Adverse psychologic consequences of positive cytologic cervical screening

Anxiety in Endometriosis Patients: Implications for Clinical Practice

Introduction

Endometriosis is a chronic disease associated with pain that affects at least 10% of all women of reproductive age. The symptoms of endometriosis have a negative impact on quality of life; they limit the patient physically and psychologically and are the cause of significant anxiety. The aim of our study was to investigate the anxiety levels of women presenting to our specialized endometriosis outpatient clinic at the RWTH Aachen University Hospital. We sought to record their anxiety symptoms and investigate the effect of extensive counseling on anxiety in patients with endometriosis. We hypothesized that detailed counseling and the planning of multimodal endometriosis therapy would reduce anxiety.

Material and Methods

Data from 183 patients with lower abdominal pain or suspected endometriosis were analyzed. Prior to the examination, the patients completed a standardized anamnesis form including the German version of the STAI (State Trait Anxiety Inventory). The diagnosis of endometriosis was made in accordance with the recent ESHRE guideline and was based on anamnesis, gynecological examination, and ultrasound by a specialist senior physician with many years of experience in treating endometriosis.

Results

Prior to the medical examination, we observed a mean STAI-State score of 48.44 ± 11.56 and STAI-Trait score 45.68 ± 11.27. Following medical examination and planning of multimodal therapy, there was a significant decrease in the mean STAI-State score from 48.44 ± 11.56 to 42.43 ± 10.01 (p < 0.0001) and a minimal but significant decrease in the mean STAI-Trait score from 45.68 ± 11.27 to 45.01 ± 11.57 (p < 0.05).

Conclusion

Our study showed that endometriosis is associated with high levels of anxiety. Detailed counseling and the planning of a multimodal therapy led to a significant improvement in anxiety levels.

ASCCP Clinical Consensus: Screening Recommendations for Clear Cell Adenocarcinomas in People Exposed to DES In Utero

OBJECTIVES

The cohort of diethylstilbestrol (DES)-exposed people is aging, and a substantial fraction have already passed the age of 65, when unexposed average-risk people may exit cervical cancer screening provided they have had adequate prior screening. Current guidelines exclude individuals with a history of in utero exposure to DES. This clinical consensus includes a systematic review of relevant studies and provides updated guidance for surveillance of the aging DES-exposed cohort.

METHODS

A literature search was performed to find all relevant DES and clear cell adenocarcinoma (CCA) papers that addressed key clinical questions. Study quality was assessed and recommendations were rated on strength (A-E) and quality of evidence (I-III) using the system described for previous American Society of Colposcopy and Cervical Pathology consensus guidelines.

RESULTS

DES-exposed patients were 40 times more likely (standardized incidence ratio = 40.9; 95% CI, 13.1-126.2) to develop cervical and vaginal CCAs compared with unexposed individuals, with most cases diagnosed in individuals between the ages of 15 and 31. DES exposure in utero significantly increases the risk of CCA compared with nonexposed people, but the absolute risk of CCA is low. While CCA does seem to occur in older exposed patients, cases were rare and calculated incidence rates were extremely low, with the largest in any of the cohorts at 2.86 per million women-years.

CONCLUSIONS

The American Society of Colposcopy and Cervical Pathology recommends people with prenatal exposure to DES receive annual screening for CCA with cytology until the age of 65 and discontinue screening beyond the age of 65 provided they otherwise meet criteria for cessation of screening.

Screening in Multiple Myeloma and Its Precursors: Are We There Yet?

BACKGROUND

Multiple myeloma (MM) is a hematological malignancy that develops over years from the asymptomatic precursors, monoclonal gammopathy of undetermined significance, and smoldering multiple myeloma. Recent evidence shows that by initiating treatment at an asymptomatic stage, outcomes in MM can be significantly improved. However, a vast majority of MM patients are diagnosed after the development of symptomatic end-organ damage and cannot reap the benefits of early treatment. The precursors of MM are easily detected by serum protein electrophoresis and free light chain assay of the serum, raising the question of whether population-based screening could detect MM at an asymptomatic stage and significantly expand the availability of early treatment in MM. Screening is a hallmark of care in many malignancies, and there are accepted criteria for when screening is appropriate.

CONTENT

Here we review the available relevant evidence for the introduction of screening and discuss whether screening for MM and its precursors fulfills these criteria. We also highlight gaps in our current knowledge, most notably a lack of data on the benefits and harms of screening and the lack of a defined target population. There are ongoing studies that may fill these critical gaps in the literature, but their results are still pending.

SUMMARY

Screening could lead to a paradigm shift in the care of patients with MM, but critical scientific questions need to be answered before screening of healthy individuals can be recommended. In short, we should not screen for MM and its precursors-yet.

[Psychological impact of the announcement of an abnormal cervical smear: How to improve patient experience and information? COLANX: a multicenter study in Seine-Maritime]

INTRODUCTION

When an anomaly in the screening by cervical smear or by the HPV-HR test is detected, the women are called for a colposcopy. Waiting for colposcopy is often an anxiety-provoking situation for women, probably linked to a widespread ignorance of the value of screening and the pathophysiology of HPV infection.

METHODS

The COLANX was a multicentric study, in Seine-Maritime, conducted with 8 colposcopist practitioners. Self-questionnaires were distributed to volunteer women, summoned for a first abnormal smear result, at the exit of colposcopy and filled out immediately on site. This questionnaire evaluated: the psychological impact of the announcement of the abnormal cervico-uterine smear, its impact on the sexual quality of life, the epidemiological characteristics of the population studied, the modalities of the announcement made of the abnormal result, the satisfaction of the women and their desire for additional information. 131 questionnaires were included, from June 1, 2020 to January 18, 2021.

RESULTS

61.5% of responding women presented proven psychological distress, as evidenced by a GHQ-12 score ≥ 2. The state of psychological distress was significantly different depending on the time left by the practitioner between the announcement of the abnormal cytology result and the colposcopy appointment. The GHQ-12 score was significantly different according to the initial classification of the cervico-uterine smear, high in case of suspicion of high-grade lesions in particular. 36.3% of patients had a significant deterioration in their sexual quality of life, demonstrated by an ASEX score ≥ 18. The women were statistically more satisfied when the announcement of their abnormal screening result had been made by telephone or during a consultation, rather than by mail, but no significant difference was found on the presence or absence of distress psychological according to this mode of announcement. 52.3% of the women in this study expressed a request for additional information support, preferably written support (for 89.4% of these women), to be delivered when the abnormal screening was announced (for 76, 5% of these women).

DISCUSSION

The main results of the COLANX study are consistent with those of the literature, in particular concerning the negative psychological impact in the announcement of an abnormal smear result.

CONCLUSION

The new methods of organized screening will increase the use of colposcopy for many women. There is a significant impact on their psyche and their intimate life. The issuance of additional information during this announcement would probably reduce this anxiety.

Early Mini-Invasive Treatment of Persistent Cervical Dysplasia: Clinical Outcome and Psycho-Relational Impact

Introduction

After the diagnosis of L-SIL, 77. 3% had a persistent infection and anomalous Pap Test results. Many of these patients had highlighted psychological consequences such as anxiety, hypochondria, fear of cancer, and sexual problems. Several studies suggested that the clearance of HR-HPV infection could be accelerated by cervical excisional procedures, especially in L-SIL. In consideration of the psychological implications for HPV infection and related dysplasia in patients with CIN1 at PAP-smear and HR-HPV positivity at least for 6 months, we decided to plan a prospective study where we tried to anticipate excisional cervical using a minimally invasive treatment: thin loop electrosurgical excision procedure (t-LEEP). This study aims to analyze the clearance of HR-HPV after 6 and 12 months, clinical outcomes related to t-LEEP, and the psycho-relational impact at 12 months after t-LEEP.

Materials and Methods

We enrolled patients with the diagnosis of L-SIL at PAP-smear and HR-HPV positivity with a persistent CIN 1 (at least for 6 months), confirmed by cervical biopsy. All enrolled patients underwent t-LEEP. We followed prospectively and performed for all patients the HPV DNA test at 6 (T1) and 12 months (T2) and STAI-Y and FSFI scores at T0 and T2.

Results

We prospectively enrolled 158 patients, 22 are excluded for the established criteria. Patients with HR-HPV and CIN 1 lesions treated with t-LEEP had an overall clearance of 83.8% at T2. In subgroups analysis at T2, we had a regression: in smoker 71.8%, in contraceptive users 69.5%, in patients aged &lt;25 years 100%, aged 25–30 years 85%, aged 30–35 years 94.4%, aged 35–40 years 92%, and aged ≥40 years 89.1%, in HPV-16 96.4%, in HPV-53 89.5%, in HPV-18 87.5%, in HPV-31 86.6%, and in coinfected 3.5%. STAI-Y and FSFI after t-LEEP (T2) were statistically significant, reducing anxiety status and improving sexual function.

Conclusion

Based on these results, the use of t-LEEP in patients with persistent CIN 1 and HPV-HR at least for 6 months could be useful for accelerating HPV-HR clearance, in particular, for a subpopulation patient with an increased risk of progression and/or patients with psychological and sexual consequences of carrying an HR-HPV infection.

Anxiety in women referred for colposcopy: a prospective observational study

Purpose

To evaluate the occurrence of anxiety in women attending a colposcopic examination within the new cervical cancer screening in Germany.

Methods

One hundred and fifty-six patients were asked to fill out Spielbergers STAI inventory form prior to their colposcopic examination. For the statistical analysis, a two by two between-group design was applied including the following group factors: the repeat factors included patients, who presented to our centre of dysplasia for the first time (new) and patients who have had an examination in our centre before (repeat). Further, the factor diagnosis included two groups: first, patients with cervical dysplasia and second, patients with vulva diseases.

Results

The analysis of the STAI results showed that patients presenting with cervical dysplasia for the first time had the highest levels of anxiety, directly followed by new patients in the vulva group. The ANOVA revealed a main effect of the repeat factor, F(1,140) = 7.53, p = 0.007. There was no significant effect of diagnosis.

Conclusion

Regardless of the diagnosis, patients being transferred for a colposcopy within the cervical cancer screening program for the first time have very high anxiety levels. The prospect of a potentially painful examination seems to be a key factor. Only a scientific evaluation of the new cervical cancer screening will be able to show if the rising numbers of colposcopic examinations is really worth the risk of exposing so many more women to the emotional distress of a colposcopy.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00404-021-06337-8.

An online survey on emotions, impact on everyday life, and educational needs of women with HPV positivity or abnormal Pap smear result

This study aimed to evaluate the emotional path, impact on everyday life, and adequacy of patient education throughout the diagnostic and therapeutic journey of women who received a positive human papillomavirus (HPV) test or Pap smear result.An online survey was designed to determine the demographic characteristics, dominant feelings throughout the diagnostic and therapeutic procedures, major lifestyle changes, impact on social life, and perceived adequacy of patient information in Italian women with a positive HPV test or abnormal cervical cytology result. In this study, the phases of the "patient's journey" included the initial test, waiting for colposcopy or biopsy, waiting for surgery, and follow-up.Anxiety, worry, and fear were the most frequently cited emotions during the initial tests and intervals between procedures. Anxiety and fear gradually decreased during the journey until surgery, and higher levels of optimism were observed postsurgery. The most frequently reported lifestyle changes were attempts to boost the immune system, increased precautions in sexual practices, and dietary changes. Social life is affected by changes in sexual and intimate relationships with partners. Women reported receiving insufficient patient education on the diagnosis and its implications, progression, management, personal care, and resolution.Significant attention should be given to the psychosocial aspects of the entire patient journey after receiving a positive HPV test or an abnormal Pap smear result. It is essential to establish a good rapport between patients and healthcare professionals, and to educate women regarding the condition by minimizing the gap between the perceived and desired adequacy of information.

Alleviating psychological distress associated with a positive cervical cancer screening result: a randomized control trial

BACKGROUND

The method of communicating a positive cancer screening result should seek to alleviate psychological distress associated with a positive result. We evaluated whether the provision of information through a leaflet would help reduce psychological distress in a randomized controlled trial.

METHODS

The participants were women aged 20-69 years who were about to undergo cervical cancer screening at health centers. Before the screening, they received hypothetical screening results, with a leaflet (intervention group, n = 493) or without it (control group, n = 479), randomly. Their psychological distress and intention to undergo further examination were then compared between the intervention and control groups.

RESULTS

After the intervention (providing a leaflet with hypothetical screening results), psychological distress appeared to be higher in the control group than in the intervention group among those who received a hypothetical positive screening result (odds ratio: 2.57, 95% confidence interval: 1.87-3.54), while 95% and 97% of those in the intervention and control groups, respectively, reported that they would undergo further examination.

CONCLUSIONS

Information provision might help reduce psychological distress but not hinder further examination among women who screen positive for cervical cancer.

TRIAL REGISTRATION

UMIN Clinical Trials Registry UMIN000029894. Date of Registration: November 2017.

Predictors of timely diagnostic follow-up after an abnormal Pap test among Hispanic women seeking care in El Paso, Texas

BACKGROUND

Diagnostic follow-up of women with an abnormal Pap test is necessary to resolve the risk developing cervical cancer. The purpose of this study is to describe patient characteristics associated with timely receipt of a diagnostic colposcopy after an abnormal Pap test among Hispanic women in El Paso, a Texas-Mexico border city.

METHODS

We conducted a retrospective chart review of Hispanic patients seen at an academic colposcopy clinic following an abnormal Pap test. An optimal diagnostic interval to colposcopy was based on a National Breast and Cervical Cancer Early Detection Program (NBCCEDP) quality indicator and was defined as receipt of colposcopy within 90 days or less from the date of an abnormal Pap test. Risk ratios (RR) were calculated by building a generalized linear model fit using a Poisson distribution, log link, and robust variance.

RESULTS

Overall, 177 of the 270 women (65.6%) received follow-up within an optimal diagnostic interval. After adjusting for other variables in the model, women who were 30 years of age or older were 32% more likely to have an optimal interval than younger women (adjusted RR = 1.32, P < 0.01). High school graduates were less likely than more educated women to have an optimal interval (adjusted RR = 0.68, P < 0.01). Participation in the NBCCEDP was not associated with receipt of follow-up within an optimal diagnostic interval.

CONCLUSIONS

Compared with women with greater educational attainment, high school graduates were less likely to receive follow-up within an optimal diagnostic interval, as were younger (≤ 30 years) women compared with older women. Participation in the NBCCEDP was not associated with receipt of care within an optimal diagnostic interval.

Women's experiences after abnormal Pap smear results: a qualitative study

Background: Abnormal Pap smear result means there have been cell changes on the cervix but are not cancer. Women with abnormal test result may be affected from this situation. What do women with abnormal Pap smear results experience from a biopsychosocial perspective?Objective: This study aimed to explore the experiences of women with abnormal Pap smear results according to the biopsychosocial model.Methods: This phenomenological study's data were collected in interviews with 12 women who had abnormal Pap smear test results. Data collection tool consists of two parts that are an "Women's Information Form (WIF)" identifying women and semi-structured "Interview Form". Interviews were done face-to-face by using in-depth interviews technique. Semi-structured interview was recorded in audio recording device. Thematic approach was used to assess the data.Results: The average age of the women was 42.5 ± 3.64, their age at first sexual intercourse was 23.0 ± 2.8 years and all of them were legally married. Five main themes were determined, which were grouped under the Biopsychosocial Model Domains. The Biological Domain themes were Perception of Health and Disease, and Cervical Cancer Risk Factors; the Psychological Domain themes were Positive Feelings and Negative Feelings; the Social Domain theme was Continuing Social Life.Conclusions: It was concluded that the cultural beliefs, perceptions, emotions and practices of women with abnormal Pap smear results should be considered in the diagnostic and treatment processes. These characteristics of women's experience are also important to consider when developing strategies to address barriers to effective cervical screening, diagnosis and treatment.

Medroxyprogesterone Acetate Prevention of Cervical Cancer through Progesterone Receptor in a Human Papillomavirus Transgenic Mouse Model

Cervical dysplastic lesions called cervical intraepithelial neoplasias (CINs) need be treated to prevent cervical cancer. Currently available surgical procedures are effective, but the development of noninvasive treatment is warranted. In human papillomavirus transgenic mice engineered to express human papillomavirus type 16 E6 and E7, short-term treatment with 17β-estradiol induces CINs that progress to cervical cancer if the treatment is continued. In the present study, this mouse model was used to determine whether medroxyprogesterone acetate (MPA), a progestin drug, is chemopreventive. Human papillomavirus transgenic mice bearing CIN lesions were treated with MPA plus 17β-estradiol. Unlike control mice treated with 17β-estradiol alone, cervical cancer was absent in the MPA-treated mice. This observation suggests that MPA prevented CIN from progressing to invasive cancer. MPA was associated with inhibited cell proliferation and the promotion of apoptosis in CIN lesions. Confirming the role of the progesterone receptor, the preventive effect of MPA was absent in human papillomavirus transgenic mice in which the expression of progesterone receptor was genetically ablated. These results suggest that MPA is efficient in treating progesterone receptor–positive CIN lesions. These findings provide the basis for a biomarker-driven clinical trial of the secondary prevention of cervical cancer.

Doctor and patient awareness of treatment options for cervical intraepithelial neoplasia 1 (CIN 1): a survey questionnaire approach

The purpose of this study was to investigate doctors' and patients' perceptions of cervical intraepithelial neoplasia 1 (CIN 1) and its treatment methods. A survey questionnaire was offered to obstetrics and gynaecology doctors and patients with CIN 1 in 2017. Only 43% of patients knew of this disease. Regarding perceptions of its aetiology, 64% of the patients perceived human papillomavirus infection to be the main cause of CIN 1. Patients' most preferred treatments were medication (20%), followed by alternative treatment (14%). Among doctors, regular follow-up was the most preferred method for managing CIN 1. The survey showed that current treatment modalities for CIN 1 were satisfactory to only half of doctors (50%) and patients (53%). Overall, 70% of doctors responded that new drug development for CIN 1 is needed. Although, CIN 1 is a low-grade lesion, doctors and patients expressed the desire for new therapeutic agents to manage it.IMPACT STATEMENTWhat is already known on this subject? In general, treatment is not recommended for CIN 1 because lesions are considered indicative of transient HPV infection and spontaneously regress in most patients.What do the results of this study add? Regular follow-up for CIN 1 were satisfactory to only half of doctors and patients. Thirty-six percent of patients wanted active treatment instead of regular follow-up. In addition, 70% of doctors responded that new drug development for CIN 1 is needed.What are the implications of these findings for clinical practice and/or further research? Our results support the need for therapeutic agents for CIN 1.

Short-term clinical and immunologic effects of poly-gamma-glutamic acid (γ-PGA) in women with cervical intraepithelial neoplasia 1 (CIN 1): A multicenter, randomized, double blind, phase II trial

OBJECTIVE

The aim of this study was to investigate the short-term efficacy and safety of Poly-gamma-glutamic acid (γ-PGA) and the immunologic changes in patients with CIN 1.

METHODS

Participants were randomly assigned to one of two groups and orally treated with placebo or 1,500 mg of γ-PGA for 4 weeks. The primary endpoint of the study was histologic regression rate of CIN 1 at 12 weeks between γ-PGA and control groups. The secondary endpoints were HPV clearance and change in immune responses.

RESULT

From April 2013 to December 2015, 195 patients participated in the study. In the intention-to-treat analysis, 42 (42.4%) of the women who received γ-PGA experienced histologic remission versus 26 (27.1%) in the control group, with a statistically significant difference (p = 0.018). In the γ-PGA group, HPV clearance was found in 37 (43.5%) of 85 patients infected with high-risk HPV, showing a significant difference compared to the control group, in which 20 (26.7%) of 75 patients exhibited HPV clearance (p = 0.026). However, there was no significant difference between the two groups in the change of NK cell activity, major histocompatibility complex (MHC) class II CD8 count, and CD56 count.

CONCLUSION

γ-PGA showed a short-term therapeutic effect on CIN 1 and high-risk HPV infection. It is a non-invasive, promising oral medication for women with these conditions.

TRIAL REGISTRATION

Clinical Trials NCT01826045.

Evaluation of Sexual Life and Marital Satisfaction in Patients with Anogenital Wart

Anogenital wart (AGW) resulting from human papilloma virus (HPV) is one of the most common sexually transmitted diseases worldwide. Herein, we aimed to evaluate the effects of AGW on patients'marital satisfaction and sexual function. This cross-sectional study was consisted of 74 consecutive patients including 37 patients with AGW and 37 healthy controls. ENRICH Marital Satisfaction Scale and Arizona Sexual Experience Scale were completed and analyzed for all patients. ENRICH scale items were not significantly different between the two groups. Sexual function was found to be lower in female than male patients (P<.001). According to our findings marital satisfaction was not affected by AGW. However, a history of previous treatment for HPV decreased the marital satisfaction. In addition, AGW had more adverse effects on females' sexual function compared to males. Our findings suggest that the psychiatric treatments should be considered when managing an AGW patient.

Needs for Professional Education to Optimize Cervical Cancer Screenings in Low-Income Countries: a Case Study from Tanzania

Cervical cancer is a significant health problem in many developing countries. Due to limited treatment facilities for cancer in Tanzania, a screening referral program was developed between two urban clinics and Ocean Road Cancer Institute (ORCI), the only cancer treatment center in Tanzania. This study aimed to evaluate the effectiveness of the program and to identify opportunities for professional education. The study included 139 patients who were referred to ORCI from the screening clinics of Magomeni and Temeke between January 2015 and May 2016. Abstracted data from the medical records included patient age, screening results, and treatment. Eight nurses performing screening at the three locations were interviewed about their screening experience. Over half of the referrals (51.9%) were false positives. False positive diagnosis was more common among younger patients (35.68 ± 8.6 years) (p < 0.001) and those referred from Magomeni (59.8%) (p < 0.01) than referrals of older patients (42.46 ± 11.1 years) or those from Temeke (33.3%). Interviews of nurses showed differences among clinics, including resources, experience, and documentation of screening results. The high false positive rates and the variation of accuracy of screening between the two clinics showed a need for professional education of nurses and improvement in the health systems. Continuous education of nurses may increase the effectiveness of cervical screening. Health system enhancement of screening facilities such as provision of Lugol's iodine, more space for screening, and consistency and completion of screening records are needed to increase the accuracy of cervical screening and referrals in Tanzania and other similar low-income countries.

False-positive screening events and worry influence decisions about surgery among high-risk women

OBJECTIVE

Studies of cancer screening have found that false positive screening events (FPSE) can affect worry about cancer risk and screening program use, we sought to further explore this.

METHOD

In a study of 1,100 women at high risk for ovarian cancer who participated in a previously published randomized controlled trial (RCT), we sought to explore whether worry might also influence the use of risk-reducing surgical procedures by women. Participants included 234 women with BRCA1/2 mutations and 866 women with high-risk pedigrees. We followed the women for up to 6 years.

RESULTS

Worry predicted risk reducing prophylactic bilateral salpingo-oophorectomy (pBSO) for both mutation carriers (HR = 1.74; p = .02), and women with high-risk pedigree (HR = 3.41; p < .001). FPSE also predicted subsequent pBSO among women with a high-risk pedigree (HR 2.31; p < .01). While screening may reduce worry among those who never receive a positive result, FPSE increase worry at least temporarily. Worry about ovarian cancer risk predicted use of preventative pBSO among high-risk women including those with BRCA1/2 mutations enrolled in an ovarian cancer-screening program. FPSE also predicted risk-reducing ovarian surgery among high-risk women without a known mutation at the time of screening program enrollment.

CONCLUSIONS

Physicians who offer screening should know that false positive results may increase use of pBSO, how this should effect clinical practice is unclear. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

What benefits and harms are important for a decision about cervical screening? A study of the perspective of different subgroups of women

Background: In cervical screening programs, women typically receive information leaflets to support their decision about participation. However, these leaflets are often based on what experts consider important benefits and harms of screening and not what women themselves consider important to know. Objective: To identify which benefits and harms women consider important for making a decision about cervical screening. Design: Cross-sectional study. Setting and participants: Women from the Dutch target group of cervical screening (N=248; 30-60 years), recruited through an online access panel. Main variables studied: Perceived importance of different benefits and harms of cervical screening, assessed through two rating items ("How important is the information about [this harm/benefit] for your decision?" and "For me it is a [benefit/harm] that participating in the screening program leads to [the benefit/harm]"), and one ranking item ("Rank the information according to their importance for your own choice"). Results: Women overall considered the benefits of cervical screening more important than the harms or disadvantages. The most important harm according to women was the chance of false positive results (M=4.88; SD=1.75). Differences between those with lower and higher numeracy/health literacy were found regarding several aspects, e.g. for the chance of false positive results, the chance of false negative results, the chance of overtreatment. Discussion and conclusion: The results suggest that leaflets could include more explicit information about false positive results.

Consequences of screening in cervical cancer: development and dimensionality of a questionnaire

Background

Cervical cancer screening will inevitably lead to unintentional harmful effects e.g. detection of indolent pathological conditions defined as overdetection or overdiagnosis. Overdiagnosis often leads to overutilisation, overtreatment, labelling and thereby negative psychosocial consequences. There is a lack of adequate psychosocial measures when it comes to measurement of the harms of medical screening. However, the Consequences of Screening questionnaire (COS) has been found relevant and comprehensive with adequate psychometric properties in breast and lung cancer screening. Therefore, the aim of the present study was to extend the Consequences of Screening Questionnaire for use in cervical cancer screening by testing for content coverage, dimensionality, and reliability.

Methods

In interviews, the suitability, content coverage, and relevance of the COS were tested on participants in cervical screening. The results were thematically analysed to identify the key consequences of abnormal screening results. Item Response Theory and Classical Test Theory were used to analyse data. Dimensionality, invariance, and reliability were established by item analysis, examining the fit between item responses and Rasch models.

Results

All COS items were found relevant by the interviewees and the ten COS constructs were confirmed each to be unidimensional in the Rasch models. Ten new themes specifically relevant for participants having abnormal cervical screening result were extracted from the interviews: ‘Uncertainty about the screening result’, ‘Uncertainty about future pregnancy’, ‘Change in body perception’, ‘Change in perception of own age’, ‘Guilt’, ‘Fear and powerlessness’, ‘Negative experiences from the pelvic examination’, ‘Negative experiences from the examination’, ‘Emotional reactions’ and ‘Sexuality’ Altogether, 50 new items were generated: 10 were single items. Most of the remaining 40 items were confirmed to fit Rasch models measuring ten different constructs. However, the two items in the scale ‘Change in perception of own age’ both possessed differential item functioning in relation to time, which can bias longitudinal repeated measurement.

Conclusions

The reliability and the dimensionality of a condition-specific measure with high content validity for women having an abnormal cervical cancer screening results have been demonstrated. This new questionnaire called Consequences Of Screening in Cervical Cancer (COS-CC) covers in two parts the psychosocial experience in cervical cancer screening.

Impact of a cervical dysplasia and its treatment on quality of life and sexual function

PURPOSE

In this case-control study, the impact on quality of life and sexual function in women with cervical dysplasia and conization will be evaluated, in order to address coping with such a premalignant lesion and to improve strategies for salutogenesis.

METHODS

This multicenter case-control study evaluates women at special dysplasia outpatient clinic (T1) as well as 3 (T2) and 6 (T3) months after the diagnosis of a dysplasia. The women were subgrouped upon dysplasia only (S2) or dysplasia with conization (S1). Sexual function as well as cervix-related and general quality of life was assessed using validated instruments (FSFI-d, EORTC-QLQ-CX24, SF-36).

RESULTS

Women with dysplasia had a lower sexual functioning than controls (FSFI: S1: 23.8 ± 9.7 (p < 0.003); S2: 25.3 ± 7.5 (p < 0.03); K: 29.1 ± 4.5) as well as a lower physical component score (SF-36: S1: 51.3 ± 8.6 (p < 0.02); S2: 51.7 ± 7.8 (p < 0.05); K: 54.2 ± 6.6) and had a significantly reduced body image (EORTC-QLQ-CX24: S1: 75.7 (p < 0.001); S2: 76.5 (p < 0.001), K:89.2). Sexual functioning was not affected by conization in the observational period over 6 months; however, sexual worry was impacted. Over temporal progression women who underwent conization worried more. Regression analysis revealed a cervical dysplasia to impact sexual function.

CONCLUSION

Data suggest that women with the diagnosis of a cervical dysplasia are impaired in their sexual function as well as general and cervix-related quality of life, mostly independent of conization or further observation. To improve salutogenesis in the long run, the communication on dysplasia and its treatment strategy at the beginning, as well as part of aftercare, or psychosomatic intervention, might be treatment options for women at risk.

The effect of ovarian cancer screening on sexual activity and functioning: results from the UK collaborative trial of ovarian cancer screening RCT

Background:

To examine the impact of multimodal (MMS) and ultrasound (USS) screening on the sexual activity and functioning of 22 966 women in the UK Collaborative Trial of Ovarian Cancer Screening (UKCTOCS) RCT.

Methods:

Fallowfield's Sexual Activity Questionnaire (FSAQ) was completed prior to randomisation, then annually in a random sample (RS) of women from MMS, USS and control groups. Any women in the study who required repeat screening due to unsatisfactory results formed an Events Sample (ES); they completed questionnaires following an event and annually thereafter.

Results:

Over time in the RS (n=1339) there was no difference between the MMS and USS groups in sexual activity compared with controls. In the ES there were significant differences between the USS group (n=10 156) and the MMS group (n=12 810). The USS group had lower pleasure scores (mean difference=−0.14, P=0.046). For both groups women who had ⩾2 repeat screens, showed a decrease in mean pleasure scores compared with their annual scores (mean difference=−0.16, P=0.005). Similarly mean pleasure scores decreased following more intensive screens compared with annual screening (mean difference=−0.09, P=0.046).

Conclusions:

Ovarian cancer screening did not affect sexual activity and functioning unless a woman had abnormal results and underwent repeated or higher level screening.

A comparison of liquid-based cytology with conventional Papanicolaou smears in cervical dysplasia diagnosis

Background:

Due to the high number of women affected by cervical cancer and the importance of an early diagnosis, combined with the frequent incidence of false-negative Papanicolaou (Pap) smear screening results for this disease, several studies have been conducted in recent years in order to find better tests. Liquid-based cytology (LBC) tests, including the liquid-based thin layer method, have demonstrated the highest potential for reducing false-negative cases and improved sample quality. This study aimed to compare the strength of the Pap smear test with fluid cytology and conventional tests in detecting cervical dysplasia.

Materials and Methods:

This descriptive-analytic study was conducted on 366 women who attended private laboratories for a Pap smear. The Pap smear sampling was conducted simultaneously using two methods: conventional Pap (CP) smear and LBC), from the cervix.

Results:

The mean age of the participants was 32 ± 8.8 years. Diagnostic results of endocervical cells, epithelial cells, vaginitis cells, and metaplastia were consistent with both conventional and liquid cytology smears, and the kappa coefficient was determined to be significant (P < 0.001). In total, 40.5% of diagnostic cases indicated bacterial inflammation 80.3% of the diagnoses in both methods were P1 and 3.9% of cases diagnosed were P2, the overall diagnostic consistency was 83.9% between the two sampling methods. The inflammation diagnosis was 40.5% and this was consistent in both methods of LBC and CP. There was one case of a false-negative diagnosis in the LBC method and 14 cases in the CP method.

Conclusion:

Results showed that the LBC may improve the sample's quality and reduce the number of unsatisfactory cases more than with the CP method.

The use of mobile technology in waiting rooms to leverage women's empowerment: A conceptual context

This article focuses on a conceptual framework that can be applied to the use of mobile technology in the waiting room with the goal of empowering women recently diagnosed with abnormal Pap test results. It further describes trends which indicate a need for improved and timely information dissemination. Genecology practice outpatients report a predominant feeling of worry on receipt of abnormal medical test results, along with a clearly expressed wish for additional information. This research suggests that there is room for improvement in existing processes through use of mobile technology with carefully vetted materials which indicate a doctor is interested in the patient's well-being.

Public awareness of human papillomavirus

Objectives

The main objective of this study was to review the evidence relating to the level of awareness of human papillomavirus (HPV) in the general population and the implications for the potential introduction of HPV vaccination and HPV testing as part of screening.

Methods

PubMed search performed on terms: ‘HPV education’, ‘HPV awareness’ ‘Genital Warts Awareness’

Results

Public awareness of HPV is generally very low, particularly with respect to its relation to abnormal smears and cervical cancer although knowledge levels vary to some extent according to sociodemographic characteristics. There is also much confusion around which types cause warts and the types that can cause cancer. The sexually transmissible nature of the infection is of major concern and confusion to women.

Conclusions

Due to the lack of current awareness of HPV, significant education initiatives will be necessary should HPV vaccination and/or HPV testing be introduced. Organized edification of healthcare workers and the media, who constitute the two most preferred sources of information, will be crucial.

Psychological impact of positive cervical cancer screening results among Japanese women

BACKGROUND

While cervical cancer screening is useful for detecting and then treating the disease at an early stage, most women with screen-positive results are free from cervical cancer but nevertheless subject to the unnecessary worry entailed in receiving such results. The purpose of this study was to examine whether receiving a screen-positive result was actually related to psychological distress among Japanese women who underwent cervical cancer screening.

METHODS

We conducted a questionnaire survey at health facilities in a semiurban city of Ibaraki prefecture, involving 1744 women who underwent cervical cancer screening and 72 who received screen-positive results and then underwent further testing. We used the K6 scale to assess their psychological distress (K6 score ≥5) and performed multiple logistic regression analyses to estimate the relative effect of receiving screen-positive results on psychological distress.

RESULTS

Psychological distress was more prevalent among women with screen-positive results (OR 2.22; 95 % CI 1.32-3.74), while it was also related to history of mental health consultation (OR 2.26; 95 % CI 1.69-3.01) and marital status (OR 1.32; 95 % CI 1.02-1.70).

CONCLUSIONS

Receiving a positive cervical cancer screening result was associated with psychological distress. To alleviate this psychological impact, the current form of communicating the screening results should be reconsidered.

The Possible Effects on Socio-Economic Inequalities of Introducing HPV Testing as Primary Test in Cervical Cancer Screening Programs

Background: Screening with HPV is more effective than Pap test in preventing cervical cancer. HPV as primary test will imply longer intervals and a triage test for HPV positive women. It will also permit the development of self-sampling devices. These innovations may affect population coverage, participation, and compliance to protocols, and likely in a different way for less educated, poorer, and disadvantaged women.

Aim: To describe the impact on inequalities, actual or presumed, of the introduction of HPV-based screening.

Methods: The putative HPV-based screening algorithm has been analyzed to identify critical points for inequalities. A systematic review of the literature has been conducted searching PubMed on HPV screening coverage, participation, and compliance. Results were summarized in a narrative synthesis.

Results: Knowledge about HPV and cervical cancer was lower in women with low socio-economic status and in disadvantaged groups. A correct communication can reduce differences. Longer intervals will make it easier to achieve high-population coverage, but higher cost of the test in private providers could reduce the use of opportunistic screening by disadvantaged women. There are some evidences that inviting for HPV test instead of Pap increases participation, but there are no data on social differences. Self-sampling devices are effective in increasing participation and coverage. Some studies showed that the acceptability of self-sampling is higher in more educated women, but there is also an effect on hard-to-reach women. Communication of HPV positivity may increase anxiety and impact on sexual behaviors, the effect is stronger in low educated and disadvantaged women. Finally, many studies found indirect evidence that unvaccinated women are or will be more probably under-screened.

Conclusion: The introduction of HPV test may increase population coverage, but non-compliance to protocols and interaction with opportunistic screening can increase the existing inequalities.

Measuring the psychosocial burden in women with low-grade abnormal cervical cytology in the TOMBOLA trial: psychometric properties of the Process and Outcome Specific Measure (POSM)

Background

There is a need for an instrument to measure the psychosocial burden of receiving an abnormal cervical cytology result which can be used regardless of the clinical management women receive.

Methods

3331 women completed the POSM as part of baseline psychosocial assessment in a trial of management of low grade cervical cytological abnormalities. Factor analysis and reliability assessment of the POSM were conducted.

Results

Two factors were extracted from the POSM: Factor 1, containing items related to worry; and Factor 2 containing items relating to satisfaction with information and support received and change in the way women felt about themselves. Factor 1 had good reliability (Cronbach’s alpha 0.769), however reliability of the Factor 2 was poorer (0.482). Data collected at four subsequent time points demonstrated that the factor structure was stable over time.

Conclusion

This study demonstrates the presence and reliability of a scale measuring worries within the POSM. This analysis will inform its future use in this population and in other related contexts.

Electronic supplementary material

The online version of this article (doi:10.1186/s12955-014-0154-8) contains supplementary material, which is available to authorized users.

How distressing is referral to colposcopy in cervical cancer screening?: a prospective quality of life study

OBJECTIVE

Referral for colposcopy because of abnormal Pap test results is likely to be distressing, but the extent and duration of these effects are unknown. We aimed to fill this gap.

METHODS

We conducted a prospective observational study at two departments of Obstetrics and Gynecology (an academic and a non-academic setting). Women referred for colposcopy completed questionnaires before colposcopy, and at 1, 3, and 6 months afterwards. A reference group of 706 screen participants, aged 29-60 years old, was included and completed questionnaires once. Main outcome measures were generic health-related quality of life (HRQoL), assessed through the EQ-5D and the SF-12 physical and mental scores (PCS-12 and MCS-12); anxiety as assessed by STAI-6, and screen-specific anxiety as assessed by the psychological consequences questionnaire (PCQ).

RESULTS

154 women responded to the questionnaire, of whom 132 were included in the analyses. Histological results were CIN 1 in 17/115 women (15%) and CIN 2+ in 62 (54%). In 36 women (31%) there was no histologically confirmed neoplasia. Before colposcopy physical HRQoL scores were similar or slightly better than in the reference group, while mental HRQoL (MSC-12) and (screen-specific) anxiety were worse (p<0.001). Irrespective of CIN-grades, anxiety washed out during follow-up (p<0.001), with changes being clinically relevant.

CONCLUSIONS

Referral for gynecological evaluation because of abnormal PAP-test results was distressing. Anxiety--and not the physical burden of management--seemed to be the most bothersome to women. For all CIN-grades, distress disappeared over six months following colposcopy, suggesting a reassuring effect of gynecological management.

Intervention to improve follow-up for abnormal Papanicolaou tests: a randomized clinical trial

OBJECTIVE

To evaluate the effect of a theory-based, culturally targeted intervention on adherence to follow-up among low-income and minority women who experience an abnormal Pap test.

METHOD

5,049 women were enrolled and underwent Pap testing. Of these, 378 had an abnormal result and 341 (90%) were randomized to one of three groups to receive their results: Intervention (I): culturally targeted behavioral and normative beliefs + knowledge/skills + salience + environmental constraints/barriers counseling; Active Control (AC): nontargeted behavioral and normative beliefs + knowledge/skills + salience + environmental constraints/barriers counseling; or Standard Care Only (SCO). The primary outcome was attendance at the initial follow-up appointment. Secondary outcomes included delay in care, completion of care at 18 months, state anxiety (STAI Y-6), depressive symptoms (CES-D), and distress (CDDQ). Anxiety was assessed at enrollment, notification of results, and 7-14 days later with the CDDQ and CES-D.

RESULTS

299 women were included in intent-to-treat analyses. Adherence rates were 60% (I), 54% (AC), and 58% (SCO), p = .73. Completion rates were 39% (I) and 35% in the AC and SCO groups, p = .77. Delay in care (in days) was (M ± SD): 58 ± 75 (I), 69 ± 72 (AC), and 54 ± 75 (SCO), p = .75. Adherence was associated with higher anxiety at notification, p < .01 and delay < 90 days (vs. 90+) was associated with greater perceived personal responsibility, p < .05. Women not completing their care (vs. those who did) had higher CES-D scores at enrollment, p < .05.

CONCLUSIONS

A theory-based, culturally targeted message was not more effective than a nontargeted message or standard care in improving behavior.

[Perception and psychological impact of an abnormal Pap smear. Results of a comparative European survey]

OBJECTIVES

The availability of information on HPV and Pap tests has increased dramatically with the introduction of national HPV vaccination programs. But data on the effectiveness of this information is limited. However, our desire is to reduce patient anxiety and promote better delivery of information.

PATIENTS AND METHODS

Therefore a questionnaire-based cohort study was conducted to investigate women's experience with the announcement of an abnormal Pap smear result, then the ensuing events, as well as their practitioner's management. This article focuses on the French experience, underpinned by comparative data with Spain and Portugal.

RESULTS

It shows that, face with stress reactions and patient's anxiety, the level of information from the medical profession is still seen as inadequate, while the Internet as an information source has its limitations and dangers. The close entourage is most relied on, which supports the need for better public information.

DISCUSSION AND CONCLUSION

Uniformity and standardization of information strategies is not yet on European time.

Interventions for reducing anxiety in women undergoing colposcopy

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

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

OBJECTIVE

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

DESIGN

Randomised controlled trial.

POPULATION

Women referred to the colposcopy clinic.

METHODS

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

MAIN OUTCOME MEASURES

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

RESULTS

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

CONCLUSIONS

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

[Diagnostic imaging studies: do they create anxiety?]

Cancer is one of the main health problems in western countries. In 2008, it represented the first cause of death in men and the second one in women. When there is a diagnosis or suspicion of cancer, performing diagnostic imaging studies has an important role in the clinical activity and may have an elevated psychological impact.

OBJECTIVE

The purpose of this study was to evaluate the level of anxiety in oncology patients during the performance of a nuclear medicine study (PET-CT) in a Nuclear Medicine Service, by means of the State Trait Anxiety Inventory (STAI).

MATERIAL AND METHODS

A total of 200 cancer patients who underwent a PET-CT study in a Nuclear Medicine Service were administered the STAI to evaluate the level of anxiety generated during this test. The STAI is a validated questionnaire developed as a research tool on anxiety in healthy adults.

RESULTS

Of the 200 patients, two thirds (n=135) (67%) of the patients evaluated had anxiety. Of the 133, 93 (70%) of the patients who underwent PET-CT study for the first time were anxious whereas 42 (62.7%) of the patients who had undergone the study on previous occasions were anxious. Those patients with the greatest anxiety were those in whom the study was performed to initially stage the disease.

CONCLUSION

Performing the PET-CT study as an initial staging method and/or to evaluate tumor recurrence is an important and statistically significant generator of anxiety. There is a high emotional and cognitive impact associated to the participation of the diagnostic tests.

Psychological impact, support and information needs for women with an abnormal Pap smear: comparative results of a questionnaire in three European countries

Background

Extensive information on cervical cancer is currently available. Its effectiveness in reducing anxiety in women receiving abnormal Pap tests is not clear. We investigated current practices of communicating abnormal Pap results to evaluate women's reactions and determine the sources of information they use subsequently.

Methods

A self-administered questionnaire-based study was performed in 1475 women in France, Spain and Portugal who had received an abnormal Pap smear result in the 12 months prior to completing the questionnaire. Questions covered methods of communication of the result, emotional reactions, support received (from the physician and entourage), and information sources, using pre-specified check box options and rating scales. Data were analyzed by country.

Results

Pap test results were mostly communicated by phone to Spanish women (76%), while physician letters were common in France (59%) and Portugal (36%). Frequent reactions were anxiety, panic and stress, which were less common in Spanish women than their French and Portuguese counterparts. After discussing with their physician, half of the participants were worried, despite rating highly the psychological support received. Over 90% of women in each country discussed their results with family or friends. Partners provided a high level of support. Overall, the abnormal diagnosis and consequences had a low to medium impact on daily, professional and family life and their relationships with their partner. Impact was higher in Spanish women than the French or Portuguese. Information on the diagnosis and its treatment was rated average, and nearly 80% of participants wanted more information, notably French women. Preferred sources were the physician and the Internet.

Conclusions

Women expressed a strong wish for more information about cervical cancer and other HPV-related diseases, and that their physician play a major role in its provision and in support. There was a heavy reliance on the close entourage and the Internet for information, highlighting the need for dissemination of accurate material. Differences between countries suggest information management strategies may need to be tailored to different geographical regions.

Healthcare use after screening for lung cancer

BACKGROUND

To evaluate the benefits of lung cancer screening, all effects of screening need to be considered. The aim of this study was to determine whether screening had an effect on healthcare use, specifically whether use increased for those with a false-positive or indeterminate screening result.

METHODS

Recruited were 400 individuals participating in a lung cancer screening study at the University of Pittsburgh. Self-reported outpatient healthcare use information was collected for the 6 months before, 0 to 6 months after, and 6 to 12 months after screening. The screening outcomes were negative, indeterminate, and suspicious. Repeated-measures Poisson regression models were used to examine changes in use over time and how changes over time varied among the screening outcome groups.

RESULTS

Approximately 58% of participants had a negative screening result, 36% had an indeterminate result, and approximately 6% had a suspicious result. The percentage of individuals who had any incidence of each type of outpatient use increased after screening, with the greatest increase noted for those with a suspicious screening result. Adjusted mean use significantly increased for nearly all types of use and for all 3 screening results categories in the 6 months after screening, but mostly declined to prescreening levels in the next 6 months.

CONCLUSIONS

Outpatient healthcare use was found to increase after screening for all individuals who were screened for lung cancer, regardless of the screening finding. The cost of the lung-related visits alone was substantial. Therefore, if lung cancer screening prevalence is increased, attendant follow-up healthcare costs are also likely to increase.

CT scan screening is associated with increased distress among subjects of the APExS

Background

The aim of this study was to assess the psychological consequences of HRCT scan screening in retired asbestos-exposed workers.

Methods

A HRCT-scan screening program for asbestos-related diseases was carried out in four regions of France. At baseline (T1), subjects filled in self-administered occupational questionnaires. In two of the regions, subjects also received a validated psychological scale, namely the psychological consequences questionnaire (PCQ). The physician was required to provide the subject with the results of the HRCT scan at a final visit. A second assessment of psychological consequences was performed 6 months after the HRCT-scan examination (T2). PCQ scores were compared quantitatively (t-test, general linear model) and qualitatively (chi²-test, logistic regression) to screening results. Multivariate analyses were adjusted for gender, age, smoking, asbestos exposure and counseling.

Results

Among the 832 subjects included in this psychological impact study, HRCT-scan screening was associated with a significant increase of the psychological score 6 months after the examination relative to baseline values (8.31 to 10.08, p < 0.0001, t-test). This increase concerned patients with an abnormal HRCT-scan result, regardless of the abnormalities, but also patients with normal HRCT-scans after adjustment for age, gender, smoking status, asbestos exposure and counseling visit. The greatest increase was observed for pleural plaques (+3.60; 95%CI [+2.15;+5.06]), which are benign lesions. Detection of isolated pulmonary nodules was also associated with a less marked but nevertheless significant increase of distress (+1.88; 95%CI [+0.34;+3.42]). However, analyses based on logistic regressions only showed a close to significant increase of the proportion of subjects with abnormal PCQ scores at T2 for patients with asbestosis (OR = 1.92; 95%CI [0.97-3.81]) or with two or more diseases (OR = 2.04; 95%CI [0.95-4.37]).

Conclusion

This study suggests that HRCT-scan screening may be associated with increased distress in asbestos-exposed subjects. If confirmed, these results may have consequences for HRCT-scan screening recommendations.

Qualitative study of women's anxiety and information needs after a diagnosis of cervical dysplasia

AIM: Each year almost 15,000 Danish women are diagnosed with cervical dysplasia, a precursor to cervical cancer. The period of medical follow-up, or 'watchful waiting', to monitor for regression or progression of the lesion before deciding if treatment by conisation is necessary can be long. The aim of this study was to examine the experiences of women with different stages of cervical dysplasia and to examine whether their knowledge of human papillomavirus (HPV) as the cause of cervical dysplasia influenced their perception of their disease. SUBJECT AND METHODS: We used focus group and individual interviews with 12 women diagnosed with different stages of cervical dysplasia-women who had and had not been conised. Interview guides were prepared on the basis of a literature review that identified important issues and questions for the participants. RESULTS: The participants considered cervical dysplasia to be a highly distressing condition and experienced monitoring as a worrying delay before regression of the lesions or treatment could be initiated. Women expressed a fear of cancer that was not proportional to the stage of their dysplasia, but was determined by their degree of knowledge about their condition. Unlike other sexually transmitted diseases, information about HPV did not result in stigmatisation as the perception of this disease was dominated by cancer. CONCLUSION: This study showed that it is extremely important to address women's fears, their need for information and to ensure better communication with medical practitioners about cervical dysplasia immediately after diagnosis, irrespective of the disease stage.

Developing a measure of health-related quality of life for women with cervical dysplasia resulting from human papillomavirus infection

Human papillomavirus (HPV) infection is the most common sexually transmitted infection in the USA, and has major physical and psychological consequences including fear, anxiety and stigma. To date, there is no measure of health-related quality of life specifically designed to assess symptoms and functioning for people with cervical dysplasia resulting from HPV infection. In the present study, we set out to develop a disease-specific measure of health-related quality of life among women with low-grade cervical dysplasia. We conducted literature reviews, open-ended interviews with patients, clinician surveys and cognitive interviews which guided item development. The result is a preliminary 36-item measure, the Functional Assessment of Chronic Illness Therapy-Cervical Dysplasia (FACIT-CD), which sets out to assess the physical and psychological health-related quality-of-life aspects of cervical dysplasia and will be validated in an upcoming study.

Mammograms and the management of existential discomfort: threats associated with the physicality of the body and neuroticism

The current research employs ideas from terror management theory to investigate why mammograms may be psychologically problematic. This perspective suggests that individuals, particularly those high in neuroticism, are threatened by that which reminds them of their physical and mortal nature. In Study 1, a laboratory experiment demonstrated that when concerns about mortality were primed, reminders of one's physical nature (i.e. creatureliness) led women who were high in neuroticism to report reduced willingness to imagine undergoing a mammogram. In Study 2, a field experiment among women receiving a mammogram showed that priming creatureliness increased perceptions of discomfort with the procedure for women high in neuroticism. Theoretical and practical implications are discussed.

HPV vaccine: Cervarix

IMPORTANCE OF THE FIELD

Cervical cancer is a major cause of morbidity and mortality worldwide and is common in relatively young women. Cervical screening programs, while successful if properly carried out, are difficult and expensive to implement, and offer secondary, not primary prevention. Vaccination against the human papillomavirus (HPV), which is the major cause of cervical cancer, is a significant step forward.

AREAS COVERED IN THIS REVIEW

The data on Cervarix, the GSK HPV vaccine, are reviewed and placed in the context of HPV vaccination as a whole. A literature review using PubMed listed publications and official product websites has been carried out.

WHAT THE READER WILL GAIN

The reader will gain an understanding of the issues involved in HPV vaccination and of the data to date.

TAKE HOME MESSAGE

Cervarix has been shown to have high efficacy against disease associated with both HPV-16 and HPV-18. Its antibody response profile allows for optimism regarding the duration of immunity. The fact that it is a virus-like particle, rather than a live-virus vaccine, is reassuring regarding safety, as are the reasonably extensive safety data for the vaccine preparation so far accrued. Cross protection against oncogenic non-vaccine HPV types, in particular HPV-45, may be important in the prevention of cervical adenocarcinoma, which is currently not well served by screening.

The quality of life of patients with genital warts: a qualitative study

BACKGROUND

Genital warts, which are caused by infection with human papillomavirus (HPV), are one of the most common sexually transmitted diseases in Europe. Although genital warts are commonly perceived as a non-serious condition, treatment is often long, of varying effectiveness and the recurrence rate is high. Very few studies have been performed on the personal consequences of genital warts. The aim of this qualitative study, set in Denmark, was to examine the ways in which genital warts may affect patients' quality of life.

METHODS

To obtain an in-depth understanding of patients' perceptions of genital warts, we used qualitative focus-group interviews with five men and five women aged between 18 and 30 years who had genital warts. The interview guide was based on a literature review that identified important issues and questions. The data were analysed using a medical anthropological approach.

RESULTS

Patients' experiences were related to cultural conceptions of venereal diseases and the respective identities and sexuality of the sexes. The disease had negative psychological and social effects both for men and for women and it affected their sex and love lives, in particular. The psychological burden of the disease was increased by the uncertain timeline and the varying effectiveness of treatment. We identified a need for more patient information about the disease and its psycho-sexual aspects.

CONCLUSIONS

The men and women participating in this study considered their quality of life to be significantly lowered because of genital warts. The experiences described by the participants give insights that may be valuable in treatment and counselling.The quadrivalent HPV vaccine that has now been added to the childhood vaccination programme for girls in Denmark for the prevention of cervical cancer can also prevent 90% of cases of genital warts. Our results suggest that HPV vaccination could considerably reduce the largely unacknowledged psychological and social burden associated with genital warts, in men as well as women.

Cost effectiveness of prophylactic HPV 16/18 vaccination in Finland: results from a modelling exercise

OBJECTIVES

the study aims to estimate the clinical-impact and cost-effectiveness value of adding human papillomavirus 16/18 vaccination against cervical cancer among women currently undergoing organised screening in Finland.

METHODS

A Markov cohort model evaluating high-risk HPV infections and cervical cancer (CC) cases combined with screening has been customised to the Finnish setting. The model outcome for a cohort of 30,000 girls aged 10 years was calibrated to age-specific annual number of Pap smears, CC incidence and mortality.

RESULTS

The observed age-specific incidence and mortality rates of CC closely match the data replicated by the model. The model predicts that with a 90% vaccine coverage rate, CC cases and mortality would be reduced by 70%. In the base-case analysis with a discount rate of 3% the incremental cost per quality-adjusted life-years (QALY) gained, from a healthcare perspective, was €17,294. Without discounting this value is €2,591/QALY gained.

CONCLUSIONS

The analysis suggests that implementing prophylactic CC vaccination within the current screening system would substantially reduce CC cases and deaths, as well as the overall disease burden expressed in pre-cancer lesions averted. Vaccination could be a cost-effective intervention in Finland despite the fact that the number of CC cases and deaths are currently relatively low. Conservative estimates of the cost effectiveness of the vaccination were provided since it was not possible to assess herd protection induced by vaccination using this Markov model.

A model of the influence of false-positive mammography screening results on subsequent screening

Decades of empirical research have demonstrated psychological and behavioural consequences of false-positive medical tests. To organise this literature and offer novel predictions, we propose a model of how false-positive mammography results affect return for subsequent mammography screening. We propose that false-positive mammography results alter how women think about themselves (e.g., increasing their perceived likelihood of getting breast cancer) and the screening test (e.g., believing mammography test results are less accurate). We further hypothesise that thoughts elicited by the false-positive experience will, in turn, affect future use of screening mammography. In addition, we discuss methodological considerations for statistical analyses of these mediational pathways and propose two classes of potential moderators. While our model focuses on mammography screening, it may be applicable to psychological and behavioural responses to other screening tests. The model is especially timely as false-positive medical test results are increasingly common, due to efforts to increase uptake of cancer screening, new technologies that improve existing tests' ability to detect disease at the cost of increased false alarms, and growing numbers of new medical tests.

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

This study was conducted in seven gynaecological clinics in New South Wales (NSW), Australia. The study aimed to assess the level of satisfaction with care, unmet needs and consequences following the procedure reported by women having a colposcopic examination. Of the 161 eligible women attending colposcopy clinics who were approached to take part, 156 (97%) gave written consent to participate and 138 (86%) completed interviews. Consenting women were telephoned within 1 week of their clinic visit to complete a computer-assisted telephone interview (CATI). The survey addressed a number of issues relating to the care they received during their colposcopic examination: satisfaction with care, satisfaction with the waiting time to have a colposcopy, preferences for provider gender, information and health care needs while waiting for the colposcopy, information and health care needs during the colposcopy, short-term physical consequences and shortterm psychosocial consequences of the procedure. Results indicate that satisfaction with care among women ranged from 69% to 96%. The highest expressed needs while waiting for the colposcopy were for information about risks of cancer (91%), reasons for needing a colposcopy (86%), and the colposcopy procedure (86%). Women reported that outcomes such as anxiety and disinterest in sex had further worsened or not been improved following the colposcopy. The results indicate that interventions to address specific concerns would need to be designed, implemented and evaluated.