Psychosocial and economic aspects of a trial of management of mild and borderline cervical abnormalities (TOMBOLA)

Interventions for reducing anxiety in women undergoing colposcopy

BACKGROUND

Prior to the development of cervical cancer abnormal cervical cells can be detected on a cervical smear. The usual practice following an abnormal cervical smear is to perform colposcopy. Colposcopy is the visualisation of the cervix using a binocular microscope. Women experience high levels of anxiety and negative emotional responses at all stages of cervical screening. High levels of anxiety before and during colposcopy can have adverse consequences, including pain and discomfort during the procedure and high loss to follow-up rates. This review evaluates interventions designed to reduce anxiety levels during colposcopic examination.

OBJECTIVES

To compare the efficacy of various interventions aimed at reducing anxiety during colposcopic examination in women.

SEARCH METHODS

We searched the Cochrane Gynaecological Cancer Group Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL), Issue 3, 2010, MEDLINE and EMBASE up to July 2010. We also searched registers of clinical trials, abstracts of scientific meetings, reference lists of included studies and contacted experts in the field.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of interventions to reduce anxiety during colposcopic examination.

DATA COLLECTION AND ANALYSIS

Two review authors independently abstracted data and assessed risk of bias. Mean differences for anxiety levels, knowledge scores, pain, patient satisfaction and psychosexual dysfunction in women who underwent colposcopy were pooled in a random effects meta-analyses.

MAIN RESULTS

We found six trials that met our inclusion criteria. These trials assessed the effectiveness of different interventions for reducing anxiety in women undergoing colposcopy for the first time.All comparisons were restricted to single trial analyses or meta analysis of just two trials. There was evidence from a reasonably large trial (n = 220) that was at low risk of bias to suggest that music during colposcopy significantly reduced anxiety levels (MD = -4.80, 95% CI: -7.86 to -1.74) and pain experienced during the procedure (MD = -1.71, 95% CI: -2.37 to -1.05) compared to not listening to music. There was no statistically significant difference between anxiety levels prior to colposcopy in women receiving information leaflets versus no leaflets and information leaflets, video and counselling versus information leaflets and video with no counselling. However, knowledge scores were significantly higher and psychosexual dysfunction scores were significantly lower in women who received leaflets compared to those who did not so there was some sort of benefit to giving patients information leaflets. There is evidence for video colposcopy from a quasi randomised trial which assessed 81 women showing significant anxiety reduction.

AUTHORS' CONCLUSIONS

Anxiety appears to be reduced by playing music during colposcopy. Although information leaflets did not reduce anxiety levels, they did increase knowledge levels and are therefore useful in obtaining clinical consent to the colposcopic procedure. Leaflets also contributed to improved patient quality of life by reducing psychosexual dysfunction.

Interventions for reducing anxiety in women undergoing colposcopy

BACKGROUND

Before cervical cancer develops the cells of the cervix become abnormal. Following an abnormal cervical smear colposcopy is performed. Colposcopy is the visualisation of the cervix using a binocular microscope. Women experience high levels of anxiety and negative emotional responses at all stages of cervical screening. High levels of anxiety before and during colposcopy can have adverse consequences, including pain and discomfort during the procedure and high loss to follow-up rates. This review evaluates interventions designed to reduce anxiety levels during colposcopic examination.

OBJECTIVES

To compare the efficacy of various interventions aimed at reducing anxiety during colposcopic examination in women.

SEARCH STRATEGY

The Cochrane Central Register of Controlled Trials (CENTRAL), (Cochrane Library, Issue 1, 2006) MEDLINE (1951-2006), EMBASE (1980-2006), CINAHL (1982-2006), Psych Lit and CancerLit, NHMRC Clinical Trials Register, UKCCCR Register of Cancer Trials, Meta-Register and Physician Data Query Protocols.

SELECTION CRITERIA

Randomised and quasi randomised controlled trials of interventions to reduce anxiety during colposcopic examination.

DATA COLLECTION AND ANALYSIS

One author searched the citations and reference lists. Studies that appeared to meet inclusion criteria were retrieved and assessed independently by the remaining three authors. The methodological quality of included studies was assessed using the Cochrane Collaboration Back Review Group's methodological quality criteria (van Tulder 2003).

MAIN RESULTS

Eleven trials were included, these trials used various interventions to reduce anxiety. These examined 1441 women's anxiety levels after different types of intervention. These included: Information leaflets - (proved not to be associated with anxiety reduction). Counselling: pre-colposcopic counselling was not associated with anxiety reduction. Information leaflets and information video and pre-colposcopy counselling was not associated with a reduction in anxiety levels. Listening to music during colposcopy: this intervention was associated with reduction in anxiety levels (p < 0.002). Video colposcopy was associated with reduction in anxiety levels, and the reduction in anxiety was significant (p < 0.0002). Information using graphs and verbal information and information video versus information only when sought: There was no significant reduction in the level of anxiety in the intervention group. Information leaflets and information video versus information leaflets only: There was a reduction in anxiety levels in the intervention group compared to the control group (p < 0.00001).

AUTHORS' CONCLUSIONS

Anxiety appears to be reduced by playing music during colposcopy, showing information videos prior to colposcopy and viewing video colposcopy during the procedure. Although information leaflets did not reduce anxiety levels, they did increase knowledge levels and so are useful in obtaining clinical consent to the colposcopic procedure.

United Kingdom cervical cancer screening and the costs of time and travel

OBJECTIVES

The aim of this study was to estimate the time and travel costs generated by women when attending for Papanicolaou (Pap) smear tests or colposcopy appointments in the United Kingdom, both absolutely and relative to the health service cost of the national cervical cancer screening programs.

METHODS

Data were obtained from questionnaires completed by two samples of women participating in a three-center trial of management of low-grade abnormalities detected by screening (n = 1,106 for Pap smears and n = 1,203 for colposcopy appointments). Women were 20 to 59 years of age and resident in Grampian or Tayside, Scotland, or Nottingham, England. Questionnaire data were supplemented with sociodemographic information previously collected at the time of recruitment to the trial.

RESULTS

The mean total time and travel costs per attendance at a smear test and at a colposcopy appointment were estimated to be 9.2 pounds and 27.4 pounds, respectively, averaged across the three trial areas (valued at 2002 prices). Statistically significant intercenter disparities in time and travel costs were identified, particularly with respect to colposcopy appointments. For these, time and travel costs in Nottingham were substantially less than those in Grampian and Tayside (22.9 pounds, 30.2 pounds, and 32.1 pounds, respectively). Time and travel costs amount to 26 and 33 percent, approximately, over and above the direct health service costs of the English and Scottish screening programs, respectively.

CONCLUSIONS

The time and travel costs associated with participation in the UK cervical cancer screening programs are substantial and are not spatially uniform across the country.

Trial of management of borderline and other low-grade abnormal smears (TOMBOLA): Trial design

Cervical screening reduces the risk of cervical cancer by detecting and treating cervical intraepithelial neoplasia (CIN). The management of women with low-grade cervical abnormalities is controversial. Two management policies exist: repeat smears in primary care and colposcopy examination. It is not clear which of these is the more effective and efficient. There is also uncertainty as to the most effective and efficient management of women at colposcopy when an area of abnormality is seen on the cervix - immediate treatment or biopsy and selective recall for treatment if the biopsy result suggests this is necessary. The result of a human papillomavirus (HPV) test might assist in deciding the appropriate management of women with low-grade abnormalities. TOMBOLA, a pragmatic randomised-controlled trial set within the cervical screening programmes in Scotland and England, addresses these three areas of uncertainty. Almost four and a half thousand women aged 20-59 with a low-grade cervical abnormality have been recruited and randomised to either repeat smears or colposcopy examination. Women in the colposcopy arm of the trial are further randomised to a policy of either immediate treatment or biopsy and selective recall for treatment if they have an abnormal transformation zone. Women are followed up to an exit examination at 3 years. HPV testing is undertaken at recruitment and at the exit examination. The primary endpoint is cumulative incidence of CIN2/3. A range of other clinical, psychosocial and economic outcomes is being considered. This paper describes the design of the trial, and discusses the rationale underlying aspects of the design and the challenges faced in designing and implementing the trial.

Balancing uncertainty and acceptance: understanding Chinese women's responses to an abnormal cervical smear result

AIMS AND OBJECTIVES

The aims of this study were to examine the responses of Hong Kong Chinese women receiving an abnormal smear result and to compare any differences in responses depending on the diagnosis of the abnormal smear.

BACKGROUND

The implementation of cervical screening programmes has resulted in an increasing number of women receiving an abnormal smear result requiring cytological surveillance or referral for colposcopy. Evidence suggests that women frequently misunderstood such results, believing that they already have cancer. However, little is known about the responses of Chinese women in this situation.

DESIGN

An exploratory qualitative study.

METHODS

Face-to-face semi-structured tape-recorded interviews were undertaken with 66 women sampled opportunistically from an urban centre of a major non-governmental service provider. Amongst this sample, 22 women required cytological surveillance, 20 required treatment for vaginitis and 24 were referred for colposcopy. Thematic analysis was undertaken of the translated interviews within and across groups to identify categories and themes illustrating women's responses to an abnormal smear result.

FINDINGS

An important difference in the comparison of the data sets was that of women's understanding of the cause of the abnormal result. Women with vaginitis understood the cause of their abnormality, whereas those in the other groups remained unclear about their abnormality, generating feelings of fear and uncertainty. Trust in practitioners influenced women's acceptance of the result.

CONCLUSIONS

Although responses of Chinese women are similar to those in other population groups, with those referred for colposcopy experiencing greater anxiety than those undergoing cytological surveillance, balancing feelings of uncertainty and acceptance influenced Chinese women's responses to their abnormal results and allowed them to make sense of their result in their everyday life. Trust in the practitioner was essential to the acceptance of their result.

RELEVANCE TO CLINICAL PRACTICE

Such findings highlight implications for nursing practice, in particular developing information-giving strategies and targeted information to help women manage feelings of uncertainty. The importance of trusting professional relationships in determining women's acceptance of an abnormal result is also highlighted. The findings suggest nurses working with Chinese women should consider the underlying influence of culture on women's beliefs and actions.

Enclosing a pen with a postal questionnaire can significantly increase the response rate

BACKGROUND AND OBJECTIVES

It is important to maximize response rates to postal questionnaires. We compared the impact of three low-cost interventions on response rates.

METHODS

A 2 x 2 x 2 factorial trial was conducted, nested within TOMBOLA (Trial Of Management of Borderline and Other Low-grade Abnormal smears). Three interventions were evaluated: (1) enclosing a TOMBOLA-branded pen with the questionnaire (as opposed to no pen); (2) sending the questionnaires by first class post (as opposed to second class); and (3) enclosing a preaddressed return envelope on which there was a second class postage stamp (rather than a freepost business-reply envelope). Nine hundred thirty women, aged 20-59 years, due to receive a TOMBOLA psychosocial questionnaire by post during June-August 2003 were randomized.

RESULTS

Enclosing a pen resulted in a statistically significant 7.0% increase in the cumulative proportion of questionnaires returned (from 61.5 to 68.5%; P = .002). The adjusted odds of response was significantly raised (odds ratio [OR] = 1.38, 95% confidence interval [CI] 1.04-1.82). Neither first class post nor providing a stamped envelope had a significant impact on response. There were no interactions between the interventions.

CONCLUSIONS

Enclosing a pen with a questionnaire can significantly increase response. This low-cost strategy was effective against a background of "good practice" with regard to the administration of postal questionnaires.

Testing the construct validity of willingness to pay valuations using objective information about risk and health benefit

This paper describes an experiment to test the construct validity of contingent valuation, by eliciting women's valuations for the NHS cervical cancer screening programme. It is known that, owing to low levels of knowledge of cancer and screening in the general population, women both over-estimate the risk of disease and the efficacy of screening. The study is constructed as a randomised experiment, in which one group is provided with accurate information about cervical cancer screening, whilst the other is not. The first hypothesis supporting construct validity, that controls who perceive greater benefits from screening will offer higher valuations, is substantiated. Both groups are then provided with objective information on an improvement to the screening programme, and are asked to value the improvement as an increment to their original valuations. The second hypothesis supporting construct validity, that controls who perceive the benefits of the programme to be high already will offer lower incremental valuations, is also substantiated.