Management of women with mild and moderate cervical dyskaryosis

Immediate referral to colposcopy versus cytological surveillance for minor cervical cytological abnormalities in the absence of HPV test

BACKGROUND

A significant number of women are diagnosed with minor cytological abnormalities on cervical screening. Many authorities recommend surveillance as spontaneous regression might occur. However, attendance for cytological follow-up decreases with time and might put some women at risk of developing invasive disease.

OBJECTIVES

To assess the optimum management strategy for women with minor cervical cytological abnormalities (atypical squamous cells of undetermined significance - ASCUS or low-grade squamous intra-epithelial lesions - LSIL) at primary screening in the absence of HPV (human papillomavirus) DNA test.

SEARCH METHODS

We searched the following electronic databases: Cochrane Central Register of Controlled Trials (CENTRAL Issue 4, 2016), MEDLINE (1946 to April week 2 2016) and Embase (1980 to 2016 week 16).

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing immediate colposcopy to cytological surveillance in women with atypical squamous cells of undetermined significance (ASCUS/borderline) or low-grade squamous intra-epithelial lesions (LSIL/mild dyskaryosis).

DATA COLLECTION AND ANALYSIS

The primary outcome measure studied was the occurrence of cervical intra-epithelial neoplasia (CIN). The secondary outcome measures studied included default rate, clinically significant anxiety and depression, and other self-reported adverse effects.We classified studies according to period of surveillance, at 6, 12, 24 or 36 months, as well as at 18 months, excluding a possible exit-examination. We calculated pooled risk ratios (RR) and 95% confidence intervals (CI) using a random-effects model with inverse variance weighting. Inter-study heterogeneity was assessed with I² statistics.

MAIN RESULTS

We identified five RCTs with 11,466 participants that fulfilled the inclusion criteria. There were 18 cases of invasive cervical cancer, seven in the immediate colposcopy and 11 in the cytological surveillance groups, respectively. Although immediate colposcopy detects CIN2+ and CIN3+ earlier than cytology, the differences were no longer observed at 24 months (CIN2+: 3 studies, 4331 women; 17.9% versus 18.3%, RR 1.14, CI 0.66 to 1.97; CIN3+: 3 studies, 4331 women; 10.3% versus 11.9%, RR 1.02, CI 0.53 to 1.97). The inter-study heterogeneity was considerable (I² greater than 90%). Furthermore, the inclusion of the results of the exit examinations at 24 months, which could inflate the CIN detection rate of cytological surveillance, may have led to study design-derived bias; we therefore considered the evidence to be of low quality.When we excluded the exit examination, the detection rate of high-grade lesions at the 18-month follow-up was higher after immediate colposcopy (CIN2+: 2 studies, 4028 women; 14.3% versus 10.1%, RR 1.50, CI 1.12 to 2.01; CIN3+: 2 studies, 4028 women, 7.8% versus 6.9%, RR 1.24, CI 0.77 to 1.98) both had substantial inter-study heterogeneity (I² greater than 60%) and we considered the evidence to be of moderate quality).The meta-analysis revealed that immediate referral to colposcopy significantly increased the detection of clinically insignificant cervical abnormalities, as opposed to repeat cytology after 24 months of surveillance (occurrence of koilocytosis: 2 studies, 656 women; 32% versus 21%, RR 1.49, 95% CI 1.17 to 1.90; moderate-quality evidence) incidence of any CIN: 2 studies, 656 women; 64% versus 32%, RR 2.02, 95% CI 1.33 to 3.08, low-quality evidence; incidence of CIN1: 2 studies, 656 women; 21% versus 8%, RR 2.58, 95% CI 1.69 to 3.94, moderate-quality evidence).Due to differences in trial designs and settings, there was large variation in default rates between the included studies. The risk for default was higher for the repeat cytology group, with a four-fold increase at 6 months, a six-fold at 12 and a 19-fold at 24 months (6 months: 3 studies, 5117 women; 6.3% versus 13.3%, RR 3.85, 95% CI 1.27 to 11.63, moderate-quality evidence; 12 months: 3 studies, 5115 women; 6.3% versus 14.8%, RR 6.39, 95% CI 1.49 to 29.29, moderate-quality evidence; 24 months: 3 studies, 4331 women; 0.9% versus 16.1%, RR 19.1, 95% CI 9.02 to 40.43, moderate-quality evidence).

AUTHORS' CONCLUSIONS

Based on low- or moderate-quality evidence using the GRADE approach and generally low risk of bias, the detection rate of CIN2+ or CIN3+ after two years does not appear to differ between immediate colposcopy and cytological surveillance in the absence of HPV testing, although women may default from follow-up. Immediate colposcopy probably leads to earlier detection of high-grade lesions, but also detects more clinically insignificant low-grade lesions. Colposcopy may therefore be the first choice when good compliance is not assured. These results emphasize the need for an accurate reflex HPV triage test to distinguish women who need diagnostic follow-up from those who can return safely to routine recall.

The impact of the National Institute for Health Research Health Technology Assessment programme, 2003-13: a multimethod evaluation

BACKGROUND

The National Institute for Health Research (NIHR) Health Technology Assessment (HTA) programme supports research tailored to the needs of NHS decision-makers, patients and clinicians. This study reviewed the impact of the programme, from 2003 to 2013, on health, clinical practice, health policy, the economy and academia. It also considered how HTA could maintain and increase its impact.

METHODS

Interviews (n = 20): senior stakeholders from academia, policy-making organisations and the HTA programme. Bibliometric analysis: citation analysis of publications arising from HTA programme-funded research. Researchfish survey: electronic survey of all HTA grant holders. Payback case studies (n = 12): in-depth case studies of HTA programme-funded research.

RESULTS

We make the following observations about the impact, and routes to impact, of the HTA programme: it has had an impact on patients, primarily through changes in guidelines, but also directly (e.g. changing clinical practice); it has had an impact on UK health policy, through providing high-quality scientific evidence - its close relationships with the National Institute for Health and Care Excellence (NICE) and the National Screening Committee (NSC) contributed to the observed impact on health policy, although in some instances other organisations may better facilitate impact; HTA research is used outside the UK by other HTA organisations and systematic reviewers - the programme has an impact on HTA practice internationally as a leader in HTA research methods and the funding of HTA research; the work of the programme is of high academic quality - the Health Technology Assessment journal ensures that the vast majority of HTA programme-funded research is published in full, while the HTA programme still encourages publication in other peer-reviewed journals; academics agree that the programme has played an important role in building and retaining HTA research capacity in the UK; the HTA programme has played a role in increasing the focus on effectiveness and cost-effectiveness in medicine - it has also contributed to increasingly positive attitudes towards HTA research both within the research community and the NHS; and the HTA focuses resources on research that is of value to patients and the UK NHS, which would not otherwise be funded (e.g. where there is no commercial incentive to undertake research). The programme should consider the following to maintain and increase its impact: providing targeted support for dissemination, focusing resources when important results are unlikely to be implemented by other stakeholders, particularly when findings challenge vested interests; maintaining close relationships with NICE and the NSC, but also considering other potential users of HTA research; maintaining flexibility and good relationships with researchers, giving particular consideration to the Technology Assessment Report (TAR) programme and the potential for learning between TAR centres; maintaining the academic quality of the work and the focus on NHS need; considering funding research on the short-term costs of the implementation of new health technologies; improving the monitoring and evaluation of whether or not patient and public involvement influences research; improve the transparency of the priority-setting process; and continuing to monitor the impact and value of the programme to inform its future scientific and administrative development.

Human papillomavirus testing versus repeat cytology for triage of minor cytological cervical lesions

BACKGROUND

Atypical squamous cells of undetermined significance (ASCUS) and low-grade squamous intra-epithelial lesions (LSIL) are minor lesions of the cervical epithelium, detectable by cytological examination of cells collected from the surface of the cervix of a woman.Usually, women with ASCUS and LSIL do not have cervical (pre-) cancer, however a substantial proportion of them do have underlying high-grade cervical intra-epithelial neoplasia (CIN, grade 2 or 3) and so are at increased risk for developing cervical cancer. Therefore, accurate triage of women with ASCUS or LSIL is required to identify those who need further management.This review evaluates two ways to triage women with ASCUS or LSIL: repeating the cytological test, and DNA testing for high-risk types of the human papillomavirus (hrHPV) - the main causal factor of cervical cancer.

OBJECTIVES

Main objective To compare the accuracy of hrHPV testing with the Hybrid Capture 2 (HC2) assay against that of repeat cytology for detection of underlying cervical intraepithelial neoplasia of grade 2 or worse (CIN2+) or grade 3 or worse (CIN3+) in women with ASCUS or LSIL. For the HC2 assay, a positive result was defined as proposed by the manufacturer. For repeat cytology, different cut-offs were used to define positivity: Atypical squamous cells of undetermined significance or worse (ASCUS+), low-grade squamous intra-epithelial lesions or worse (LSIL+) or high-grade squamous intra-epithelial lesions or worse (HSIL+).Secondary objective To assess the accuracy of the HC2 assay to detect CIN2+ or CIN3+ in women with ASCUS or LSIL in a larger group of reports of studies that applied hrHPV testing and the reference standard (coloscopy and biopsy), irrespective whether or not repeat cytology was done.

SEARCH METHODS

We made a comprehensive literature search that included the Cochrane Register of Diagnostic Test Accuracy Studies; the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), MEDLINE (through PubMed), and EMBASE (last search 6 January 2011). Selected journals likely to contain relevant papers were handsearched from 1992 to 2010 (December). We also searched CERVIX, the bibliographic database of the Unit of Cancer Epidemiology at the Scientific Institute of Public Health (Brussels, Belgium) which contains more than 20,000 references on cervical cancer.More recent searches, up to December 2012, targeted reports on the accuracy of triage of ASCUS or LSIL with other HPV DNA assays, or HPV RNA assays and other molecular markers. These searches will be used for new Cochrane reviews as well as for updates of the current review.

SELECTION CRITERIA

Studies eligible for inclusion in the review had to include: women presenting with a cervical cytology result of ASCUS or LSIL, who had undergone both HC2 testing and repeat cytology, or HC2 testing alone, and were subsequently subjected to reference standard verification with colposcopy and colposcopy-directed biopsies for histologic verification.

DATA COLLECTION AND ANALYSIS

The review authors independently extracted data from the selected studies, and obtained additional data from report authors.Two groups of meta-analyses were performed: group I concerned triage of women with ASCUS, group II concerned women with LSIL. The bivariate model (METADAS-macro in SAS) was used to assess the absolute accuracy of the triage tests in both groups as well as the differences in accuracy between the triage tests.

MAIN RESULTS

The pooled sensitivity of HC2 was significantly higher than that of repeat cytology at cut-off ASCUS+ to detect CIN2+ in both triage of ASCUS and LSIL (relative sensitivity of 1.27 (95% CI 1.16 to 1.39; P value < 0.0001) and 1.23 (95% CI 1.06 to 1.4; P value 0.007), respectively. In ASCUS triage, the pooled specificity of the triage methods did not differ significantly from each other (relative specificity: 0.99 (95% CI 0.97 to 1.03; P value 0.98)). However, the specificity of HC2 was substantially, and significantly, lower than that of repeat cytology in the triage of LSIL (relative specificity: 0.66 (95% CI 0.58 to 0.75) P value < 0.0001).

AUTHORS' CONCLUSIONS

HPV-triage with HC2 can be recommended to triage women with ASCUS because it has higher accuracy (significantly higher sensitivity, and similar specificity) than repeat cytology. When triaging women with LSIL, an HC2 test yields a significantly higher sensitivity, but a significantly lower specificity, compared to a repeat cytology. Therefore, practice recommendations for management of women with LSIL should be balanced, taking local circumstances into account.

Ten-year outcomes of a one-stop colposcopy clinic: a unique service for low grade cytology

OBJECTIVE

To determine patient acceptance of treatment, and treatment default rate, at a one-stop clinic, and to establish the concordance of punch and loop histology for high grade cervical intraepithelial neoplasia (CIN) by date of excisional treatment.

STUDY DESIGN

Retrospective review of computerised data and clinic files of 2090 women with low grade cytology undergoing cervical punch biopsies between 2001 and 2011 at the colposcopy clinic, Northern Gynaecological Oncology Centre, Gateshead, UK. Punch biopsies were micro-wave processed and reported within 2h, and women were offered immediate loop biopsy if high grade CIN was confirmed. Data were collected regarding patients' choice for immediate or deferred treatment and default rate. Histological outcomes were compared between those undergoing immediate and deferred loop biopsies.

RESULTS

Of the 360 women (17%) with high grade CIN on punch biopsy, 259 (72%) opted to have immediate loop treatment at the first visit. Of these women, 190 (73%) had high grade CIN on loop histology. Of 97 women (27%) who had deferred loop biopsy after a median of 28 days (range 7-112), 65 (67%) had high grade CIN on loop histology. The default rate at return for treatment appointments was 0% amongst all patients.

CONCLUSION

This one-stop colposcopy clinic reduces defaulting from treatment. It has proven to be a sustainable service and the majority of women, when given the choice, opt for immediate loop treatment at their first visit.

Genotyping of human papillomavirus in triaging of low-grade cervical cytology

OBJECTIVE

The objective of the study was to evaluate whether typing of human papillomavirus (HPV) among women with low-grade cervical cytology can improve the ability to identify women with cervical cancer or cervical intraepithelial neoplasia grade III (CIN III or worse).

STUDY DESIGN

A total of 1595 women with low-grade cervical cytology participating in a randomized implementation trial of HPV triaging using Hybrid Capture II were also HPV genotyped and CIN III or worse predictive values evaluated.

RESULTS

HPV 16 was detected in 57% of cases with CIN III or worse but only among 24% of all tested women. Testing for the 3 HPV types with highest risk (HPV16/31/33) detected 77% of CIN III or worse, with 36% of women testing positive. Positivity for the other high-risk HPV types had a decreased risk for CIN III or worse.

CONCLUSION

Different high-risk HPV types confer different risks for the presence of CIN III or worse, implying that HPV genotyping could be useful for the optimization of triaging strategies.

Which women default from follow-up cervical cytology tests? A cohort study within the TOMBOLA trial

OBJECTIVE

To identify factors associated with default from follow-up cervical cytology tests.

METHODS

A cohort study was conducted involving 2166 women, aged 20-59, with recent low-grade cervical cytology taken within the NHS Cervical Screening Programmes in Scotland and England, and managed by 6-monthly cytology in primary care. For the first (6-month) and second (12-month) surveillance cytology tests separately, women were categorized as 'on-time attendees' (attended ≤6 months of test being due), 'late attendees' (attended greater than 6 months after test was due) or 'non-attendees' (failed to attend). Multivariate odds ratios (ORs) were computed for factors associated with late and non-attendance.

RESULTS

For the first surveillance test, risk of non-attendance was significantly higher in younger women, those without post-secondary education, and non-users of prescribed contraception. Factors significantly associated with late attendance for the first test were the same as for non-attendance, plus current smoking and having children. The most important predictor of non-attendance for the second surveillance test was late attendance for the first test (OR = 9.65; 95% CI, 6.60-16.62). Non-attendance for the second test was also significantly higher among women who were younger, smokers and had negative cytology on the first surveillance test. Late attendance for the second surveillance test was higher in women who were younger, smokers, had children and attended late for the first test.

CONCLUSIONS

Women at highest risk of default from follow-up cytology tend to be young, smoke, lack post-secondary education, and have defaulted from a previous surveillance appointment. Tackling default will require development of targeted strategies to encourage attendance and research to better understand the reasons underpinning default.

Responsiveness of the EQ-5D to HADS-identified anxiety and depression

RATIONALE

The use of generic measures of health-related quality of life enables cost effectiveness comparisons of different health care interventions to be made. Nevertheless, there exists a concern that generic instruments may be insufficiently sensitive to detect the differences or changes in outcome identified by condition-specific instruments. This paper compares the psychometric properties of the EQ-5D generic instrument with a widely used specific measure of distress, the Hospital Anxiety and Depression Scale (HADS).

METHOD

The analysis was based on data obtained from a large sample of women (n = 3119) with low-grade cervical cytological abnormalities detected at routine screening. These women completed EQ-5D and HADS questionnaires at recruitment and at 12 months thereafter. We examined the strength of association between HADS-determined severity of distress and EQ-5D scores at recruitment and between changes in severity and in scores over time.

RESULTS

A higher likelihood of HADS-identified anxiety and/or depression was associated with significantly lower EQ-5D index and visual analogue scores. Over time, the EQ-5D score rose significantly when the likelihood of an individual representing a HADS-defined anxiety and/or depression case decreased.

CONCLUSION

We conclude that the EQ-5D has shown itself to be responsive to differing degrees of HADS-assessed distress, although generalization beyond the UK context requires further investigation.

Risk of invasive cervical cancer in relation to management of abnormal Pap smear results

OBJECTIVE

We sought to evaluate the management of women with abnormal cytology in terms of subsequent risk of invasive cervical cancer.

STUDY DESIGN

The screening histories of all invasive cervical cancer cases diagnosed in Sweden 1999-2001 and of 5 population-based controls per case were reviewed. In all, 159 patients and 258 control subjects aged < 67 years had an abnormal smear result 0.5-6.5 years prior to cancer diagnosis. The cervical cancer risk was estimated in relation to management by calculating odds ratios.

RESULTS

Histologic assessment of low-grade squamous abnormalities strongly reduced the risk compared to repeated cytology (odds ratio, 0.46; 95% confidence interval, 0.24-0.89). Delaying histologic assessment was also associated with a higher risk (odds ratio, 5.65; 95% confidence interval, 1.39-23.05). After high-grade squamous atypia, absence of any cytologic or histologic specimen was a major determinant of cancer risk (odds ratio, 12.52; 95% confidence interval, 1.42-infinitive).

CONCLUSION

For adequate protection against invasive cervical cancer, further assessment with histology must be recommended also for women with low-grade squamous abnormalities.

Cytological surveillance compared with immediate referral for colposcopy in management of women with low grade cervical abnormalities: multicentre randomised controlled trial

OBJECTIVES

To examine the effectiveness of cytological surveillance in primary care compared with immediate referral for colposcopic examination in women with low grade abnormal results on cervical cytology tests.

DESIGN

Multicentre individually randomised controlled trial.

SETTING

NHS cervical screening programmes in Grampian, Tayside, and Nottingham.

PARTICIPANTS

4439 women, aged 20-59, with a cytology result showing borderline nuclear abnormalities or mild dyskaryosis, October 1999-October 2002.

INTERVENTIONS

Cytological screening every six months in primary care (n=2223) or referral for colposcopy and related interventions (n=2216). All women were followed for three years, concluding with an exit appointment at which colposcopic examination was undertaken. Colposcopists assessing outcome at this appointment were blinded to randomisation.

MAIN OUTCOME MEASURES

Primary end point: cumulative incidence of cervical intraepithelial neoplasia grade II or more severe disease. Other end points: cervical intraepithelial neoplasia grade III or worse, clinically significant anxiety and depression, other self reported after effects, and rates of non-attendance. Analysis was by intention to treat; all those randomised were included.

RESULTS

The cumulative incidence of cervical intraepithelial neoplasia grade II or worse was 79 per 1000 person years in the colposcopy arm and 58 per 1000 person years in the cytological surveillance arm (relative risk 1.37, 95% confidence interval 1.19 to 1.57). This difference was less marked for cervical intraepithelial neoplasia grade III or more severe disease, but the incidence was still higher in the colposcopy arm (relative risk 1.26, 1.04 to 1.53). Among women randomised to immediate colposcopy, 79% (74.9% to 82.5%) of cases of cervical intraepithelial neoplasia grade II or worse were diagnosed at the time of the immediate colposcopy, while among women randomised to cytological surveillance, 77% (72.1% to 81.2%) of cases were detected by surveillance cytology and related interventions. Similar proportions of women were anxious or depressed in the two arms. A higher proportion of women in the colposcopy arm reported after effects, and these were of longer duration and more severe. Non-attendance was low in both arms.

CONCLUSION

The more marked difference between the arms in the occurrence of cervical intraepithelial neoplasia grade II or worse than in the occurrence of grade III or worse can probably be accounted for by the spontaneous regression of some cases of grade II neoplasia. Compared with cytological surveillance, a policy of immediate colposcopy detects more cervical intraepithelial neoplasia grade II or worse, and some more grade III or worse, but might lead to overtreatment. Such a policy is associated with a higher rate of reported after effects, which are more severe and of longer duration than those associated with cytological surveillance.

TRIAL REGISTRATION

ISRCTN 34841617.

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.

Correspondence between EQ-5D health state classifications and EQ VAS scores

BACKGROUND

The EQ-5D health-related quality of life instrument comprises a health state classification followed by a health evaluation using a visual analogue scale (VAS). The EQ-5D has been employed frequently in economic evaluations, yet the relationship between the two parts of the instrument remains ill-understood. In this paper, we examine the correspondence between VAS scores and health state classifications for a large sample, and identify variables which contribute to determining the VAS scores independently of the health states as classified.

METHODS

A UK trial of management of low-grade abnormalities detected on screening for cervical pre-cancer (TOMBOLA) provided EQ-5D data for over 3,000 women. Information on distress and multi-dimensional health locus of control had been collected using other instruments. A linear regression model was fitted, with VAS score as the dependent variable. Independent variables comprised EQ-5D health state classifications, distress, locus of control, and socio-demographic characteristics. Equivalent EQ-5D and distress data, collected at twelve months, were available for over 2,000 of the women, enabling us to predict changes in VAS score over time from changes in EQ-5D classification and distress.

RESULTS

In addition to EQ-5D health state classification, VAS score was influenced by the subject's perceived locus of control, and by her age, educational attainment, ethnic origin and smoking behaviour. Although the EQ-5D classification includes a distress dimension, the independent measure of distress was an additional determinant of VAS score. Changes in VAS score over time were explained by changes in both EQ-5D severities and distress. Women allocated to the experimental management arm of the trial reported an increase in VAS score, independently of any changes in health state and distress.

CONCLUSION

In this sample, EQ VAS scores were predictable from the EQ-5D health state classification, although there also existed other group variables which contributed systematically and independently towards determining such scores. These variables comprised psychological disposition, socio-demographic factors such as age and education, clinically-important distress, and the clinical intervention itself.

TRIAL REGISTRATION

ISRCTN34841617.

Cost-effectiveness of active versus conservative colposcopic management of mild dyskaryosis

Management of mild dyskaryosis remains controversial. In this study, we compared the cost-effectiveness of active versus conservative colposcopic management of women presenting with mild dyskaryosis in two different hospital settings. All women presenting in 2001 with a mild dyskaryotic smear and requiring colposcopy were studied in two different clinical settings (70 women at Darent Valley Hospital (DVH) and 327 at St George's Hospital (SGH)). At DVH, treatment is offered should there be any evidence of cervical intraepithelial neoplasia (CIN). On the other hand, a more conservative approach of cytological and colposcopical follow-up is offered to patients with evidence of low-grade disease at SGH. The outcome of both groups of patients was determined in terms of the number of colposcopy visits per patient, the risk of missing disease as a consequence of patients lost to follow-up and hospital costs as well as costs to patient over a four-year period. The majority (70%) of DVH patients had 1-2 colposcopy visits whereas the majority (60%) of SGH patients had 3-7 visits. At SGH 44% of untreated patients were lost to follow-up and an unknown number of those might have had high-grade disease. Active management is more cost-effective compared with conservative management ( pound323 and pound589 as cost per patient effectively treated in the two hospitals respectively). In conclusion, active management of low-grade disease is associated with lower hospital and patient costs compared with the conservative strategy.

Management of minor cervical cytological abnormalities: A systematic review and a meta-analysis of the literature

BACKGROUND

A significant number of women are diagnosed with a low grade cytological abnormality on cervical screening. Many authorities recommend surveillance as spontaneous regression might occur. However, protracted attendance for cytological follow-up decreases with time and might put some women at risk of developing invasive disease. The aim of this review was to assess management options for women with minor cervical disease.

METHODS

An electronic literature search was conducted. All randomised controlled studies comparing immediate colposcopy to cytological surveillance in women with cervical atypia/borderline nuclear changes or low-grade lesions were included. The main outcomes studied were the default rates from the colposcopy clinic and the histological status of biopsies within immediate management protocols compared to biopsies taken on completion of surveillance. Pooled relative risks and 95% confidence intervals were calculated using a random-effect model and inter-study heterogeneity was assessed with Cochrane's Q-test.

RESULTS

Three randomised controlled trials identified from the literature search with different surveillance periods were combined. The analysis revealed that compliance with follow-up declines over time and reaches significance at the end of 24 months of surveillance (RR: 74.10 [10.36, 529.79]). There was a significantly higher incidence of HPV and CIN 1 in those women referred to immediate colposcopy/treatment compared to those at the end of 24 months surveillance period (32% vs 21%) (RR 1.49, 95% CI 1.17-1.90) and (21% vs 8%) (RR 2.58, 95% CI 1.69-3.94), respectively, possibly explained by spontaneous regression of clinically non-important lesions. Finally, there was no significant difference in the incidence of CIN2 or worse at initial colposcopy compared with the observation group (24 months) (RR 1.72, 95% CI 0.85-3.48).

CONCLUSION

Cytological surveillance puts women at risk as many show poor compliance and such women might have occult high grade abnormalities. A general policy should be immediate colposcopy for all women after a single low grade cervical smear.

A long-term study of women with normal colposcopy after referral with low-grade cytological abnormalities

BACKGROUND

About 50,000 women are referred annually to colposcopy in England because of a low-grade smear. About 35% of these women have no colposcopic abnormality but are followed up in the colposcopy clinic because of uncertainty about the risk of significant pathology.

OBJECTIVE

This study determined the 5-year rate of disease when initial colposcopy was normal and smear was non-dyskaryotic.

DESIGN

Retrospective study.

SETTING

Colposcopy clinic of an inner city postgraduate teaching hospital. Population Two thousand one hundred and fifty seven women referred between January 1990 and December 2001 with mild dyskaryosis (Low Grade Squamous Intraepithelial Lesion [LSIL]) or borderline nuclear changes (Abnormal Squamous Changes of Uncertain Significance [ASCUS]).

METHODS

Information was obtained from the colposcopy clinic database and Open-Exeter. Time plots of the disease-free rates were generated using the Kaplan-Meier method, and statistical comparisons were performed using Cox regression.

MAIN OUTCOME MEASURES

Cumulative rates of cytological and histological abnormalities.

RESULTS

High-grade or invasive disease was diagnosed histologically in 12.8% of 805 women referred with borderline nuclear changes and in 35.8% of 1352 referred with mild dyskaryosis. Among 620 women with normal colposcopy and a negative or borderline repeat smear, high-grade disease was found after 5 years of follow up in 1.3% of women originally referred with a borderline smear and in 8.5% referred because of mild dyskaryosis.

CONCLUSION

Women referred to colposcopy with borderline nuclear changes or mild dyskaryosis whose colposcopy findings are normal and whose repeat smear in the clinic is non-dyskaryotic may be discharged for routine 3-yearly screening in the community because the risk of high-grade disease in the next 5 years is small.

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.

Human papillomavirus in cervical screening and vaccination

Recent decades have witnessed a reduction in the incidence of cervical cancer in countries where screening programmes have achieved broad coverage. The recognized importance of high-risk HPV (human papillomavirus) infection in the aetiology of cervical cancer may introduce a role for HPV DNA testing in cervical screening programmes. Positive HPV DNA tests indicate women at risk of cervical cancer with greater sensitivity, but reduced specificity, compared with exfoliative cytology. Combining HPV testing with cytology may be useful in the triage of minor cytological abnormalities into those requiring referral to colposcopy (HPV positive) compared with those who can be safely managed by cytological surveillance (HPV negative). With its high sensitivity and high-negative-predictive value, HPV testing may also be useful for predicting treatment failure, since residual disease is very unlikely in the event of a negative HPV test. Ultimately, prevention is better than cure, and the advent of HPV prophylactic vaccines may obviate the need for population-based cervical screening programmes in the future. A multivalent vaccine administered to adolescents prior to the onset of sexual activity and boosted at regular intervals throughout their sexually active life may provide protection against type-specific HPV infection, malignant precursors and invasive cervical disease. Several large randomized placebo-controlled trials have been conducted with promising results. For those generations of women already exposed to high-risk HPV infection, therapeutic vaccines may offer advantages over conventional treatment, although much work still needs to be done.

Gynaecological oncology: The role of colposcopy in the follow up of women treated for cervical intraepithelial neoplasia

OBJECTIVE

To determine the effect of colposcopy on the sensitivity and specificity of follow-up procedures in the detection of residual or recurrent disease after treatment for cervical intraepithelial neoplasia (CIN).

DESIGN

A retrospective study of information held in a colposcopy database.

SETTING

A teaching hospital colposcopy clinic.

POPULATION

A total of 2244 women treated in Hammersmith Hospital for histologically confirmed CIN between 1 January 1988 and 31 December 2002.

METHODS

Data from the records of women treated with some form of local conservative therapy for CIN1-CIN3 between January 1988 and December 2002 were extracted from the colposcopy database. Women with histological confirmation of post-treatment disease were identified.

MAIN OUTCOME MEASURES

The sensitivity and specificity of cytology alone was compared with the sensitivity and specificity of the combination of colposcopy and cytology.

RESULTS

Colposcopy improved the sensitivity of cytology for the detection of high-grade disease from 64 to 91% but reduced the specificity from 95 to 88%. With a 3% rate of post-treatment high-grade disease, colposcopy detected 8 extra cases per 1000 women but resulted in 88 more false alarms per 1000 women. Among women in whom the treatment margins were involved or uncertain, colposcopy detected 13 extra cases per 1000 women but resulted in 12 fewer false alarms per 1000 women because the prevalence of post-treatment disease was higher.

CONCLUSIONS

Colposcopy does improve the detection rate of post-treatment disease but at a cost of additional false alarms. The benefit of colposcopy will be greater in high-risk groups of women with higher rates of treatment failure.

Outcome of women with index smear showing mild dyskaryosis: effects of age and evidence of HPV infection

OBJECTIVE

Recent national guidelines (NHSCSP Document 20) recommend colposcopy referral after one mildly dyskaryotic smear, compared with the current practice of cytological surveillance and referral if the abnormality persists. The aim of this study was to identify the percentage of women whose first abnormal smear, showing mild dyskaryosis, returned to normal with cytological surveillance. Colposcopy could therefore be avoided in this group. This study also assessed whether age or human papillomavirus (HPV) status affected this outcome and the impact of non-attenders on the reliability of surveillance.

METHODS

This was a retrospective study examining the follow-up of 1484 women whose first abnormal smear showed mild dyskaryosis between 1996 and 1998. The possible outcomes were: persisting abnormality referred to colposcopy, follow-up by cytology alone (negative follow-up), lost to follow-up or moved out of the area. Results were further assessed in terms of age (over or under 35 years) and cytological evidence of HPV effect.

RESULTS

In this study 50.9% of women, presenting with a mildly dyskaryotic smear, returned to normal without colposcopy within the follow-up period of 6-8 years. Age (over/under 35) or cytological evidence of HPV did not significantly affect this figure.

CONCLUSIONS

Immediate colposcopy would overtreat 50% of the study group resulting in 159 extra colposcopies in this unit per year. High-grade abnormalities were twice as prevalent (22% versus 11%) in the younger age group, suggesting that younger rather than older women would benefit from immediate referral.

Prevalence of high-grade CIN following mild dyskaryotic smears in different age groups

OBJECTIVE

The new guidelines of the British Society of Colposcopy and Cervical Pathology suggest that women should be offered colposcopy after only one mildly dyskaryotic smear. This is expected to generate increased workload for the colposcopy clinics, at least in the short term. The main objective of this study was to estimate the incidence of high-grade cervical intraepithelial neoplasia (CIN) in women with mildly dyskaryotic smears and investigate whether there is any variation in different age groups. The rationale was to determine whether we could reduce the burden on colposcopy services by prioritizing the mild dyskaryotic referrals by age, as we hypothesized that high-grade CIN is less frequent in younger women.

METHODS

The study sample included all women who were referred for colposcopy with a cervical smear suggesting mild dyskaryosis (with or without koilocytosis) from April 2000 to March 2003.

RESULTS

We studied 510 women. They were divided into three age groups (<20, 20-25 and >25 years). The overall prevalence of high-grade CIN (CIN II and III) was 28.7%. The positive predictive value of a mildly dyskaryotic smear for high-grade CIN was similar in all groups.

CONCLUSIONS

Our results show that we are not in a position to prioritize our referrals by age group and reduce the initial pressure for colposcopies. We are also concerned that with the implementation of the new guidelines, a significant number of women <25 years will be carrying high-grade CIN for more than 5 years before they are first screened.

A comparison of the human papillomavirus test and Papanicolaou smear as a second screening method for women with minor cytological abnormalities

BACKGROUND

Of the estimated one million Papanicolaou (pap) smears performed annually in Sweden, about 4% show any degree of abnormality. Approximately, 1% of these cases contain moderate or severe atypia (high-grade squamous intraepithelial lesions) and the rest contain low-grade atypia. Recommendations for the management of minor abnormalities vary in various parts of Sweden. Generally, a second Pap smear is obtained 4-6 months after the first one showing low-grade atypia. The aim of this study is to compare the sensitivity of human papilloma virus (HPV)-DNA testing for the detection of cervical intraepithelial neoplasia (CIN) 2-3 with that of a second Pap smear in women, who had low-grade atypia in their first Pap smear.

METHODS

Women with low-grade atypia in the Stockholm area, detected at a population-based cytology screening, were enrolled. A repeat Pap smear, HPV test, and colposcopically directed biopsies were obtained. For the detection of HPV, Hybrid Capture II (HC II) was used.

RESULTS

The HPV-DNA test was positive in 66% of the 177 participating women. The sensitivity of the second Pap smear and HPV-DNA test to detect CIN 2-3 was 61 (95% CI = 45-74) and 82% (95% CI = 67-91), respectively. The positive and negative predictive values of HPV testing were 27 (95% CI = 18-35) and 89% (95% CI = 80-97), respectively.

CONCLUSIONS

In Sweden, a second Pap smear is often obtained for the follow-up of women with low-grade atypia. The results of our study show that compared to the second Pap smear, HPV testing with HC II is a more sensitive method for detecting high-grade lesions.

Outcome after a cervical cytology report of low-grade squamous abnormality in Australia

BACKGROUND

The current study was undertaken to assist with providing an evidence-based approach to the management of women with cervical cytology reports of low-grade squamous abnormality as used in the Australian organized screening program.

METHODS

Using the Pap Test Registers, an audit was performed of the outcome over 24 months of Australian women who received an index cervical cytology report of low-grade squamous abnormality in 1999.

RESULTS

Information was available for 76,709 of the 90,566 women whose first cytology report in 1999 was of a low-grade squamous abnormality. Forty-one cases of histologically confirmed cervical carcinoma were diagnosed during the subsequent 24 months (10 Stage IA, 31 Stage IB or worse). Five of the 10 women who were diagnosed with Stage IA carcinoma during the 24 months of follow-up had an intervening cervical biopsy of high-grade intraepithelial abnormality. The risk of cervical carcinoma diagnosis during the 24 months was 0.05% (95% confidence interval [CI], 0.03-0.07%) for the women with nonspecific minor change index cytology, 0.03% (95% CI, 0.00-0.07%) for the women with human papillomavirus index cytology, and 0.07% (95% CI, 0.03-0.11%) for the women with Grade 1 cervical intraepithelial neoplasia index cytology.

CONCLUSIONS

Cervical carcinoma was a very rare outcome within 2 years of a cytology report of low-grade squamous abnormality in Australia. A simplified terminology for low-grade squamous cervical cytology reports should be considered by Australia, with uniform management for asymptomatic women.

Management of cervical premalignant lesions

Management of cervical preneoplasia starts with an abnormal smear result. The use of the Bethesda system is recommended. The management of patients with low-grade abnormal smear results varies around the world. Patients with atypical squamous cells on cytology are recommended to be subclassified into atypical squamous cells of undetermined significance (ASCUS) and atypical squamous cells where high-grade squamous intra-epithelial lesions (HSIL) cannot be excluded (ASCH) groups. While patients with ASCUS can be followed with cytology or colposcopy, the risk of having cervical intra-epithelial neoplasia (CIN) is higher in patients with ASCH. Such patients, as well as those with low-grade squamous intra-epithelial lesions on cytology, should be referred for colposcopy to ensure that diagnosis and treatment in CIN is detected. Patients with HSIL should be referred promptly for colposcopic assessment. This should, usually at the same clinic visit, be followed by large loop excision of the transformation zone (LLETZ). Although this is effective treatment, around 15% of patients will have persistent/recurrent disease on cytological follow-up. Patients with positive human papillomavirus DNA tests at follow-up seem to have a considerably higher risk of recurrent preneoplasia than those who have negative tests. Patients over 50 years of age have much higher recurrence risks than younger patients. These factors impact on second-line treatment and follow-up schedules. An important benefit of conservative treatment for CIN with LLETZ is retention of fertility. LLETZ is associated with an increased risk of preterm prelabour rupture of membranes and preterm birth, but not with other adverse pregnancy outcome measures. Conservative excisional management of adenocarcinoma in situ by LLETZ or cold knife cone biopsy is not reported to be as effective as that of CIN, with high risk of residual and recurrent disease at follow-up. Conversely, LLETZ may be acceptable treatment for micro-invasive squamous carcinoma if the excision margins are free of disease and there is no evidence of lymphovascular involvement. The ability to detect and treat premalignant lesions on the cervix reversed the natural history of cervical cancer. Methods of conservative treatment that evolved over decades have been proven safe and effective, allowing retention of fertility. Good clinical guidelines have been developed for most clinical scenarios while some uncertainties persist for other scenarios.

Five-year follow-up of women with borderline and mildly dyskaryotic cervical smears

This study investigated the 5-year follow-up status of women with cervical smears showing borderline nuclear changes (BNC) or mild dyskaryosis and the effect of koilocytosis on the outcome. Thirteen per cent of women with cervical smears showing BNC had high-grade cervical intraepithelial neoplasia (CIN). In contrast, 28% of women with cervical smears showing mild dyskaryosis had high-grade CIN. The presence of koilocytosis (24% for borderline smears and 34% for mild dyskaryotic smears) did not appear to influence the risk of developing high-grade CIN. Our results suggest that the simultaneous implementation of the British Society for Clinical Cytology proposed terminology and the colposcopy guidelines from the British Society for Colposcopy and Cervical Pathology could have an impact on colposcopy services.

Cervical screening in England and Wales: an update

PURPOSE OF REVIEW

The National Health Service Cervical Screening Programme (NHSCSP) has played a major role in reducing the mortality from cervical cancer in England and Wales. However, the current system has numerous shortcomings and it is likely that its success has reached a plateau. In light of this, significant changes have recently been made to the programme. These alterations, as well as further potential developments, are considered here.

RECENT FINDINGS

The aim of any change to the programme is to improve its sensitivity and specificity whilst reducing patient morbidity and maintaining cost-effectiveness. Alterations to NHSCSP guidelines include the replacement of the Papanicolau smear with liquid-based cytology, the referral for colposcopy of women with a single dyskaryotic cytology result and the commencement of screening at the later age of 25. These changes appear to be beneficial overall. The role of newer technologies in the programme is being clarified and it is likely that human papillomavirus testing will be incorporated in the near future. Progress is being made in the field of human papillomavirus vaccines, particularly prophylactic, which may go on to have the most profound impact on the incidence of cervical cancer. The disease is now largely a burden of the developing world, where the use of these technologies is considered.

SUMMARY

Changes currently being instituted in the NHSCSP should go some way towards improving the service. The importance of increasing coverage rates, reducing patient waiting times and the associated anxiety must not be overlooked.

Virologic Versus Cytologic Triage of Women With Equivocal Pap Smears: A Meta-analysis of the Accuracy To Detect High-Grade Intraepithelial Neoplasia

BACKGROUND

The appropriate management of women with minor cytologic lesions in their cervix is unclear. We performed a meta-analysis to assess the accuracy of human papillomavirus (HPV) DNA testing as an alternative to repeat cytology in women who had equivocal results on a previous Pap smear.

METHODS

Data were extracted from articles published between 1992 and 2002 that contained results of virologic and cytologic testing followed by colposcopically directed biopsy in women with an index smear showing atypical cells of undetermined significance (ASCUS). Fifteen studies were identified in which HPV triage and the histologic outcome (presence or absence of a cervical intraepithelial neoplasia of grade II or worse [CIN2+]) was documented. Nine, seven, and two studies also documented the accuracy of repeat cytology when the cutoff for abnormal cytology was set at a threshold of ASCUS or worse, low-grade squamous intraepithelial lesion (LSIL) or worse, or high-grade squamous intraepithelial lesion (HSIL) or worse, respectively. Random-effects models were used for pooling of accuracy parameters in case of interstudy heterogeneity. Differences in accuracy were assessed by pooling the ratio of the sensitivity (or specificity) of HPV testing to that of repeat cytology.

RESULTS

The sensitivity and specificity were 84.4% (95% confidence interval [CI] = 77.6% to 91.1%) and 72.9% (95% CI = 62.5% to 83.3%), respectively, for HPV testing overall and 94.8% (95% CI = 92.7% to 96.9%) and 67.3% (95% CI = 58.2% to 76.4%), respectively, for HPV testing in the eight studies that used the Hybrid Capture II assay. Sensitivity and specificity of repeat cytology at a threshold for abnormal cytology of ASCUS or worse was 81.8% (95% CI = 73.5% to 84.3%) and 57.6% (95% CI = 49.5% to 65.7%), respectively. Repeat cytology that used higher cytologic thresholds yielded substantially lower sensitivity but higher specificity than triage with the Hybrid Capture II assay. The ratio of the sensitivity of the Hybrid Capture II assay to that of repeat cytology at a threshold of ASCUS or worse pooled from the four studies that used both triage tests was 1.16 (95% CI = 1.04 to 1.29). The specificity ratio was not statistically different from unity.

CONCLUSION

The published literature indicates that the Hybrid Capture II assay has improved accuracy (higher sensitivity, similar specificity) than the repeat Pap smear using the threshold of ASCUS for an outcome of CIN2+ among women with equivocal cytologic results. The sensitivity of triage at higher cytologic cutoffs is poor.

A randomised controlled trial of cytological surveillance versus patient choice between surveillance and colposcopy in managing mildly abnormal cervical smears

OBJECTIVE

To determine whether choice of colposcopy or six month cytological surveillance would be beneficial to women with mildly abnormal smears when compared with the national policy of six months surveillance in terms of psychological morbidity.

DESIGN

A randomised trial based on the Zelen design.

SETTING

A hospital-based research clinic.

POPULATION

Four hundred and seventy-six women who had had a recurrent borderline or mildly dyskaryotic smear on routine cervical screening in primary care.

METHODS

Women were randomised either to six months cytological surveillance or to make a choice between that or colposcopy and were followed up for 1 year.

MAIN OUTCOME MEASURES

The primary outcome measure was caseness (score >or=4) on the General Health Questionnaire at 12 months follow up. Other measures were the Spielberger State and Trait scores, default rates and cytology/colposcopy outcomes.

RESULTS

There was no significant difference between the arms for General Health Questionnaire (GHQ) scores and Spielberger State and Trait at 12 months. There was a significant reduction in psychometric morbidity between baseline and 12 months in both arms. Overall rates of default from the protocol were the same in both arms, but default that led to uncertain ascertainment of cervical pathology was greater in the no-choice arm.

CONCLUSIONS

This trial indicates that having choice did not impact favourably or harmfully on anxiety or feelings of wellbeing. If a patient is anxious, allowing the patient to choose immediate colposcopy may be preferable because it will improve ascertainment of underlying disease in a group who are more likely to default.

HPV infection and number of lifetime sexual partners are strong predictors for 'natural' regression of CIN 2 and 3

The aim of this paper was to evaluate the factors that predict regression of untreated CIN 2 and 3. A total of 93 patients with colposcopic persistent CIN 2 and 3 lesions after biopsy were followed for 6 months. Human papillomavirus (HPV) types were determined by polymerase chain reaction at enrolment. We analysed the biologic and demographic predictors of natural regression using univariate and multivariate methods. The overall regression rate was 52% (48 out of 93), including 58% (22 out of 38) of CIN 2 and 47% (26 out of 55) of CIN 3 lesions (P=0.31 for difference). Human papillomavirus was detected in 84% (78 out of 93) of patients. In univariate analysis, 80% (12 out of 15) of lesions without HPV regressed compared to 46% (36 out of 78) of lesions with HPV infection (P=0.016). Women without HPV and those who had a resolution of HPV had a four-fold higher chance of regression than those with persistent HPV (relative odds=3.5, 95% CI=1.4-8.6). Women with five or fewer lifetime sexual partners had higher rates of regression than women with more than five partners (P=0.003). In multivariate analysis, HPV status and number of sexual partners remained as significant independent predictors of regression. In conclusion, HPV status and number of lifetime sexual partners were strongly predictive of regression of untreated CIN 2 and 3.

Adjunctive human papillomavirus testing in the 2-year follow-up of women with low-grade cervical cytologic abnormalities: a randomized trial and economic evaluation

CONTEXT

Although human papillomavirus (HPV) testing may aid in managing low-grade abnormality on screening cervical cytology, patient compliance with repeat testing programs requires consideration.

OBJECTIVES

To determine effectiveness and costs of repeated Papanicolaou (Pap) test and oncogenic HPV testing for detecting cervical intraepithelial neoplasia 2 or 3.

DESIGN

We conducted a randomized controlled trial of combined Pap test and cervical HPV testing by Hybrid Capture 1 test compared with Pap test alone; tests were performed every 6 months for up to 2 years. The study end point was colposcopic examination performed on all women at 2 years, or earlier if an HPV test was positive or if a Pap test showed high-grade squamous intraepithelial lesion.

SETTING

Sixty-six community family practices.

PARTICIPANTS

Two hundred fifty-seven women with atypical squamous cells of undetermined significance or low-grade squamous intraepithelial lesion on screening cervical cytology.

MAIN OUTCOME MEASURES

Detection of histologically confirmed cervical intraepithelial neoplasia 2 or 3, fully allocated costs, and loss to follow-up.

RESULTS

Combined Pap test and HPV testing detected 11 (100%) of 11 cases of cervical intraepithelial neoplasia 2/3, whereas Pap test alone detected 7 (63.6%) of these 11 cases (P =.14); corresponding specificities were 39 (46.4%) of 84 and 45 (71.4%) of 63 (P =.005). The cost-effectiveness ratio was Can $4456 per additional case of high-grade cervical intraepithelial neoplasia. Sixty-nine (26.8%) of the 257 women (24.6% combined group vs 29.1% Pap test only group, P =.41) defaulted from testing or from colposcopy when referred with an abnormal result.

CONCLUSIONS

Combined testing was more costly but may detect more cases of cervical intraepithelial neoplasia 2/3 than Pap test alone. However, poor adherence limits usefulness of a management strategy that requires repeated follow-up.

Persistent minor smear abnormalities: is large loop excision of the transformation zone (LLETZ) the solution?

This prospective observational study was carried out to evaluate the efficacy of large loop excision of the transformation zone (LLETZ) as a management strategy for women with four or more smears showing borderline changes or mild dyskaryosis. A total of 102 women with four or more smears showing minor abnormalities and no colposcopic evidence of high-grade disease opted to undergo LLETZ in preference to continued cytological surveillance. Histology of the LLETZ specimens showed 11 cases of CIN2/3, one CGIN, 32 CIN1 and 10 HPV changes. In 97 of the 102 (95%) women, the follow-up cervical smear reverted to negative.

Detection of cervical neoplasia using measurement of Brn-3a in cervical smears with persistent minor abnormality

Measurement of the Brn-3a cellular transcription factor in cervical smears from women referred for colposcopy may improve the detection of underlying cervical neoplasia. In those women referred with persisting borderline or mildly dyskaryotic smears, those who had histologically proven underlying CIN II/III, had statistically significant higher Brn-3a levels than those with a similar smear but histologically shown to have HPV, CIN I, or no cervical abnormality. These results indicate that Brn-3a could play an important role in the near future in improving cervical cancer screening.

Triage by HPV-DNA testing: is it useful in women with persistent minor smear abnormalities?

BACKGROUND

This study was carried out to evaluate the efficacy of HPV-DNA (Human Papilloma Virus) testing as a triage strategy for persistent borderline and mild cytological abnormalities.

METHODS

A prospective cross-sectional study involving 321 women registered between January and December 2001 with two smears showing borderline or mild dyskaryosis, taken 6 months apart. This study was undertaken in a colposcopy unit in a large district general hospital in central London.

RESULTS

Three hundred and twenty-one women referred with persistent borderline and mild dyskaryosis were recruited in this study. HPV-DNA testing was positive in 194 women (60.4%). Histology of colposcopically directed biopsy showed CIN2/3 in 57 women (18%). Fifty-one of these 57 women were detected by HPV-DNA testing (sensitivity for high-grade disease 89.5%). Specificity for high-grade disease was 45.8%. Negative predictive value was 95.3%. Women with a positive HPV-DNA result had a 7.2 times higher risk of having a high-grade cervical cancer precursor lesion.

CONCLUSION

Negative predictive value of HPV-DNA testing for high-grade cervical lesion is very high. Hence, it can be used as a triage strategy for persistent borderline changes and mild dyskaryosis.

Communicating mild and borderline abnormal cervical smear results: how and what are women told?

The way in which women are informed about borderline or mild smear results can have a significant psychological impact. By means of a questionnaire survey of general practices in Nottingham, England, this study audited the means by which abnormal smear results were normally communicated to subjects and analysed the content of these communications. Transmitting abnormal smear results, either by letter or by telephone call, was typically the responsibility of the practice nurse, and communications varied widely in informational content. We conclude that the method and content of communications imparting mild or borderline smear results differs between general practices, even within a small geographical area.

Human papillomavirus testing for triage of women referred because of abnormal smears. a decision analysis considering outcomes and costs

The objective of this article was to evaluate the utility of high-risk human papillomavirus (HR-HPV) testing for triage of women referred for colposcopy because of abnormal smears. We considered women with persistent mild or moderate dyskaryosis and women with severe dyskaryosis who were referred for colposcopy. For both patient groups we evaluated three alternative management policies: (1) conventional management based on histological assessment; (2) HR-HPV-triage with direct treatment without prior histologic assessment for HR-HPV-positive women and conventional management for HR-HPV-negative women; and (3) direct treatment without histologic assessment for all referred women. For each policy the average number of medical procedures, doctor visits, and the costs per referred woman were calculated. Based on a literature review, the results were tested and translated to other patient groups. Per woman with persistent mild or moderate dyskaryosis and compared with conventional policy, HR-HPV-triage will avoid 0.51 colposcopically directed biopsies, but adds 0.05 local treatments of the cervix (i.e., loop excision of the transformation zone) and 0.09 outpatient visits, and will cost $134 US dollars extra. HPV triage is less efficient in women with borderline or mildly dyskaryotic cytology. In women with severe dyskaryosis, direct treatment is more efficient as conventional management or HPV triage. The decision to introduce HPV testing or direct treatment in women with persistent mild or moderate dyskaryosis strongly depends on the relative burden attributed to a colposcopically directed biopsy and an outpatient visit compared to loop excision of the transformation zone treatment of the cervix. For women with severe dyskaryosis, direct treatment should be seriously considered.

Highly active antiretroviral therapy and cervical intraepithelial neoplasia

Highly active antiretroviral therapy (HAART) has improved HIV prognosis, but its effect on cervical intraepithelial neoplasia (CIN), which is associated with HIV, is uncertain. Among 71 HAART-treated women the prevalence of CIN before HAART was 55%. After a median of 10 months after starting HAART the prevalence had increased to 62% (P = 0.20); 13% of patients experienced regression of a CIN lesion, and this was most strongly associated with a greater increase in CD4 cell count. Such studies will provide the basis for guidelines for monitoring CIN in HIV-positive women in the HAART era.

Workup of the abnormal Pap test

Cytologic evaluation of cells obtained from the cervix and vagina was first proposed by Papanicolaou and Traut in the 1940s as a method of detecting cervical cancer and its precursor lesions. Since that time, cervical cytology has proved to be the most efficacious and cost-effective method of cancer screening. By increasing detection of preinvasive and early invasive disease, use of Papanicolaou's (Pap) test has decreased both the incidence and mortality of cervical cancer in areas with well-established screening programs (1). The American Cancer Society has estimated that in the United States, cervical cancer will be diagnosed in 14,900 women and 4500 women will die as a result of this disease during the year 2000. More than 50 million Pap tests are performed annually in the United States, and about 5% of them will be abnormal (2). Consequently, it is incumbent on the practicing primary care physician to be familiar with the clinical significance and natural history of abnormal cervical cytologic diagnoses as well as the available treatment options. This discussion will delineate practical management protocols for the full range of cervical dysplasia commonly encountered in clinical practice.

Molecular detection of human papillomavirus in women with minor-grade cervical cytology abnormalities

BACKGROUND

Human papillomavirus (HPV) has been shown to be the major risk factor for the development of cervical carcinoma, the second most common cancer among women worldwide. Cervical cytology has been the main screening tool for detection of premalignant lesions in last 50 years.

OBJECTIVE

The utility of a molecular assay for detection of HPV in cervical smears was evaluated.

STUDY DESIGN

A total of 466 women with minor-grade cervical cytology abnormality supposed to be produced by HPV were included. Patients were classified into three groups: Patients with reactive changes, patients with cervical intraepithelial neoplasia grade 1 (CIN 1), and patients with cervical intraepithelial neoplasia grade 2 (CIN 2). In all patients, another cervical swab was obtained and tested for the HPV genome using the Digene Hybrid Capture II. This assay is able to distinguish between high-risk and low-risk HPV types.

RESULTS

Based on cytology results, 44 patients showed reactive changes, 250 patients displayed CIN 1, and 172 patients displayed CIN 2. With the molecular assay, HPV was detected in 289/466 (62%) patients. The high-risk HPV type was present in 263 (56.4%) patients and the low-risk type in 26 (5,5%) patients. In 25% of patients with reactive changes, the HPV genome was detected. Corresponding rates for patients with CIN 1 and CIN 2 were 55 and 81%, respectively.

CONCLUSION

Molecular detection of HPV should additionally be used to cytology in patients whose cervical smears display reactive changes, CIN 1, or CIN 2. The employed assay allows identification of patients who are at risk for development of high-grade cervical lesions.