (QOL) and (2) to assess the association between self-esteem and QOL.

METHODS

A sample of cervical cancer survivors diagnosed with invasive and noninvasive cervical cancer during 1995-1996 was drawn from the metropolitan Detroit Surveillance, Epidemiology, and End Results (SEER) cancer registry. There were 145 participating survivors, 42 with invasive and 103 with noninvasive cervical cancer. Data were collected using a structured interview, conducted primarily over the telephone. The outcome measures were the QOL (measured by the Medical Outcomes Study Short Form-36 [SF-36]) summary scales, the Physical Component Summary (PCS) score and the Mental Component Summary (MCS) score. Differences in MCS and PCS between women with invasive and noninvasive cancer were determined using analysis of covariance (ANCOVA). Multivariate analysis was performed to determine the association between self-esteem and MCS and PCS.

RESULTS

There were no differences in either PCS or MCS scores between long-term survivors of invasive and noninvasive cervical cancer. Self-esteem was associated with MCS but not with PCS in women with invasive cancer as well as in women with noninvasive cancer.

CONCLUSIONS

The distinctive association of self-esteem with MCS but not PCS indicates that interventions for supporting and improving self-esteem may be more effective by promoting psychological well-being rather than physical well-being. Moreover, women with noninvasive cervical cancer, a group often neglected in cervical cancer studies, should also be targeted for these interventions.

Age-specific prevalence of HPV genotypes in cervical cytology samples with equivocal or low-grade lesions

Background:

To define the spectrum of human papillomavirus (HPV) types and establish an age limit for triage HPV testing in atypical squamous cells of undetermined significance (ASCUS) and low-grade squamous intraepithelial lesion (LSIL).

Materials and methods:

343 liquid-based cytological samples from the population-based screening programme with minor abnormalities were subjected to HPV genotyping (Linear Array, Roche, Basel, Switzerland).

Results:

High-risk human papillomavirus (HR-HPV) was found in 71% of LSIL and 49% of ASCUS cases (P<0.001). High-risk human papillomavirus prevalence was age-dependent in LSIL (P=0.01), with decreasing prevalence until the age of 50 years, followed by a slight increase. Human papillomavirus type 16 was the most common HR-HPV, found in 23% of HPV-positive women. Human papillomavirus type 18 was the sixth most common, found in 9.9% (P<0.001). An age-dependent quadratic trend was observed for multiple infections (P=0.01) with a trough at about 42 years. The most common HR-HPV types to show a coinfection with HPV16 (clade 9) were HPV39 (28%), 45 (38%), and 59 (46%), belonging to HPV18 clade 7. The frequency of low-risk (LR) vs probable HR and HR-HPV also followed an age-dependent quadratic trend.

Conclusions:

After the age of 25 years, HR-HPV prevalence is similar in LSIL and ASCUS cases, motivating a low age limit for triage HPV testing. Multiple infections and LR/HR-HPV dominance are age-dependent. Genotyping in longitudinal design is needed to elucidate the importance of multiple infections in cancer progression and in cross-protection from vaccination.

Women's initial experience of abnormal papanicolaou smear

To discover the early subjective experience of women affected by abnormal Papanicolaou smear, a qualitative study was undertaken with 8 North Carolina women, 4 to 12 months postnotification of their first abnormal result. Data were analyzed via grounded theory methodology to identify a core theory that could guide interventions to improve follow-up for cancer prevention. This theoretical process is described as a labyrinth journey-an imperative healing process undertaken by all participants, who undertook the following tasks: evaluating peril, seeking refuge, obtaining information, and reframing their self-image. Women who also learned they were infected with the human papillomavirus faced a prolonged sense of threat to their sense of sexual well-being. Their additional tasks related to reevaluating their sexual self-image, and they continued to work on these reframing tasks throughout their 1st year's journey. Progress through the labyrinth depended upon emotional or spiritual support, nonjudgmental acceptance and access to accurate information.

Natural history of human papillomavirus infections, cytologic and histologic abnormalities, and cancer

Over 100 human papillomavirus (HPV) types have been identified to date, of which over 40 infect the genital tract, primarily through sexual transmission. The many different genital HPV types appear to infect, resolve, or persist, and cause abnormal cytology and cervical intraepithelial neoplasia. Several cofactors have been associated with HPV persistence and lesion progression, including smoking, long-term oral contraceptive use, other sexually transmitted infections, host immunogenetics, and viral factors, such as HPV type and HPV variants. Given the discovery of HPV as the single primary cause of invasive cervical cancer, primary and secondary interventions have been realized, including HPV testing in cervical screening programs and prophylactic HPV vaccines. Because first generation HPV vaccines only target the two most common HPV types found in cervical cancer (HPV 16 and 18), cervical screening programs must continue, and the relative roles of HPV vaccination in young women and HPV testing in older women (alone or in conjunction with cytology) will be determined over the next decades.

Anxiety, fear of cancer, and perceived risk of cancer following lung cancer screening

BACKGROUND

Lung cancer screening can result in a high rate of indeterminate findings and has not yet been proven to be efficacious in reducing mortality. To date, the psychological consequences of receiving an indeterminate screening result are not known.

METHODS

Four hundred individuals were recruited into this study. Participants completed 4 surveys: baseline, after lung screening results were known, and at 6 and 12 mo after screening. Demographics, state/trait anxiety, fear of cancer, and perceived risk of lung cancer were measured. Mixed-model regressions were used to determine whether the levels and time trends of outcome variables were different among individuals with different screening outcomes.

RESULTS

An indeterminate screening result increased state anxiety of participants, although anxiety then decreased over time. The objective risk of cancer is lower for individuals with an indeterminate screen than their initial perceived risk, and screening did not change their perceived risk of cancer. Those with a suspicious screening result had increased perceived risk of cancer and fear of cancer after screening, and these effects also diminished over time. Individuals with a negative screen had a temporary reduction in perceived risk of cancer.

CONCLUSIONS

Individuals who are screened for lung cancer and receive an indeterminate or suspicious screening result have some negative psychological effects from being screened. The results suggest that individuals who are considering screening should be fully informed of the risk of negative psychosocial consequences and that individuals who have been screened should receive clear and detailed information on interpreting screening results.

Outcome analysis of 4 years' follow-up of patients referred for colposcopy with one smear showing mild dyskaryosis

OBJECTIVE

To assess the 4-year outcome of patients after one smear showing mild dyskaryosis with respect to smear regression rate, prevalence of cervical intraepithelial neoplasia (CIN) and the effect of age.

METHODS

Retrospective analysis of patients diagnosed with initial mildly dyskaryotic smear during the year 2000 with a follow-up period of 48 months. These women had not had any previous abnormal smears.

SETTINGS

Cytopathology Department and Colposcopy Unit, King's College Hospital, London, UK.

RESULTS

We identified 524 patients of whom 375 patients with complete follow-up data are included. The age range was 19-67 years with a median of 29 years. There were 207 patients aged 35 years or less (55%). At 6 months, 258 smears were performed and 47.8% of them were negative (95% CI: 41.6-54.0%). The total number of negative follow-up smears in the first year was 198 out of a total of 397 smears performed (50%). This proportion has significantly increased between 1 and 4 years' follow-up to 67.5% (RR: 1.24; 95% CI: 1.14-1.35). Over the 4-year period, 791 smears were performed and 477 were negative (60.3%; 95% CI: 56.9-63.7%). Of the 477 negative smears there were only 61 smears (12.8%; 95% CI: 10-16%), in 54 patients (14%; 95% CI: 11-18%) that reverted back to low-grade cytological abnormality. In only one case the repeat smear showed high-grade abnormality after initial negative follow-up; however, on biopsy, histology showed CIN I. Out of the 375 patients, 70 required treatment with excisional biopsy (19%; 95% CI: 15.0-22.9%). Histology confirmed high-grade CIN in only 41 cases giving a prevalence of 11% (95% CI: 8.1-14.5%). There were no cases of microinvasive or invasive cancer detected. Age (< or =35 years versus >35 years) did not significantly affect either cytological or histological outcome.

CONCLUSION

Sixty per cent of follow-up smears after initial mild dyskaryosis subsequently became negative; of them 87.2% remained negative over the 4 year follow-up. Treatment was only required in 19% of patients, with 11% prevalence of high-grade CIN. Age did not affect the outcome. These results are reassuring and indicate that colposcopic referral may not be necessary after only one mildly dyskaryotic smear.

A longitudinal study of sexual functioning in women referred for colposcopy: a 2-year follow up

OBJECTIVE

To elucidate psychosexual problems in women referred for colposcopy after an abnormal cervical smear and a 6-month and 2-year follow up.

DESIGN

Prospective study.

SETTING

Department of Gynaecology, Malmö University Hospital, Sweden.

POPULATION

One hundred consecutive women referred for colposcopy for the first time subsequent to receiving notification of an abnormal cervical smear.

METHODS

The women completed the State-Trait Anxiety Inventory, a psychosexual questionnaire and had one psychosocial interview prior to colposcopy at all three visits.

MAIN OUTCOME MEASURES

Depending upon the result of the cervical biopsy, women had either a loop electrosurgical excision procedure (LEEP) or not. Psychosexual variables, anxiety measures, and psychosocial variables were used to estimate sexual functioning at the beginning of the study and at follow up. Differences in sexual functioning between LEEP and non-LEEP groups were estimated.

RESULTS

'Spontaneous interest in sex', 'frequency of intercourse', and 'sexual arousal' were reported to be statistically significant lower at 6 months compared with the first visit, and at 2 years, 'spontaneous interest in sex' and 'frequency of intercourse' still remained low. There was no difference in sexual functioning between the LEEP and non-LEEP groups at follow up.

CONCLUSIONS

Two years after referral for colposcopy, women still had an effect on sexual functioning, that is, lesser 'spontaneous interest' and decreased 'frequency of intercourse'. We found no support for a relationship between treatment of cervical intraepithelial neoplasia by LEEP and deterioration in sexual functioning.

Review of the economic and quality-of-life burden of cervical human papillomavirus disease

OBJECTIVE

The purpose of this study was to conduct a systematic literature review on the economic burden and health-related quality-of-life impact of cervical human papillomavirus disease.

STUDY DESIGN

A systematic review of cost-of-illness studies and health-related quality-of-life studies was conducted. PubMed, Embase, and PsycINFO databases were searched with the use of predefined terms.

RESULTS

Nine economic and 24 quality-of-life studies were identified. The annual health care costs of human papillomavirus-related conditions in the United States range from 2.25-4.6 billion dollars (2005 US dollars). The burden of human papillomavirus is second only to human immunodeficiency virus among sexually transmitted diseases. Health-related quality-of-life areas that are impacted substantially by human papillomavirus include emotional, social, and sexual functioning.

CONCLUSION

The economic and quality-of-life burden of cervical human papillomavirus disease is significant and highlights the need for treatment and prevention options for this condition.

Lessons Learned

Although the incidence rate of cervical cancer has decreased over the last several years, low-income ethnic minority women remain at increased risk for morbidity and mortality from cervical cancer. We conducted a pilot study to examine the feasibility and acceptability of mindfulness-based stress reduction (MBSR) program among multiethnic low-income women with abnormal Pap smears. Spanish- and English-speaking women recruited through convenience sampling participated in MBSR classes 2 hours each week over 6 consecutive weeks. State anxiety and self-compassion were measured before and after the MBSR program. Focus groups and surveys were used to evaluate the program. Although 51 women were initially recruited, pre- and post-MBSR data were available only for 8 women. There was a significant reduction in anxiety and a trend toward increased self-compassion in this group of women. The participants evaluated the MBSR program very positively. The high attrition rate highlights the challenges of conducting MBSR research with this demographic of women. Potential strategies for improving recruitment and retention of low-income multiethnic women are discussed.

Women's experiences of repeated HPV testing in the context of cervical cancer screening: a qualitative study

OBJECTIVE

To evaluate the psychosocial impact of taking part in repeated testing for human papillomavirus (HPV) in the context of cervical cancer screening.

METHODS

In-depth interviews were carried out with 30 women who were HPV positive with normal cytology at trial baseline, and attended for a repeat HPV test 12 months later. Interview transcripts were analysed qualitatively using Framework Analysis to identify emergent themes.

RESULTS

Although women often experienced serious negative emotional consequences at the time of their first positive result, these did not generally last during the year between tests once questions about HPV had been resolved. The emotional impact of testing positive a second time was greater for many women, sometimes causing them to overcome their embarrassment about having a sexually transmitted infection in order to disclose their result and seek support. Among the women interviewed there was an overwhelming preference for immediate colposcopy rather than continued surveillance for persistent HPV. This was associated with the desire for a speedy resolution, and fears about progression to cancer.

CONCLUSIONS

Although most women did not appear to suffer on-going anxiety while waiting for a second HPV test, this seemed contingent on their information needs being met. Women appeared to be more distressed by a second HPV positive result than a single one, and expressed a clear preference for immediate colposcopy over continued surveillance. This finding might have implications for the way in which HPV testing could be used in cervical cancer screening programmes.

Cervical cancer screening--"For better or worse...": women's experience of screening

In Sweden, the population-based cervical cancer screening program has been in progress since the 1970s and is directed toward women between 23 and 60 years of age. The aim of this study was to explore women's experience of cervical screening after being diagnosed with cancer. A qualitative study inspired by Grounded Theory was used. Eleven women were interviewed. The interviews were analyzed using the constant comparative method. "Screening-For Better or Worse..." was identified as the core category, around which the categories "Unawareness," "Trust," "Search for Understanding," and "Making the Invisible Visible" were integrated and on which the conceptual model was built. The experience of screening had both a positive and a negative dimension for the women stricken by cervical cancer. The women had a positive experience of screening as such and they believed in its benefits. However, many women felt deceived and, because of their unawareness, questions arose for which they searched for understanding. The women requested adequate and understandable information. Their trust remained because the contact with healthcare professionals involved in screening and in the follow-up program had been reassuring.

Psychologic morbidities prior to loop electrosurgical excision procedure in the treatment of cervical intraepithelial neoplasia

The objective of this study was to assess and compare anxiety and distress in patients undergoing colposcopic examinations and loop electrosurgical excision procedure (LEEP). Patients seen for evaluation of cervical intraepithelial neoplasia (CIN) and LEEP were recruited. All patients received further teaching with respect to their abnormality right after the colposcopic evaluation by nursing staff. The Hospital anxiety and Depression Scale (HADS) and the Psychosocial Effects of Abnormal Pap Smears (PEAPS) questionnaires were used to measure and compare distress between the two groups. Linear regression models were built to identify significant predictive variables for psychologic morbidities. Twenty-one colposcopy and 20 LEEP patients participated in this study. No significant demographic differences were noted. Eighty-one percent of patients having colposcopy and 65% of those undergoing LEEP can be classified as having significant anxiety and depression based on the HADS questionnaire. Patients undergoing LEEP scored significantly better than colposcopy patients on the mean total PEAPS score and on the self-belief/cancer concern and effects on sexual relationship dimension scores. Significant psychologic morbidities exist in patients diagnosed with CIN. Face-to-face individualized education and support after colposcopy can decrease patients' distress at subsequent treatment visits.

Adverse psychological outcomes in colorectal cancer screening: does health anxiety play a role?

People who are anxious about their health are more likely to misinterpret health information as personally threatening and less likely to be reassured by medical investigations that show they are free from disease. Consequently, health anxious people would be expected to react more adversely to cancer screening, but this possibility has rarely been explored. The moderating role of health anxiety on the psychological impact of participating in colorectal cancer screening was examined among a sub-sample of 3535 participants in a large, community-based trial of colorectal cancer screening in the UK. The screening modality was flexible sigmoidoscopy, which examines the bowel for pre-cancerous polyps. It was predicted that health anxiety would be associated with more worry about cancer before screening, a greater increase in worry if polyps were detected, and less reassurance after a clear result. As expected, health anxious participants were more anxious and more worried about bowel cancer both before and after screening. However, they experienced greater reductions in anxiety and worry about cancer following the examination. They reported lower levels of reassurance following screening, but also expressed more positive reactions to the experience. The positive psychological benefits of attending medical investigations should be examined in future work, because this may go some way towards explaining why health anxious people repeatedly seek medical interventions.

Cervical cancer screening programmes and policies in 18 European countries

A questionnaire survey was conducted by the Epidemiology Working Group of the European Cervical Cancer Screening Network, and the International Agency for Research on Cancer, IARC, between August and December 2003 in 35 centres in 20 European countries with reliable cervical cancer incidence and/or mortality data in databanks held at IARC and WHO. The questionnaire was completed by 28 centres from 20 countries. The final tables included information on 25 centres from 18 countries. Six countries had started screening in the 1960s, whereas 10 countries or regions had started at least a pilot programme by 2003. There were six invitational and nine partially invitational programmes, the rest employing opportunistic screening only. Recommended lifetime number of smears varied from seven to more than 50. Coverage of smear test within the recommended screening interval (usually 3 or 5 years) was above 80% in three countries. Screening registration took place in 13 programmes. Eight programmes reported the rates of screen-detected cervical cancers and precursor lesions. There was wide variation in the CIN3 detection rates. International guidelines and quality assurance protocols are useful for monitoring and evaluating screening programmes systematically. Our survey indicated that the recommendations as currently given are met in only few European countries. Health authorities need to consider stronger measures and incentives than those laid out in the current set of recommendations.