Do women with high-grade cervical intraepithelial neoplasia prefer a see and treat option in colposcopy?

Overtreatment in the see-and-treat approach for high-grade squamous cervical cytology

Objectives

To evaluate overtreatment with the 'see-and-treat' approach in patients with high-grade squamous cervical cytology, and identify the clinical factors associated with overtreatment.

Study design

Patients with high-grade squamous intra-epithelial lesion (HSIL) cytology undergoing colposcopy and loop electrosurgical excision procedure (LEEP) in a single visit or the 'see-and-treat' approach from January 2005 to December 2019 were reviewed retrospectively. The overtreatment rate and complications following LEEP were explored.

Results

In total, 220 cases were identified. The overtreatment rate was 11.4%, and surgical complications were haemorrhage (n = 3, 1.36%) and infection (n = 9, 4.09%). On univariable analysis, factors associated with overtreatment were current cytological result and colposcopic impression. On multi-variable analysis, current cytological result of non-HSIL compared with HSIL/cancer, and colposcopic diagnosis of low-grade lesion or normal compared with high-grade lesion or cancer had adjusted odds ratios of 13.81 [95% confidence interval (CI) 1.23-155.20; p = 0.033] and 3.58 (95% CI 1.32-9.74; p = 0.013), respectively.

Conclusions

The overtreatment rate with the 'see-and-treat' approach was 11.4%. Independent factors associated with overtreatment were current cervical cytological result of non-HSIL, and low-grade or normal colposcopic diagnosis.

Screen-and-treat approach in managing cervical cancer precursor lesions: An observational study with 524 women

OBJECTIVE

To detect factors related to overtreatment with the "Screen-and-treat" approach (S&T) in women with suspicious cervical precancerous lesions.

STUDY DESIGN

A retrospective observational study of 524 women with high-grade squamous intraepithelial lesions (HSIL) or more severe (HSIL+) in cytology, treated by the Large Loop Excision of the Transformation Zone (LLETZ): 161 without a previous biopsy (S&T group) and 363 with a previous biopsy (biopsy group) from January 2017 to July 2020. The main outcome was a diagnosis of LLETZ: negative (negative or low-grade squamous intraepithlelial lesion LSIL) or HSIL+. A negative diagnosis was interpreted as "overtreatment." Results were analyzed as a function of the S&T approach (whether previous biopsy or not). Variables were obtained from medical records, and were compared with Chi-square or Fisher's exact test (p, p-value), to estimate the chances of a logistic regression analysis (Odds Ratio, OR, or admitting a Confidence Interval (CI) of 95 %).

RESULTS

No differences were observed in groups regarding menopausal status, smoking, hormonal contraceptive use, colposcopy findings, LLETZ diagnosis, and recurrence. Comparing biopsy vs S&T groups, the frequency of women over 40 years was 28.4 % vs 39.7 % (p = 0.011), and transformation zone type 3 was 12.2 vs 26.8 % (p < 0.001), respectively. In women managed by S&T, when compared to a LLETZ diagnosis, an HSIL+ result was more frequent in women presenting with TZ 1 (93.1 % TZ1 vs 78.5 % TZ2 vs 73.8 % TZ3, p = 0.008) and in women with abnormal colposcopy (92.9 % abnormal vs 38.1 % negative, p < 0.001). Multiple regression analysis found that women with negative colposcopic findings presented a higher risk for negative LLETZ diagnosis (LSIL/Negative final histology) (18.6; 6.18-56.02).

CONCLUSIONS

No difference was observed in the LLETZ diagnosis in women who did or did not use the S&T approach: it was adequate for women referred by cytological HSIL along with high-grade colposcopic findings.

Overtreatment rate after immediate local excision of suspected cervical intraepithelial neoplasia: A prospective cohort study

OBJECTIVE

The gold standard of cervical intraepithelial neoplasia (CIN) treatment is large loop excision of the transformation zone (LLETZ) after histopathological diagnosis from punch biopsies. In addition, treatment may be appropriate at initial colposcopy. Our objective was to study the applicability of immediate treatment strategy according to clinical parameters.

METHODS

We conducted a prospective cohort study among patients referred to colposcopy at Helsinki University Hospital, Finland, between January 2014, and September 2018 (ISRCTN10933736). Patients treated with LLETZ, either after biopsies or immediately at initial colposcopy, were included. The main outcome measure was overtreatment (OT) rate defined as normal or low-grade histopathological findings in LLETZ specimen within both treatment groups.

RESULTS

A total of 572 patients treated with LLETZ were included: 360 treated after biopsies and 212 treated immediately at initial colposcopy. When LLETZ was performed immediately after high-grade referral cytology and with colposcopic impression of high-grade disease, the overtreatment (OT) rate was 10.0% (95% CI 9.10 to 17.2), whereas when LLETZ was done after biopsy-confirmed high-grade lesions, the OT rate was 18.9% (95% CI 14.7 to 23.7), resulting in risk difference (RD) -8.91% (95% CI -16.0 to -1.82). Among HPV16/18 positive patients the OT rate was 8.22% (95% CI 3.08 to 17.0) for immediate treatment, resulting in RD of -10.7% (95% CI -18.3 to -3.04) compared to LLETZ after biopsies.

CONCLUSIONS

Immediate LLETZ does not result in overtreatment when applied on selected cases, especially after high-grade referral cytology and when high-grade lesion is also colposcopically suspected.

Increased detection of high grade CIN, when using electrical impedance spectroscopy as an adjunct to routine colposcopy, is maintained when used across international boundaries: Prospective data from nine European countries

OBJECTIVE

To evaluate the performance of EIS (ZedScan) with colposcopy in the detection of high grade CIN (HG-CIN) in different health care settings.

METHOD

Pooled analysis of data from 26 colposcopy centres in 9 countries. All women underwent colposcopy and ZedScan examination. Data was recorded prospectively via a proforma. Indications for referral to colposcopy were according to national guidelines. Pathology was reported according to national guidelines.

RESULTS

5257 women were examined by 82 colposcopists, median 93 women per centre (range 41 - 2684), 3 users per centre (range 1-8). Referral indications were; 19.3% high grade cytology, 50.4% low grade, 30.3% clinical or HPV positive / cytology negative. The prevalence of HG-CIN was 26.5%; 79.1% in high grade referrals, 16.7% low grade, 9.4% clinical or HPV positive / cytology negative. The use of ZedScan detected an extra 269 cases of high grade CIN (24% increase) (7.5% increase for high grade referrals, 57.9% for low grade and 52% for clinical or HPV positive/cytology negative). Based upon colposcopic impression (CI), the sensitivity of colposcopy for CIN2 + was 74.1% compared with 91.6% for colposcopy with ZedScan (Chi² p < 0.0001). The PPV for a ZedScan directed biopsy varied according to referral cytology and colposcopic impression (19.5% to 85.7%). 489 women underwent treatment at first visit, when ZedScan suggested treatment, 95.1% had HG-CIN/HG-CGIN or cervical cancer. The pooled results for the whole 26 centres were consistent with the results obtained for the largest centre (Sheffield) alone and also with the results with this largest centre excluded.

CONCLUSIONS

The addition of EIS (ZedScan) increases detection of HG-CIN with the PPV for a ZedScan directed biopsy consistent with the published literature. Results were similar in multiple healthcare settings. With more women being referred to colposcopy at low risk of HG-CIN, due to HPV vaccination and primary HPV screening, this study confirms the value of a real time adjunctive technology.

Comparative performance evaluation of different HPV tests and triaging strategies using self-samples and feasibility assessment of thermal ablation in 'colposcopy and treat' approach: A population-based study in rural China

Human papillomavirus (HPV) test, self-sampling and thermal ablation for cervical intraepithelial neoplasia (CIN) have been developed separately to increase screening coverage and treatment compliance of cervical cancer screening programmes. A large-scale study in rural China screened 9,526 women with their combinations to explore the optimal cervical cancer-screening cascade in the real-world. Participants received careHPV and polymerase chain reaction (PCR) HPV tests on self-collected samples. Women positive on either HPV test underwent colposcopy, biopsy and thermal ablation in a single visit. Samples positive on either HPV test were retested for genotyping. Absolute and relative performance of HPV tests, triage strategies, 'colposcopy and thermal ablation' approach were statistically evaluated. PCR HPV test detected 33.3% more CIN grade two or worse (CIN2+) at a cost of 28.1% more colposcopies compared to careHPV. Sensitivities of PCR HPV and careHPV tests to detect CIN2+ were 96.7 and 72.5%. Specificities for the same disease outcome were 82.1 and 86.0%. Triaging HPV-positive women with HPV16/18 genotyping considerably improved the positive predictive value for CIN2+ (4.8-5.0 to 18.2-19.2%). Ninety-six women positive on HPV and having abnormal colposcopy were eligible for thermal ablation and all accepted same-day treatment, contributing to 64.6% being treated appropriately (CIN1+ on histopathology), which reached up to 84.8% among women positive on HPV 16/18 triage. No serious side-effects/complications were reported. The combination of PCR HPV test followed by HPV 16/18 triaging on self-collected samples and colposcopy of triage positive women followed by immediate thermal ablation might be the appropriate screening cascade for rural China.

Psychological distress in cervical cancer screening: results from a German online survey

Purpose

The PODCAD study aimed at assessing the degree of psychological stress that women experience due to notification of an abnormal Papanicolaou (Pap) smear finding or a positive human papillomavirus (HPV) test result.

Methods

We designed a survey to address the question of psychological burden due to abnormal Pap smear results and/or positive HPV tests. In this online campaign approach, we aimed to reach > 2000 women all over Germany irrespective of kind and number of abnormal screening findings. We asked for different kinds of anxiety, distress and uncertainty regarding both, Pap and HPV status.

Results

A total of 3753 women completed the survey at least partially, and almost 2300 fully completed the survey. Of these, more than 50% were affected already since more than 1 year, and almost half of them had experienced at least three Pap smears in follow-up examinations. Almost 70% of the women were afraid of developing cancer. Intriguingly, almost half of the women with abnormal findings were not aware of their stage of the Pap smear. Furthermore, almost 30% of the women displayed signs of a post-traumatic stress disorder.

Conclusion

Abnormal results in cervical cancer screening have an impact on patients’ psychology, irrespective of the knowledge and severity of the findings. Better information concerning risks and benefits of cervical cancer screening and about the meaning of the outcome of its procedures are required to decrease this anxiety.

Electronic supplementary material

The online version of this article (10.1007/s00404-020-05661-9) contains supplementary material, which is available to authorized users.

Clinical practice variation and overtreatment risk in women with abnormal cervical cytology in the Netherlands: two-step versus see-and-treat approach

BACKGROUND

Only a few small studies have compared the 2-step method (biopsy followed by treatment) with a see-and-treat (immediate treatment) approach in women both low-grade or high-grade referral cytology. The clinical practice variation in the Netherlands has not been reviewed before.

OBJECTIVES

To determine overtreatment rates in the 2-step versus see-and-treat approach in women referred for colposcopy because of abnormal cytology results, and to evaluate clinical practice variation in the Netherlands.

MATERIALS AND METHODS

This was a population-based retrospective cohort study including 36,581 women with a histologic result of the cervix identified from the Dutch Pathology Registry (PALGA) between 2016 and 2017. Odds ratios for overtreatment, defined primarily as cervical intraepithelial neoplasia grade 1 or less, were determined for the 2-step and see-and-treat approach in relation to age, high-risk human papillomavirus status, and referral cytology.

RESULTS

Of the included women 10,713 women (29.3%) received the 2-step method; 6,851 women (18.7%) underwent see-and-treat; and 19,017 women (52.0%) received conservative management after colposcopy with histologic assessment with cytologic follow-up or another type of treatment. Despite the existence of a national guideline advising see-and-treat only in case of suspected high-grade disease in women who have completed their childbearing, there is a wide practice variation between the 2 strategies in the Netherlands, with 7.0-88.3% of the women receiving see-and-treat per laboratory. The median time between cytology and treatment was 1-2 months (range, 0-12 months) in women receiving see-and-treat and the 2-step method, respectively. A total of 4119 women (23.5%) were overtreated, with older women, high-risk human papillomavirus-negative women, and women with low-grade cytology results being more likely to be overtreated. Women with low-grade cytology results and see-and-treat were associated with a higher overtreatment rate than women receiving the 2-step method (65.0% [1414 of 2174] versus 32.1% [1161 of 3613], respectively; odds ratio, 3.34; 95% confidence interval, 2.92-3.82). However, in women with high-grade cytology results, see-and-treat was inversely associated with overtreatment (11.3% [529 of 4677] versus 14.3% [1015 of 7100], respectively; odds ratio, 0.68; 95% confidence interval, 0.58-0.81).

CONCLUSION

A see-and-treat approach is justified only in women with high-grade cytology results who have completed their childbearing. There is a wide practice variation between the 2 strategies in the Netherlands, and gynecologists should adhere to the guideline to prevent overtreatment.

'I Want the Whole Package'. Elderly Patients' Preferences for Follow-Up After Abnormal Cervical Test Results: A Qualitative Study

BACKGROUND

The incidence of cervical cancer peaks around the age of 75 years, and elderly patients are more frequently diagnosed with advanced-stage cervical cancer than younger patients. There is considerable practice variation regarding follow-up of elderly patients with abnormal cervical test results at risk of cervical cancer, both nationally and internationally, due to uncertainty about risks and benefits for this particular patient group. The treatment preferences of these patients are, however, poorly described in the current literature. The aim of this study was to explore elderly patients' experiences with abnormal cervical test results and preferences for follow-up.

MATERIALS AND METHODS

We performed focus group interviews with seventeen Danish patients aged 60-79 years who had undergone biopsy and colposcopy in gynaecological outpatient clinics or at private gynaecologists due to a positive human papillomavirus (HPV) test result and/or abnormal cytology. A focus group interview guide was designed to cover experiences with abnormal cervical test results, including realistic risk and benefit scenarios related to underdiagnosis and overtreatment. Data were analysed thematically using a phenomenological approach.

RESULTS

The patients were surprised that elderly could also have an HPV infection. Most preferred treatment and follow-up at the gynaecologist over continuous control visits at the general practitioner. In case of persistent HPV infection and cervical intraepithelial neoplasia, a quick solution including cone biopsy was preferred even if it carried a risk of overtreatment. The patients wanted clear recommendations and demonstrated considerable intolerance towards healthcare professionals' clinical uncertainty regarding optimum follow-up.

CONCLUSION

Most elderly patients wanted closure involving cone biopsy, and they expressed tolerance towards overtreatment to reduce their risk of cervical cancer. Thus, clinicians should present known risks and benefits to elderly patients facing risk of overtreatment after abnormal cervical test results.

See-and-Treat Loop Electrosurgical Excision Procedure for High-Grade Cervical Cytology: Are We Overtreating?

OBJECTIVES

To report the overtreatment rate for see-and-treat versus 3-step conventional strategy (cervical cytology, colposcopic biopsies, then LEEP) for patients with high-grade squamous intraepithelial lesion (HSIL) cytology. Our second aim was to identify risk factors for overtreatment.

METHODS

We included 178 women with HSIL cytology from our university-based colposcopy clinic who underwent LEEP between 2007 and 2014. Overtreatment was defined as cervical intraepithelial neoplasia (CIN) 1 or less on LEEP specimen. Differences between treatment groups were compared using chi-square test, 2-sample t test, or Mann-Whitney rank-sum test as appropriate.

RESULTS

CIN2+ was found in 69 (80%) of women in the see-and-treat group and 69 (75%) of the conventional management group (P = 0.093), with overtreatment in 17 (20%) and 23 (25%, P = 0.403), respectively. Women who underwent see-and-treat (n = 86) were older (mean age, 36 vs 31 years; P = 0.007), and a greater proportion completed childbearing (30% vs 13%, P = 0.024). There were no differences in top hat excision; however, a higher proportion of the see-and-treat group had CIN2+ in endocervical samples (54% vs 27%, P = 0.047). Overtreatment, regardless of management strategy, was associated with age at time of LEEP, where older women were more likely to be overtreated (median age, 37 vs 32 years, respectively; OR, 1.04; 95% CI, 1.01-1.08; P = 0.011).

CONCLUSIONS

A see-and-treat strategy minimizes risk of loss to follow-up with a similar overtreatment rate compared with conventional management. With CIN2+ in some three-fourths of women with HSIL, a see-and-treat should be favored especially when adherence to follow-up is questionable.

High-Grade Cervical Dysplasia After Negative Loop Electrosurgical Excision Procedure

OBJECTIVES

To describe the prevalence and correlates of high-grade cervical intraepithelial neoplasia (CIN2+) after a negative loop electrosurgical excision procedure (LEEP), performed for high-grade squamous intraepithelial lesion (HSIL) cervical cytology.

METHODS

One hundred six women from our university-based colposcopy clinic underwent LEEP between 2007 and 2014. Negative LEEP was defined as CIN1 or less. Persistence/recurrence estimates were calculated by treatment (see-and-treat vs 3-step conventional strategy-cervical cytology, colposcopic biopsy, LEEP) and LEEP results (negative vs positive) using the Kaplan-Meier method. Predictors of CIN2+ after a negative LEEP were examined by multivariate Cox proportional hazards model.

RESULTS

Overall, the prevalence of CIN2+ after a negative LEEP for HSIL was 14%. Persistence/recurrence of CIN2+ was similar between women with a negative and positive see-and-treat LEEP (25% vs 15%) and those with a negative or positive 3-step conventional LEEP (7% vs 22%) (log-rank, P = 0.58). Positive LEEP margin was more common among women with a positive LEEP (53.7% see-and-treat vs 42.6% conventional) compared with a negative result (0% see-and-treat vs 3.7% conventional, P < 0.0001). The risk of CIN2+ after a negative LEEP did not differ by management strategy (log-rank, P = 0.85) or LEEP result (log-rank, P = 0.58). In multivariate analysis, correlates of persistent/recurrent CIN2+ included older age (adjusted odds ratio [aOR], 1.09; P = 0.0003), history of previous LEEP (aOR, 8.99; P < 0.0001), and positive LEEP margin (aOR, 13.56; P = 0.0005).

CONCLUSIONS

A negative LEEP does not allow less stringent surveillance, as CIN2+ risk is similar to that after CIN2+ is found in the LEEP specimen, whether the specimen was obtained by see-and-treat or conventional 3-step approach.

A retrospective observational study for the outcomes of women presenting to a colposcopy clinic with a high-grade Pap smear - Implications for a 'see and treat' approach to management

BACKGROUND

The current Australian National Health and Medical Research Council guidelines discourage the use of 'see and treat' colposcopic management due to concerns regarding over-treatment. However, this approach has been shown to have benefits in several studies, including cost savings, elimination of loss to follow up and decreased patient anxiety.

AIMS

To provide Australian data on treatment outcomes for women presenting with a high-grade Pap smear to a large metropolitan colposcopy unit and to determine whether a 'see and treat' approach would meet specified standards.

MATERIALS AND METHODS

Retrospective review of women referred to the Royal Prince Alfred Hospital colposcopy unit with a high-grade smear. Patient data, colposcopy findings, treatment and pathology results were collated and analysed to determine treatment outcomes using the current 'biopsy and treat' approach. The feasibility of 'see and treat' was assessed by determining which women with high-grade colposcopy findings had high-grade disease confirmed on biopsy or excisional specimens.

RESULTS

One hundred and thirty-seven women underwent either excisional or ablative treatment. Of those undergoing excisional procedures, 81.3% had high-grade dysplasia or invasive cancer, 11.6% had CIN1 and 7.1% had no dysplasia on histopathology. One hundred and twenty-one with high-grade colposcopy findings had histopathology results available. Using a 'see and treat' approach, 92.6% would have had confirmed dysplasia of any grade, while 91.7% had confirmed high-grade dysplasia.

CONCLUSIONS

'See and treat' colposcopy is feasible in the Australian setting when applied to selected patients with high-grade cytology and high-grade colposcopic findings.

Adverse psychological outcomes following colposcopy and related procedures: a systematic review

BACKGROUND

Although colposcopy is the leading follow-up option for women with abnormal cervical cytology, little is known about its psychological consequences.

OBJECTIVES

We performed a systematic review to examine: (1) what, if any, are the adverse psychological outcomes following colposcopy and related procedures; (2) what are the predictors of adverse psychological outcomes post-colposcopy; and (3) what happens to these outcomes over time.

SEARCH STRATEGY

Five electronic databases (PubMed, PsychINFO, CINAHL, Web of Science, Scopus) were searched for studies published in English between January 1986 and February 2014.

SELECTION CRITERIA

Eligible studies assessed psychological wellbeing at one or more time-points post-colposcopy.

DATA COLLECTION AND ANALYSIS

Two reviewers independently screened titles and abstracts. Full texts of potentially eligible papers were reviewed. Data were abstracted from, and a quality appraisal performed of, eligible papers.

MAIN RESULTS

Twenty-three papers reporting 16 studies were eligible. Colposcopy and related procedures can lead to adverse psychological outcomes, particularly anxiety. Ten studies investigated predictors of adverse psychological outcomes; management type and treatment had no impact on this. Seven studies investigated temporal trends in psychological outcomes post-colposcopy; findings were mixed, especially in relation to anxiety and distress. Studies were methodologically heterogeneous.

CONCLUSIONS

Follow-up investigations and procedures for abnormal cervical cytology can cause adverse psychological outcomes among women. However, little is known about the predictors of these outcomes or how long they persist. There is a need for a more standardised approach to the examination of the psychological impact of colposcopy, especially longer-term outcomes.

TWEETABLE ABSTRACT

Follow-up investigations for abnormal cervical cytology can cause adverse psychological outcome among women.

The role of individually targeted information to reduce anxiety before colposcopy: a randomised controlled trial

OBJECTIVE

We investigated whether providing targeted information on an individual level by mail and by phone reduces anxiety in women referred to the colposcopy clinic.

DESIGN

Randomised controlled trial.

POPULATION

Women referred to the colposcopy clinic.

METHODS

Between December 2007 and April 2010, 169 patients with abnormal smear results were randomised into two study arms. Group A received individually targeted information about the diagnosis and procedure by mail and phone. Group B received the standard folder about colposcopies alone. Patients were requested to fill out a questionnaire prior to their first colposcopy appointment.

MAIN OUTCOME MEASURES

The questionnaire included the hospital anxiety and depression scale (HADS), and the Spielberger state-trait anxiety inventory (STAI), as well as a short self-administered questionnaire.

RESULTS

Twenty women were excluded from further analyses after randomisation, leaving 149 women for evaluation. The median STAI state anxiety score was high (50.0), but there was no significant difference in median STAI state anxiety and HADS anxiety scores between both groups. However, knowledge about human papillomavirus and the colposcopy procedure did significantly increase in group A (P = 0.004).

CONCLUSIONS

Anxiety levels before primary colposcopy are surprisingly high, and are not reduced following individually targeted information given before colposcopy.

Long-term psychosocial impact of alternative management policies in women with low-grade abnormal cervical cytology referred for colposcopy: a randomised controlled trial

BACKGROUND

The debate continues regarding the best management for women with low-grade abnormal cervical cytology attending colposcopy. We compared psychosocial outcomes of alternative management policies in these women.

METHODS

In all, 989 women, aged 20-59 years, with low-grade abnormal cytology, were randomised to immediate large loop excision (LLETZ) or two to four targeted punch biopsies taken immediately with recall for LLETZ if these showed cervical intra-epithelial neoplasia 2/3. At 6 weeks after the last procedure, women completed the hospital anxiety and depression scale (HADS) and the impact of event scale (IES). At 12, 18, 24 and 30 months post recruitment, women completed the HADS and process outcome specific measure (POSM). Prevalence of significant depression (≥ 8), significant anxiety (≥ 11) and distress (≥ 9) and median POSM scores were compared between arms. Multivariate odds ratios (ORs) for immediate LLETZ vs biopsy and recall were computed.

RESULTS

Over the entire follow-up, there was no significant difference between arms in cumulative prevalence or risk of significant depression (OR=0.78, 95% CI 0.52-1.17) or significant anxiety (OR=0.83, 95% CI 0.57-1.19). At 6 weeks post procedure, distress did not differ significantly between arms. At later time points, 8-11% had significant depression and 14-16% had significant anxiety but with no differences between arms. The POSM scores did not differ between the arms.

CONCLUSIONS

There is no difference in long- or short-term psychosocial outcomes of immediate LLETZ and punch biopsies with selective recall.

Biopsy and selective recall compared with immediate large loop excision in management of women with low grade abnormal cervical cytology referred for colposcopy: multicentre randomised controlled trial

OBJECTIVES

To compare the effectiveness of punch biopsy and selective recall for treatment versus a policy of immediate treatment by large loop excision in the management of women with low grade abnormal cervical cytology referred for colposcopy.

DESIGN

Multicentre individually randomised controlled trial, nested within the NHS cervical screening programmes.

SETTING

Grampian, Tayside, and Nottingham.

PARTICIPANTS

1983 women, aged 20-59, with cytology showing borderline nuclear abnormalities or mild dyskaryosis, October 1999-October 2002.

INTERVENTIONS

Immediate large loop excision or up to four targeted punch biopsies taken immediately with recall for treatment (by large loop excision) if these showed cervical intraepithelial neoplasia grade II or III or worse. Participants were followed for three years, concluding with an exit colposcopy.

MAIN OUTCOME MEASURES

Clinical end points: cumulative incidence of cervical intraepithelial neoplasia grade II or worse and grade III or worse at three years. Clinically significant anxiety and depression and self reported after effects assessed six weeks after colposcopy, biopsies, or large loop excision.

RESULTS

879 women (44%) had a normal transformation zone at colposcopy and had no further procedures at that time. Colposcopists were less likely to classify the transformation zone as abnormal when the allocation was large loop excision (603 (60%) in the biopsy and selective recall group; 501 (51%) in the immediate large loop excision group). Of women randomised to biopsy and recall, 157 (16%) required a second clinic visit for treatment. Specimens from almost 60% (n=296) of women who underwent immediate large loop excision showed no cervical intraepithelial neoplasia (31%; n=156) or showed cervical intraepithelial neoplasia grade I (28%; n=140). The percentages of women diagnosed with grade II or worse up to and including the exit examination were 22% (n=216) in the biopsy and recall arm and 23% (n=228) in the immediate large loop excision arm. There was no significant difference between the arms in cumulative incidence of cervical intraepithelial neoplasia grade II or worse (adjusted relative for risk large loop excision v biopsy 1.04, 95% confidence interval 0.86 to 1.25) or grade III or worse (1.03, 0.79 to 1.34). A greater proportion of disease was detected at initial investigation and less during follow-up and at exit in the immediate large loop excision arm, but time of detection did not differ significantly between arms. Levels of anxiety and depression and reported pain did not differ between arms. Higher proportions of women randomised to large loop excision reported moderate or more severe bleeding and discharge.

CONCLUSION

A policy of targeted punch biopsies with subsequent treatment for cervical intraepithelial neoplasia grade II or III and cytological surveillance for grade I or less provides the best balance between benefits and harms for the management of women with low grade abnormal cytology referred for colposcopy. Immediate large loop excision results in overtreatment and more after effects and should not be recommended.

TRIAL REGISTRATION

ISRCTN 34841617.

Options for managing low grade cervical abnormalities detected at screening: cost effectiveness study

OBJECTIVE

To estimate the cost effectiveness of alternative methods of managing low grade cervical cytological abnormalities detected at routine screening. Design Cost analysis within multicentre individually randomised controlled trial.

SETTING

Grampian, Tayside, and Nottingham.

PARTICIPANTS

4201 women with low grade abnormalities.

INTERVENTIONS

Cytological surveillance or referral to colposcopy for biopsy and recall if necessary or referral to colposcopy with immediate treatment based on colposcopic appearance.

MAIN OUTCOME MEASURES

Data on resource use collected from participants throughout the duration of the trial (36 months), enabling the estimation of both the direct (health care) and indirect (time and travel) costs of management. Quality of life assessed at recruitment and at 12, 18, 24, and 30 months, using the EQ-5D instrument. Economic outcomes expressed as costs per case of cervical intraepithelial neoplasia (grade II or worse) detected, by trial arm, as confirmed at exit, and cost utility ratios (cost per quality adjusted life year (QALY) gained) for the three pairwise comparisons of trial arms.

RESULTS

The mean three year discounted costs of surveillance, immediate treatment, and biopsy and recall were pound150.20 (euro177, $249), pound240.30 (euro283, $415), and pound241.10 (euro284, $4000), respectively, viewed from the health service perspective. From the social perspective, mean discounted costs were pound204.40 (euro241, $339), pound339.90 (euro440, $563), and pound327.50 (euro386, $543), respectively. Estimated at the means, the incremental cost effectiveness ratios indicated that immediate treatment was dominated by the other two management methods, although it did offer the lowest cost per case of cervical intraepithelial neoplasia detected and treated. The pronounced skews in the distributions indicated that probabilistic uncertainty analysis would offer more meaningful estimates of cost effectiveness. The observed differences in the cost effectiveness ratios between trial arms were not significant.

CONCLUSION

Judged within the time frame of the TOMBOLA evaluation, there is no compelling economic reason to favour any one follow-up method over either of the others.

TRIAL REGISTRATION

ISRCTN 34841617.

An audit of standards of the 'see and treat' approach in women with a high-grade squamous intraepithelial lesion on Pap smears

This study was undertaken to audit the performances of the 'see and treat' approach in women with a high-grade squamous intraepithelial lesion (HSIL) cytology at Chiang Mai University Hospital using selective criteria from the National Health Service Cervical Screening Programme (NHSCSP) 2004 guidelines. Women with a HSIL smear, who had undergone colposcopy and immediate loop electrosurgical excision procedure (LEEP) during June 2006 and September 2008, were reviewed. The standard measurement was determined by the following criteria: (1) the proportion of women treated at the first visit who have evidence of cervical intraepithelial neoplasia (CIN) on histology to be >90%; (2) the primary haemorrhage must be <5%; (3) the proportion of patients admitted as inpatients owing to treatment complication to be <2%. Of 247 women in this study, the histopathological results were as follows: CIN II-III, 188 (76.1%); cancer, 31 (12.6%); adenocarcinoma in situ, 5 (2.0%); CIN I, 5 (2.0%); and no CIN, 18 (7.3%). The prevalence of CIN I or higher was 92.7%. Primary haemorrhage was observed in 13 (5.3%) women. Four (1.6%) women were admitted as inpatients because of LEEP-related complications. In conclusion, the 'see and treat' approach in our institute has acceptable overtreatment and complication rates.

After-effects reported by women following colposcopy, cervical biopsies and LLETZ: results from the TOMBOLA trial

OBJECTIVE

Few studies have investigated physical after-effects of colposcopy. We compared post-colposcopy self-reported pain, bleeding, discharge and menstrual changes in women who underwent: colposcopic examination only; cervical punch biopsies; and large loop excision of the transformation zone (LLETZ).

DESIGN

Observational study nested within a randomised controlled trial.

SETTING

Grampian, Tayside and Nottingham.

POPULATION

Nine hundred-and-twenty-nine women, aged 20-59, with low-grade cytology, who had completed their initial colposcopic management.

METHODS

Women completed questionnaires on after-effects at approximately 6-weeks, and on menstruation at 4-months, post-colposcopy.

MAIN OUTCOME MEASURES

Frequency of pain, bleeding, discharge; changes to first menstrual period post-colposcopy.

RESULTS

Seven hundred-and-fifty-one women (80%) completed the 6-week questionnaire. Of women who had only a colposcopic examination, 14-18% reported pain, bleeding or discharge. Around half of women who had biopsies only and two-thirds treated by LLETZ reported pain or discharge (biopsies: 53% pain, 46% discharge; LLETZ: 67% pain, 63% discharge). The frequency of bleeding was similar in the biopsy (79%) and LLETZ groups (87%). Women treated by LLETZ reported bleeding and discharge of significantly longer duration than other women. The duration of pain was similar across management groups. Forty-three percent of women managed by biopsies and 71% managed by LLETZ reported some change to their first period post-colposcopy, as did 29% who only had a colposcopic examination.

CONCLUSIONS

Cervical punch biopsies and, especially, LLETZ carry a substantial risk of after-effects. After-effects are also reported by women managed solely by colposcopic examination. Ensuring that women are fully informed about after-effects may help to alleviate anxiety and provide reassurance, thereby minimising the harms of screening.

Review: Optical Micrometer Resolution Scanning for Non-invasive Grading of Precancer in the Human Uterine Cervix

Management of cervical precancer is archetypal for other cancer prevention programmes but has to consider diagnostic and logistic challenges. Numerous optical tools are emerging for non-destructive near real-time early diagnosis of precancerous lesions of the cervix. Non-destructive, real-time imaging modalities have reached pre-commercial status, but high resolution mapping tools are not yet introduced in clinical settings. The NCBI PubMed web page was searched using the keywords ‘CIN diagnosis’ and the combinations of ‘cervix {confocal, optical coherence tomography, ftir, infrared, Raman, vibrational, spectroscopy}’. Suitable titles were identified and their relevant references followed. Challenges in precancer management are discussed. The following tools capable of non-destructive high resolution mapping in a clinical environment were selected: confocal microscopy, optical coherence tomography, IR spectroscopy, and Raman spectroscopy. Findings on the clinical performance of these techniques are put into context in order to assist the reader in judging the likely performance of these methods as diagnostic tools. Rationale for carrying out research under the prospect of the HPV vaccine is given.