Psychosocial impact of alternative management policies for low-grade cervical abnormalities: results from the TOMBOLA randomised controlled trial

An Artificial Neural Network Prediction Model of Depressive Symptoms among Women with Abnormal Papanicolaou Smear Results before and after Diagnostic Procedures

(1) Background: Cervical screening and additional diagnostic procedures often lead to depression. This research aimed to develop a prediction model for depression in women who received an abnormal Papanicolaou screening test, prior to and following the diagnostic procedures. (2) Methods: The study included women who had a positive Papanicolaou screening test (N = 172) and attended the Clinical Center of Kragujevac in Serbia for additional diagnostic procedures (colposcopy/biopsy/endocervical curettage). Women filled out a sociodemographic survey and the Center for Epidemiologic Studies Depression questionnaire (CES-D scale) before and after diagnostic procedures. A prediction model was built with multilayer perceptron neural networks. (3) Results: A correlation-based filter method of feature selection indicated four variables that correlated with depression both prior to and following the diagnostic procedures-anxiety, depression, worry, and concern about health consequences. In addition, the use of sedatives and a history of both induced and spontaneous abortion correlated with pre-diagnostic depression. Important attributes for predicting post-diagnostic depression were scores for the domains 'Tension/discomfort' and 'Embarrassment' and depression in personal medical history. The accuracy of the pre-diagnostic procedures model was 70.6%, and the area under the receiver operating characteristic curve (AUROC) was 0.668. The model for post-diagnostic depression prediction showed an accuracy of 70.6%, and an AUROC = 0.836. (4) Conclusions: This study helps provide means to predict the occurrence of depression in women with an abnormal Papanicolaou screening result prior to and following diagnostic procedures, which can aid healthcare professionals in successfully providing timely psychological support to those women who are referred to further diagnostics.

Predictors of Anxiety Before and After Diagnostic Procedures in Women with Abnormal Papanicolaou Smear in Cervical Cancer Screening Program

Anxiety is one of the most common causes of withdrawal from follow-up among women with abnormal Papanicolaou screening results. The purpose of this study was to investigate predictors of anxiety in women with abnormal Papanicolaou smear in cervical cancer screening program. A population-based, cross-sectional study concerning the factors related to anxiety was carried out during 2017 in a cohort of women (N = 172) with positive Papanicolaou screening test before and after diagnostic procedures (colposcopy/biopsy/endocervical curettage) at one university Clinical Center in Serbia. Women completed a socio-demographic questionnaire and scale concerning anxiety (Hospital Anxiety and Depression Scale, subscale HADS-Anxiety) immediately before and 2-4 weeks after the diagnostic procedures. Multivariate logistic regression was applied in the data analysis. In our study, 35.2% (n = 52) of women had abnormal anxiety scores before the diagnostic procedures and 40.1% (n = 69) after the diagnostic procedures. Predictors of anxiety before diagnostic procedures were family history of noncervical gynecological cancers, higher level of worry and high burden of depressive symptoms. Significant independent predictors of anxiety after diagnostic procedures in women were rural residence, tension and discomfort during medical procedures, and less satisfaction with information/support. Although there was no significant difference in the prevalence of anxiety before and after diagnostic procedures in women with abnormal Papanicolaou screening results, results of this research will enable doctors to successfully make decisions concerning timely psychological support for women with positive screening test for cervical cancer that is necessary to decrease anxiety in our population.

Psychological Distress in Women With Abnormal Pap Smear Results Attending Cervical Cancer Screening

OBJECTIVE

Women often experience psychological distress upon receipt of an abnormal Pap test result. This study aimed to evaluate psychological distress and its correlates among women who received an abnormal Pap screening test result.

MATERIAL AND METHODS

A cross-sectional study was performed in a cohort of 172 consecutive women who had attended screening for cervical cancer and who received abnormal Pap smear results and underwent additional diagnostic procedures (colposcopy/biopsy/endocervical curettage). The participants filled out a questionnaire on sociodemographic variables and the Cervical Dysplasia Distress Questionnaire. Multivariate linear regression was used for the analysis of the data. For multiple comparisons, the Bonferroni correction was applied to adjust the level of significance.

RESULTS

In women who received an abnormal Pap smear result, the independent correlate of higher psychological distress (by Cervical Dysplasia Distress Questionnaire score) before diagnostic procedures was lower satisfaction with information/support received from other people ( p = .002). Correlates of psychological distress in women older than 40 years with abnormal Pap smear were anxiety ( p = .042) and worry about having cervical cancer, general health and having sex ( p = .044).

CONCLUSIONS

The authors' findings could enable control of factors predictive of psychological distress in women who received a positive Pap smear screening test before undergoing diagnostic procedures, primarily via active provision of targeted information.

A Systematic Review of Population-Based Studies of Chronic Bowel Symptoms in Cancer Survivors following Pelvic Radiotherapy

Pelvic radiotherapy can damage surrounding tissue and organs, causing chronic conditions including bowel symptoms. We systematically identified quantitative, population-based studies of patient-reported bowel symptoms following pelvic radiotherapy to synthesize evidence of symptom type, prevalence, and severity. Medline, CINAHL, EMBASE, and PsychINFO were searched from inception to September 2022. Following independent screening of titles, abstracts, and full-texts, population and study characteristics and symptom findings were extracted, and narrative synthesis was conducted. In total, 45 papers (prostate, n = 39; gynecological, n = 6) reporting 19 datasets were included. Studies were methodologically heterogeneous. Most frequently assessed was bowel function ('score', 26 papers, 'bother', 19 papers). Also assessed was urgency, diarrhea, bleeding, incontinence, abdominal pain, painful hemorrhoids, rectal wetness, constipation, mucous discharge, frequency, and gas. Prevalence ranged from 1% (bleeding) to 59% (anal bleeding for >12 months at any time since start of treatment). In total, 10 papers compared radiotherapy with non-cancer comparators and 24 with non-radiotherapy cancer patient groups. Symptom prevalence/severity was greater/worse in radiotherapy groups and symptoms more common/worse post-radiotherapy than pre-diagnosis/treatment. Symptom prevalence varied between studies and symptoms. This review confirms that many people experience chronic bowel symptoms following pelvic radiotherapy. Greater methodological consistency, and investigation of less-well-studied survivor populations, could better inform the provision of services and support.

Predictors of depressive symptoms before and after diagnostic procedures in women with abnormal Pap smear attending cervical cancer screening programme in Serbia

OBJECTIVES

Receipt of a positive Papanicolaou screening result and subsequent referral for diagnostic tests can cause psychological stress. Still, not enough is known about depression before and after the diagnostic test in these women. The aim of this study was to determine the burden and predictors of depressive symptoms prior to and after diagnostic investigations in women who had received a positive Papanicolaou screening result.

METHODS

This was a cross-sectional study. Study cohort comprised women who received an abnormal Papanicolaou screening result. Women completed the socio-demographic questionnaire and 'The Center for Epidemiologic Studies Depression, CES-D' questionnaire before and after diagnostic tests (colposcopy/biopsy/endocervical curettage) to assess factors related to depression.

RESULTS

No significant difference was noted in the frequency of depressive symptoms (CES-D score ≥ 16) before and after diagnostic investigations, but the mean score on CES-D scale showed a significant difference before and after diagnostic investigations (13.98 ± 9.56 and 12.74 ± 9.15, respectively). A significant predictor of depression before diagnostic investigations was spontaneous abortion, whereas family history of other gynaecological cancers was a predictor of depression after diagnostic investigations.

CONCLUSIONS

Our findings could contribute to improving the rates of cervical cancer screening, by identifying women at risk for depression before and after investigations.

Depression before and after diagnostic procedures among women with abnormal finding of Papanicolaou screening test

Background

Some studies did find significant differences in the level of depression of women while undergoing diagnostic evaluation of an abnormal Papanicolaou screening smear, but findings were not consistent. This study aimed to assess prevalence and correlates of depression in women with abnormal cervical screening results before and after diagnostic procedures.

Methods

A cross‐sectional study was carried out during 2017 in a cohort of women with positive Papanicolaou screening test before and after diagnostic procedures (colposcopy/biopsy/endocervical curettage) at the university Clinical Centre Kragujevac, Serbia. Women completed a questionnaire about demographics, lifestyle, and other factors of interest. Also, questionnaire “Hospital Anxiety and Depression Scale” (HADS) was used immediately before and 2–4 weeks after the diagnostic procedures: a score of ≥8 on HADS‐D and HADS‐A subscales indicated depression and anxiety, respectively. Multivariate logistic regression was applied in the data analysis.

Results

The study comprised 172 women, giving a response rate of 72.3%. The mean age of the participants was 47.8 ± 11.1 years (range 23–65). The frequency of depressive symptoms was significantly higher after diagnostic procedures (48.3%) than before diagnostic procedures (37.2%) (p = 0.038). Before diagnostic procedures, older age (OR = 1.60; 95% CI = 1.09–2.34; p = 0.017), and level of anxiety according to the HADS‐A subscale (OR = 1.61; 95% CI = 1.38–1.88; p < 0.001) were significant independent predictors of depression. After diagnostic procedures, significant independent predictors of depression were urban place of residence (OR = 0.12; 95% CI = 0.03–0.47; p = 0.002) and level of anxiety according to the HADS‐A subscale (OR = 1.85; 95% CI = 1.54–2.21; p < 0.001).

Conclusion

Our study showed that older age, rural residence, and anxiety play a role in shaping the risk of depression among women undergoing additional diagnostic procedures after receiving an abnormal Papanicolaou screening result.

Do different treatment strategies influence women's level of psychosexual distress? Observational cohort study of women with premalignant HPV-associated genital lesions

OBJECTIVE

To examine the impact of different treatment strategies - surgical treatment or watchful waiting- on sexual activity, psychosocial distress, and fear of progression in women with Human Papillomavirus (HPV)-associated premalignant genital lesions.

STUDY DESIGN

Observational cohort study of women diagnosed with HPV-associated premalignant lesions of the cervix, vagina or vulva. Patients were stratified into two groups depending on the severity of their premalignancy: surgical treatment or watchful waiting. Validated patient administered questionnaires, i.e. Fear of Progression questionnaire (FoP-Q), Cervical Dysplasia Distress Questionnaire (CDDQ), and Sexual Activity Questionnaire (SAQ) were completed after clinical evaluation (baseline), at 6- and 12-months follow-ups.

RESULTS

209 women treated with surgery (N = 125) were compared with women who were monitored in regular intervals (N = 82). During an observational period of 12 months there were no significant differences in fear of progression, psychosocial distress, and sexual activity (p > 0.05). The level of concerns and anxiety about the future, and fear of progression were present, mostly at baseline. While there was a small increase of tension from visit to visit in both groups, patients generally were able to cope with their clinical situation quite well.

CONCLUSIONS

Fear of progression, psychosocial distress and sexual activity in women with precancerous HPV- associated premalignant genital lesions seem to be independent from type of treatment. Both treatment strategies may be applied without major psychological sequelae, as long as adequate information is provided.

Treatment of Cervical Dysplasia by Clinicians Who Perform Colposcopy in German-speaking Countries - a Questionnaire-based Study

Introduction In connection with the reorganisation of cervical carcinoma screening, the importance of colposcopy as an integral part of the planned series of clarification testing will greatly increase. Quality standards for performing the colposcopic examination should therefore be defined in detail. A precondition for this is surveying the current standard in clinical practice. The objective of this study was to evaluate the current practice of colposcopy and conisation in Germany by means of a questionnaire aimed at gynaecologists who perform colposcopies in order to document the actual therapeutic standard of treatment of cervical dysplasia. Materials and Methods Gynaecologists were invited via e-mail or during events to participate in a web-based survey. The questionnaire contained 38 questions on management before, during and after the examination as well as questions on the technical implementation of colposcopy and conisation. Results From February 2018 to April 2018, 961 e-mails were sent. A response was received in 197 cases (response rate 20.5%). Responses were received for another 40 questionnaires during events (response rate approx. 80%). After taking the inclusion criteria into account, 160 questionnaires were evaluated. The majority of those surveyed take an average of 2 cervical biopsies (67.3%) and nearly all of those surveyed (94.5%) do not use any local anaesthetic. As a standard method for removing cervical precancerous cells, most of the physicians surveyed perform a loop excision with the electrosurgical loop (91.2%) under colposcopic visualisation (61.2%) under general anaesthesia (92.5%). Postoperative bleeding prophylaxis by means of tamponade is performed only in 27.6% of all cases. Conclusion A differential colposcopy with two colposcopically targeted biopsies and treatment with the electrosurgical loop are the methods most frequently used by clinicians who perform colposcopy in Germany. A uniform procedure should be defined in detail within the scope of directives or guidelines.

Psychosocial morbidity in women with abnormal cervical cytology managed by cytological surveillance or initial colposcopy: longitudinal analysis from the TOMBOLA randomised trial

OBJECTIVE

To compare psychosocial outcomes (follow-up related worries and satisfaction with follow-up related information and support) over 30 months of two alternative management policies for women with low-grade abnormal cervical cytology.

METHODS

Women aged 20-59 years with low-grade cytological abnormalities detected in the National Health Service Cervical Screening Programme were randomised to cytological surveillance or initial colposcopy. A total of 3399 women who completed psychosocial questionnaires at recruitment were invited to complete questionnaires at 12, 18, 24 and 30 months. Linear mixed models were used to investigate differences between arms in the two psychosocial outcomes. Each outcome had a maximum score of 100, and higher scores represented higher psychosocial morbidity.

RESULTS

On average, over 30 months, women randomised to colposcopy scored 2.5 points (95%CI -3.6 to -1.3) lower for follow-up related worries than women randomised to cytological surveillance. Women in the colposcopy arm also scored significantly lower for follow-up related satisfaction with information and support (-2.4; -3.3 to -1.4) over 30 months. For both outcomes, the average difference between arms was greatest at 12th- and 18th-month time points. These differences remained when the analysis was stratified by post-school education.

CONCLUSIONS

Women with low-grade cytology, irrespective of their management, have substantial initial psychosocial morbidity that reduces over time. Implementation of newer screening strategies, which include surveillance, such as primary HPV screening, need to consider the information and support provided to women. © 2016 The Authors. Psycho-Oncology published by John Wiley & Sons Ltd.

A model to evaluate the costs and clinical effectiveness of human papilloma virus screening compared with annual papanicolaou cytology in Germany

OBJECTIVES

We modelled human papilloma virus (HPV) primary screening scenarios compared with Pap cytology to evaluate clinical effectiveness and projected annual costs in Germany.

STUDY DESIGN

A Markov cohort model was built to compare the budget impact of annual Pap cytology with different 5-yearly HPV screening scenarios: (1) a positive HPV test followed by Pap cytology; (2) a positive HPV test followed by p16/Ki-67 dual-stained cytology; (3) a positive HPV test followed by colposcopy if HPV-16/18-positive or p16/Ki-67 dual-stained cytology if positive for other subtypes; (4) co-testing with HPV and Pap. Screening scenarios were based on a 10-year horizon.

RESULTS

All HPV screening scenarios in the model were associated with fewer deaths from missed diagnosis of cervical cancer compared with Pap screening; 10-year totals n=172-344 (1.5-3 per 100,000) versus n=477 (4.1 per 100,000), respectively. Total annual costs were lower with HPV screening than Pap cytology. The projected average annual cost for HPV screening ranged from €117 million to €136 million compared with €177 million for Pap screening, representing annual savings of €41-60 million. The greatest clinical impact was achieved with primary HPV screening (with genotyping) followed by colposcopy for HPV 16/18-positive women or p16/Ki-67 dual-stained cytology for women positive for other HPV subtypes.

CONCLUSION

Screening strategies including primary HPV testing for high-risk subtypes (HPV-16/18) in conjunction with p16/Ki-67 dual-stained cytology can improve the detection of cervical cancer at a lower total annual cost than conventional Pap cytology screening.

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.

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.

Diagnostic colposcopic accuracy by the gynocular and a stationary colposcope

OBJECTIVES

The aim of this study was to evaluate the diagnostic accuracy of sensitivity and specificity of cervical lesions by the low-cost, portable Gynocular colposcope and a stationary colposcope, in women referred for colposcopy with abnormal cervical cytology.

METHODS

A randomized cross-over clinical trial for evaluating the diagnostic accuracy in detecting cervical lesions by the Gynocular and a stationary colposcope. The Swede score systematic colposcopy system was used for evaluation of colposcopic abnormalities. Directed punch biopsy and excisional cone biopsy were used as the "gold-standard" by histologically confirmed high grade cervical lesions CIN2+ (CIN2, CIN3, CIN3+). In total, 123 women referred for colposcopy due to abnormal cervical cytology were recruited at the Department of Obstetrics and Gynecology, Danderyd Hospital, Stockholm, Sweden. The percentage agreement and the kappa statistic were calculated for Swede score by the Gynocular and a stationary colposcope. Swede scores were compared with the results from directed punch biopsy and excisional cone biopsy.

RESULTS

The Gynocular and the stationary colposcope had a high agreement of Swede scores with a Kappa statistic of 0.947, p < .0001. Punch biopsy diagnosed CIN2+ (CIN2, CIN3, and invasive cancer) in 44 (35.7 percent) women while cytology detected CIN2+ in 34 (27.6 percent) women. There were no significant differences of the sensitivity and specificity for different Swede scores by the Gynocular or a stationary colposcope in detecting CIN 2+.

CONCLUSIONS

There were no significant differences in sensitivity or specificity in detecting cervical lesions by the Gynocular or stationary colposcope. The Gynocular is as accurate in diagnosing cervical lesions as a stationary colposcope.