Women's experiences of having a colposcopic examination: self-reported satisfaction with care, perceived needs and consequences

The use of biomarkers and HPV genotyping to improve diagnostic accuracy in women with a transformation zone type 3

BACKGROUND

Twenty percent of women referred to colposcopy have a type 3 transformation zone-where colposcopic assessment for high-grade dysplasia (CIN2+) is not possible. This study examines the effectiveness of HPV biomarkers and genotyping in combination with techniques that sample an endocervical TZ.

METHODS

A prospective diagnostic accuracy study. Women booked for large-loop excision (LLETZ) with squamous dyskaryosis, high-risk HPV and a TZ3 were recruited. Immediately prior to LLETZ samples were collected for p16/Ki-67 dual-stained cytology, HPV genotyping and H&E, p16- and Ki-67-stained endocervical curettings.

RESULTS

In women with low-grade screening (n = 64), 35.9% had CIN2+; dual-stained cytology had the greatest effect on the PPV of routine screening (76.1% vs 35.9%) and perfectly predicted the absence of CIN2+. In women with a high-grade screening result (n = 37); 75.6% had CIN2+ and dual-stained curettings improved the PPV (96.5 vs 75.6%).

CONCLUSIONS

With high-grade screening and a TZ3, LLETZ appears safest as three quarters have CIN2+ . Women with low-grade screening and a TZ3 have a twofold increased risk of CIN2+ when compared to women where the TZ is visible. The use of dual-stained cytology may help identify those women who can be safely offered surveillance and those who require treatment.

Unsatisfactory colposcopy: clinical decision-making in conditions of uncertainty

BACKGROUND

Unsatisfactory colposcopy, where the cells of interest are not visible in women with a positive cervical screening test, is a common area of clinical uncertainty due to the lack of clear evidence and guidance. Colposcopists' opinions and experiences are likely to have a significant influence on service provision and the development of national policy. The aim of this study was to analyse decision-making when applied to women with unsatisfactory colposcopy.

METHODS

A multi-centre qualitative study utilizing a series of focus groups in an English healthcare region. Sampling aimed to ensure heterogeneity of experience and healthcare provider demographics. A topic guide covered a range of clinical and cytological variables and was compiled by the researchers and three expert Colposcopists. Using an iterative approach, thematic analysis was selected as the most appropriate method to identify factors affecting decision-making.

RESULTS

Twenty-three Colposcopists from four units participated. The decision to treat was easier in women with high-grade cytology and high risk women with low-grade cytology such as heavy smokers, poor attenders, older women, those who had completed their families and women opting for treatment. Where decision-making was more complex, intuition and a multi-disciplinary approach were used to guide management. Areas of dissonance, which are affected by paucity of evidence and emotive factors, included cytological collection device, clinical setting and length of conservative follow-up and depth of excision in women at high risk of treatment-related morbidity.

CONCLUSIONS

Anxiety of missing a cancer deters long-term cytological follow-up, resulting in heterogeneity of care and higher than anticipated excisional treatments in women with low-grade screening and unsatisfactory colposcopy. In areas of clinical uncertainty when decisions are dominated by affect, clinical guidance can reduce the difficulty and anxiety of decision-making.

Physical after-effects of colposcopy and related procedures, and their inter-relationship with psychological distress: a longitudinal survey

OBJECTIVE

To estimate prevalence of post-colposcopy physical after-effects and investigate associations between these and subsequent psychological distress.

DESIGN

Longitudinal survey.

SETTING

Two hospital-based colposcopy clinics.

POPULATION

Women with abnormal cytology who underwent colposcopy (±related procedures).

METHODS

Questionnaires were mailed to women 4, 8 and 12 months post-colposcopy. Details of physical after-effects (pain, bleeding and discharge) experienced post-colposcopy were collected at 4 months. Colposcopy-specific distress was measured using the Process Outcome-Specific Measure at all time-points. Linear mixed-effects regression was used to identify associations between physical after-effects and distress over 12 months, adjusting for socio-demographic and clinical variables.

MAIN OUTCOME MEASURES

Prevalence of post-colposcopy physical after-effects. Associations between the presence of any physical after-effects, awareness of after-effects, and number of after-effects and distress.

RESULTS

Five-hundred and eighty-four women were recruited (response rate = 73, 59 and 52% at 4, 8 and 12 months, respectively). Eighty-two percent of women reported one or more physical after-effect(s). Multiple physical after-effects were common (two after-effects = 25%; three after-effects = 25%). Psychological distress scores declined significantly over time. In adjusted analyses, women who experienced all three physical after-effects had on average a 4.58 (95% CI: 1.10-8.05) higher distress scored than those who experienced no after-effects. Women who were unaware of the possibility of experiencing after-effects scored significantly higher for distress during follow-up.

CONCLUSIONS

The prevalence of physical after-effects of colposcopy and related procedures is high. The novel findings of inter-relationships between awareness of the possibility of after-effects and experiencing multiple after-effects, and post-colposcopy distress may be relevant to the development of interventions to alleviate post-colposcopy distress.

TWEETABLE ABSTRACT

Experiencing multiple physical after-effects of colposcopy is associated with psychological distress.

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.

Understanding Women's Differing Experiences of Distress after Colposcopy: A Qualitative Interview Study

BACKGROUND

Women who have an abnormal cervical cytology test may be referred for a colposcopy. Accumulating evidence suggests some women may experience distress after colposcopy. This exploratory study examined women's differing experiences of post-colposcopy distress with the aim of identifying factors that are predictive of, or protective against, distress.

METHODS

We carried out semistructured, qualitative interviews with 23 women who had undergone colposcopies. Interviews were transcribed verbatim, coded, and analyzed thematically. The Framework Approach was used to summarize and organize the data and identify emerging higher order themes.

RESULTS

Two forms of post-colposcopy distress emerged: 1) short term and 2) long term. Short-term distress was experienced immediately after the colposcopy and in the days afterward, and was usually related to the physical experience of the colposcopy. Long-term distress typically persisted over time and was related to concerns about fertility, cervical cancer, and sexual intercourse. The drivers of short-term and long-term distress differed. Factors related to short-term distress were feeling unprepared for the procedure, having a negative experience of the procedure, and attending the clinic alone. Factors related to long-term distress were future intentions to have (more) children, having physical after-effects of the procedure that impacted on the woman's life, and being under on-going clinic surveillance. Absence of these factors (e.g., being accompanied to the clinic) was protective against short- and long-term distress.

CONCLUSIONS

Colposcopy can lead to short- and long-term post-procedural distress for some women. We identified a range of factors, some potentially modifiable, that seem to influence the chances of experiencing distress. These results may inform the development of strategies or interventions aimed at preventing or minimizing distress after colposcopy and related procedures.

Does treatment for cervical and vulvar dysplasia impact women's sexual health?

Human papillomavirus-associated disease represents an immense public health burden worldwide. Persistent human papillomavirus infection can lead to the development of cervical dysplasia and vulvar dysplasia, both of which have been increasing in incidence in women in recent years. Numerous studies have focused on methods for screening and diagnosis of cervical dysplasia, but few have looked at the effects of treatment on women's psychological and sexual health. Even fewer studies have addressed these issues in women with vulvar dysplasia. The aim of this article was to provide a comprehensive review of the existing evidence concerning the impact of therapy for cervical and vulvar precancers on women's sexual function and sexual relationships. We performed a search of the medical literature for the time period up to and including August 2013 on PubMed. The findings from a limited number of studies to date indicate that psychosexual vulnerability increases after diagnosis and treatment of both cervical and vulvar dysplasia. More in-depth research is needed to better understand the effects of different treatment modalities on women's sexual health and relationships during and following treatment.

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.

Qualitative insights into the psychological stress before and during colposcopy: a focus group study

OBJECTIVE

To determine the reasons for women's anxiety and psychological stress before and during colposcopy, in order to define strategies to decrease their stress.

METHODS

Qualitative study with 15 women participating in four focus groups between April 2011 and April 2012. All participants were diagnosed with a cervical cytological abnormality and attended a gynecologist's clinic to undergo colposcopy. The focus group interview was audio-taped and transcribed verbatim. The data were analyzed using qualitative content analysis to identify themes.

RESULTS

Psychological stress before colposcopy was seen as being caused by unsatisfactory explanation of abnormal cervical smears and the colposcopy procedure itself. Additionally, a fear of cancer, pain and discomfort, embarrassment, waiting time in the hospital, and a longer interval between referral and the actual colposcopy appointment increased psychological stress and anxiety. Women indicated that more detailed and practical information about the cervical smear result and the colposcopy procedure may reduce stress and anxiety.

CONCLUSION

In order to minimize the adverse psychological consequences of an abnormal cervical smear and colposcopy, timely, practical and detailed information needs to be provided to the women, and waiting and access times need to be as short as possible. These measures may reduce the psychological stress and anxiety, however some stress and anxiety will always remain, and may even be desirable in order to ensure proper follow-up of abnormal cervical smears.

Human papillomavirus vaccination in the resourced and resource-constrained world

Human papillomavirus has been established as the causal agent for cervical cancer. The identification of a clear cause presents an unparalleled opportunity for cancer control. As such, the development of prophylactic human papillomavirus vaccines has been rightly hailed as one of the significant scientific triumphs of the past 20 years. This story of scientific triumph over disease, however, is not yet complete. The fruit of scientific labour must be delivered to the people in order to fulfil the underlying intent of the research (i.e. to prevent cancer and save lives). The success of a vaccination programme, however, does not depend on the biological efficacy of the vaccine alone. Various other local factors, such as poverty, gender inequality, cultural traditions, or religious beliefs, can significantly constrain the success of any vaccination programme. In this chapter, we provide an overview of how the human papillomavirus vaccine works and its global uptake, as well as, how variations in local contexts can affect the successful implementation of a vaccination programme. Other factors besides vaccine costs also need serious attention. With better understanding of such factors, policy makers and medical health professionals will be better equipped to make informed decisions to maximise the potential benefits of the human papillomavirus vaccines for the most number of people in individual countries.

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.

Long-term cytological and histological outcomes in women managed with loop excision treatment under local anaesthetic for high-grade cervical intraepithelial neoplasia

OBJECTIVE

This study examines the impact of excision margin status after large loop excision of the transformation zone (LLETZ) under local anaesthetic for high-grade cervical intraepithelial neoplasia (HG-CIN) on the cytological and histological outcomes up to 5 years after treatment.

METHODS

  Prospective cytological and histological data were obtained by examination of the colposcopy database at Addenbrooke's Hospital, Cambridge, UK. All women aged between 19 and 50 years who underwent treatment for HG-CIN by LLETZ under local anaesthetic were included in the study. Patients without follow-up data were excluded from the study. The excision margin status was correlated with the subsequent cytological and histological outcomes.

RESULTS

A series of 967 women with CIN2 and CIN3 underwent LLETZ excision under local anaesthetic. Overall, 42% of women had disease present at the excision margin following LLETZ. Women with CIN3 were more likely than those with CIN2 to have an involved excision margin (P<0.0001). Cytological recurrence was highest at 12 months (16%) and did not correlate with the CIN grade or excision margin status. Histological recurrence/persistence was also highest at 12 months follow-up (15%) and this correlated with grade of CIN and margin status (P<0.0001).

CONCLUSIONS

Histological recurrence/persistence correlates with grade of CIN and excision margin status. Management of HG-CIN in an outpatient setting under local anaesthetic is safe, cost effective and yields a favourable long-term outcome.

Psychological distress associated with colposcopy: patients' perception

OBJECTIVE

Cervical screening and colposcopy are associated with varying degrees of anxiety in women. Interventions are in place to reduce anxiety but the effectiveness of these needs examination. Our objective was to develop an understanding of factors associated with anxiety in relation to colposcopy and to seek women's opinion on interventions designed to reduce anxiety.

STUDY DESIGN

Prospective, anonymised survey. Determination of anxiety level and effectiveness of interventions within the colposcopy experience, i.e. information leaflet, video-screen display, nursing and medical intervention and exploration of medical terms, i.e. 'CIN'.

RESULTS

Prior to attendance 36% of patients felt they were very worried, 54% slightly worried and 10% not worried. All patients found the standardised NHS information leaflet helpful to a variable degree. During colposcopy 30% of patients found watching on a video-screen display very helpful, whilst a significant number (18%) found it increased their worry. Stratification of results showed that women with pre-existing high level of anxiety were least satisfied with indices examined.

CONCLUSION

Our results indicate that the higher the index level of anxiety regarding colposcopy, the less likely women were to find either the leaflet or the video-screen display helpful. Research should focus on the 'very anxious' women, as they are least satisfied with existing measures in place to reduce anxiety. However, evidence is presented to imply this may not be possible.

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.