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Marlow LAV, Schmeising-Barnes N, Warwick J, Waller J. P sychological Impact of the Galleri test (sIG(n)al): protocol for a longitudinal evaluation of the psychological impact of receiving a cancer signal in the NHS-Galleri trial. BMJ Open 2023; 13:e072657. [PMID: 37479515 PMCID: PMC10364178 DOI: 10.1136/bmjopen-2023-072657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 07/07/2023] [Indexed: 07/23/2023] Open
Abstract
INTRODUCTION Multi-cancer early detection (MCED) blood tests look for cancer signals in cell-free deoxyribonucleic acid. These tests have the potential to detect cancers at an earlier (asymptomatic) stage, improving cancer outcomes. Any screening method needs careful consideration of the psychological harms prior to implementation. The aim of this research is to explore the psychological impact of having a cancer signal detected following an MCED blood test. METHODS AND ANALYSIS The project is embedded in the NHS-Galleri trial (ISRCTN91431511; NCT05611632), a large clinical trial in eight Cancer Alliances in England. In the trial, over 140 000 members of the general population aged 50-77 have been randomised 1:1 to either the intervention (blood tested with MCED test) or control (blood stored) arm. The proposed project focuses on participants in the intervention arm, who have a cancer signal detected. All participants who have a cancer signal detected (expected to be around 700 assuming a 1% test positive rate) will be sent a questionnaire at three timepoints: soon after receiving their result, 6 months and approximately 12 months later. The primary outcome is anxiety, assessed using the short-form 6-item Spielberger State Trait Anxiety Inventory. We will also assess the psychological consequences of screening (using the Psychological Consequences of Screening Questionnaire), reassurance/concern about the test result, understanding of results and help/health-seeking behaviour. A subsample of 40 participants (20 with a cancer diagnosis and 20 for whom no cancer was found) will be invited to take part in a one-to-one semistructured interview. ETHICS AND DISSEMINATION Ethical approval for this work has been granted by the Wales Research Ethics Committee as part of the NHS-Galleri trial (Ref 21/WA/0141). Consent to be sent questionnaires is collected as part of the main trial. A separate consent form will be required for interview. Results will be disseminated via peer-reviewed publication and conference presentations.
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Affiliation(s)
- Laura A V Marlow
- King's Cancer Prevention Group, School of Cancer and Pharmaceutical Sciences, King's College London, London, UK
| | - Ninian Schmeising-Barnes
- King's Cancer Prevention Group, School of Cancer and Pharmaceutical Sciences, King's College London, London, UK
| | - Jane Warwick
- King's Cancer Prevention Group, School of Cancer and Pharmaceutical Sciences, King's College London, London, UK
| | - Jo Waller
- King's Cancer Prevention Group, School of Cancer and Pharmaceutical Sciences, King's College London, London, UK
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Nagele E, Trutnovsky G, Greimel E, Dorfer M, Haas J, Reich O. Do different treatment strategies influence women's level of psychosexual distress? Observational cohort study of women with premalignant HPV-associated genital lesions. Eur J Obstet Gynecol Reprod Biol 2019; 236:205-209. [PMID: 30965187 DOI: 10.1016/j.ejogrb.2019.03.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Revised: 03/28/2019] [Accepted: 03/31/2019] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Eva Nagele
- Div. of Gynecology, Obstetrics and Gynecology, Medical University of Graz, Austria
| | - Gerda Trutnovsky
- Div. of Gynecology, Obstetrics and Gynecology, Medical University of Graz, Austria.
| | - Elfriede Greimel
- Div. of Gynecology, Obstetrics and Gynecology, Medical University of Graz, Austria
| | - Martha Dorfer
- Div. of Gynecology, Obstetrics and Gynecology, Medical University of Graz, Austria
| | - Josef Haas
- Div. of Gynecology, Obstetrics and Gynecology, Medical University of Graz, Austria
| | - Olaf Reich
- Div. of Gynecology, Obstetrics and Gynecology, Medical University of Graz, Austria
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Risica PM, Matthews NH, Dionne L, Mello J, Ferris LK, Saul M, Geller AC, Solano F, Kirkwood JM, Weinstock MA. Psychosocial consequences of skin cancer screening. Prev Med Rep 2018; 10:310-316. [PMID: 29868385 PMCID: PMC5984251 DOI: 10.1016/j.pmedr.2018.04.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Revised: 04/08/2018] [Accepted: 04/13/2018] [Indexed: 01/01/2023] Open
Abstract
Screening for melanoma may save lives, but may also cause patient distress. One key reason that preventative visual skin examinations for skin cancer are not currently recommended is the inadequate available evidence to assess potential harm to psychosocial wellbeing. We investigated potential psychological harms and benefits of skin examinations by conducting telephone surveys in 2015 of 187 screened participants; all were ≥35 years old. Participants had their skin examined by practitioners who had completed INFORMED, a validated web-based training for detection of skin cancers, particularly melanoma. Participants underwent the Spielberger State-Trait Anxiety Inventory (STAI), Psychological Consequences of Screening (PCQ), Hospital Anxiety and Depression (HAD) scale, and the 12-Item Short Form Health Survey (SF-12). Analyses were conducted in 2017. Of the entire study sample, 40% were thoroughly screened as determined by patient-reported level of undress and skin areas examined. Participants who were thoroughly screened: did not differ on negative psychosocial measures; scored higher on measures of positive psychosocial wellbeing (PCQ); and were more motivated to conduct monthly self-examinations and seek annual clinician skin examinations, compared to other participants (p < 0.05). Importantly, thoroughly screened patients were more likely to report skin prevention practices (skin self-examinations to identify a concerning lesion, practitioner provided skin exam), recommend skin examinations to peers, and feel satisfied with their skin cancer education than less thoroughly screened individuals (p < 0.01). Our results suggest that visual screening for skin cancer does not worsen patient psychosocial wellbeing and may be associated with improved skin cancer-related practices and attitudes.
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Affiliation(s)
- Patricia Markham Risica
- Center for Health Equity Research, Brown School of Public Health, Providence, RI, United States
- Department of Behavioral and Social Sciences, Brown School of Public Health, Providence, RI, United States
- Department of Epidemiology, Brown School of Public Health, Providence, RI, United States
| | - Natalie H. Matthews
- Department of Dermatology, The Warren Alpert Medical School of Brown University, Providence, RI, United States
| | - Laura Dionne
- Center for Health Equity Research, Brown School of Public Health, Providence, RI, United States
| | - Jennifer Mello
- Center for Health Equity Research, Brown School of Public Health, Providence, RI, United States
| | - Laura K. Ferris
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Melissa Saul
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Alan C. Geller
- Department of Social and Behavioral Sciences, Harvard TH Chan School of Public Health, Boston, MA, United States
| | - Francis Solano
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - John M. Kirkwood
- Department of Social and Behavioral Sciences, Harvard TH Chan School of Public Health, Boston, MA, United States
| | - Martin A. Weinstock
- Department of Epidemiology, Brown School of Public Health, Providence, RI, United States
- Department of Dermatology, The Warren Alpert Medical School of Brown University, Providence, RI, United States
- Department of Dermatology, Veterans Medical Center, Providence, RI, United States
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Manley KM, Simms RA, Platt S, Patel A, Bahl R. Unsatisfactory colposcopy: clinical decision-making in conditions of uncertainty. BMC Med Inform Decis Mak 2017; 17:125. [PMID: 28830493 PMCID: PMC5567663 DOI: 10.1186/s12911-017-0516-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Accepted: 08/01/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Unsatisfactory colposcopy, where the cells of interest are not visible in women with a positive cervical screening test, is a common area of clinical uncertainty due to the lack of clear evidence and guidance. Colposcopists' opinions and experiences are likely to have a significant influence on service provision and the development of national policy. The aim of this study was to analyse decision-making when applied to women with unsatisfactory colposcopy. METHODS A multi-centre qualitative study utilizing a series of focus groups in an English healthcare region. Sampling aimed to ensure heterogeneity of experience and healthcare provider demographics. A topic guide covered a range of clinical and cytological variables and was compiled by the researchers and three expert Colposcopists. Using an iterative approach, thematic analysis was selected as the most appropriate method to identify factors affecting decision-making. RESULTS Twenty-three Colposcopists from four units participated. The decision to treat was easier in women with high-grade cytology and high risk women with low-grade cytology such as heavy smokers, poor attenders, older women, those who had completed their families and women opting for treatment. Where decision-making was more complex, intuition and a multi-disciplinary approach were used to guide management. Areas of dissonance, which are affected by paucity of evidence and emotive factors, included cytological collection device, clinical setting and length of conservative follow-up and depth of excision in women at high risk of treatment-related morbidity. CONCLUSIONS Anxiety of missing a cancer deters long-term cytological follow-up, resulting in heterogeneity of care and higher than anticipated excisional treatments in women with low-grade screening and unsatisfactory colposcopy. In areas of clinical uncertainty when decisions are dominated by affect, clinical guidance can reduce the difficulty and anxiety of decision-making.
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Affiliation(s)
- Kristyn M. Manley
- Department of Women’s Health, University Hospitals Bristol NHS Foundation Trust, St. Michael’s Hospital, Level D, St. Michaels Hospital, Bristol, BS2 8EG UK
- University of Bristol, Bristol, UK
| | - Rebecca A. Simms
- Department of Women’s Health, University Hospitals Bristol NHS Foundation Trust, St. Michael’s Hospital, Level D, St. Michaels Hospital, Bristol, BS2 8EG UK
- University of Bristol, Bristol, UK
| | - Sarah Platt
- Department of Women’s Health, University Hospitals Bristol NHS Foundation Trust, St. Michael’s Hospital, Level D, St. Michaels Hospital, Bristol, BS2 8EG UK
| | - Amit Patel
- Department of Women’s Health, University Hospitals Bristol NHS Foundation Trust, St. Michael’s Hospital, Level D, St. Michaels Hospital, Bristol, BS2 8EG UK
| | - Rachna Bahl
- Department of Women’s Health, University Hospitals Bristol NHS Foundation Trust, St. Michael’s Hospital, Level D, St. Michaels Hospital, Bristol, BS2 8EG UK
- University of Bristol, Bristol, UK
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Fielding S, Rothnie K, Gray NM, Little J, Cruickshank ME, Neal K, Walker LG, Whynes D, Cotton SC, Sharp L. Psychosocial morbidity in women with abnormal cervical cytology managed by cytological surveillance or initial colposcopy: longitudinal analysis from the TOMBOLA randomised trial. Psychooncology 2017; 26:476-483. [PMID: 27297097 PMCID: PMC5412834 DOI: 10.1002/pon.4163] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Revised: 04/20/2016] [Accepted: 04/21/2016] [Indexed: 12/31/2022]
Abstract
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.
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Affiliation(s)
- S. Fielding
- Medical Statistics Team, Division of Applied Health SciencesUniversity of AberdeenAberdeenScotland
| | - K. Rothnie
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine and Faculty of MedicineImperial College LondonLondonUK
| | - N. M. Gray
- Scottish Improvement Science Collaborating Centre, School of Nursing and Health SciencesUniversity of DundeeDundeeScotland
| | - J. Little
- School of Epidemiology, Public Health and Preventive MedicineUniversity of OttawaOttawaCanada
| | - M. E. Cruickshank
- Division of Medical and Dental EducationUniversity of AberdeenAberdeenScotland
| | - K. Neal
- Consultant EpidemiologistLondon and South East PHE CentresLondonUK
| | | | - D. Whynes
- School of EconomicsUniversity of NottinghamNottinghamUK
| | - S. C. Cotton
- Division of Applied Health SciencesUniversity of AberdeenAberdeenUK
| | - L. Sharp
- Institute of Health & SocietyNewcastle UniversityNewcastleUK
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Kyrgiou M, Kalliala IEJ, Mitra A, Fotopoulou C, Ghaem-Maghami S, Martin-Hirsch PP, Cruickshank M, Arbyn M, Paraskevaidis E. Immediate referral to colposcopy versus cytological surveillance for minor cervical cytological abnormalities in the absence of HPV test. Cochrane Database Syst Rev 2017; 1:CD009836. [PMID: 28125861 PMCID: PMC6464319 DOI: 10.1002/14651858.cd009836.pub2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
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.
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Affiliation(s)
- Maria Kyrgiou
- West London Gynaecological Cancer Centre, Queen Charlotte's & Chelsea, Hammersmith Hospital, Imperial NHS Healthcare Trust, Du Cane Road, London, UK, W12 0NN
- The Institute of Reproductive and Developmental Biology (IRDB), Surgery and Cancer, Imperial College London, IRDB Building, 3rd floor, Hammersmith Campus, Du Cane Road, London, UK, W12 0HS
| | - Ilkka E J Kalliala
- West London Gynaecological Cancer Centre, Queen Charlotte's & Chelsea, Hammersmith Hospital, Imperial NHS Healthcare Trust, Du Cane Road, London, UK, W12 0NN
- The Institute of Reproductive and Developmental Biology (IRDB), Surgery and Cancer, Imperial College London, IRDB Building, 3rd floor, Hammersmith Campus, Du Cane Road, London, UK, W12 0HS
| | - Anita Mitra
- The Institute of Reproductive and Developmental Biology (IRDB), Surgery and Cancer, Imperial College London, IRDB Building, 3rd floor, Hammersmith Campus, Du Cane Road, London, UK, W12 0HS
| | - Christina Fotopoulou
- West London Gynaecological Cancer Centre, Queen Charlotte's & Chelsea, Hammersmith Hospital, Imperial NHS Healthcare Trust, Du Cane Road, London, UK, W12 0NN
- The Institute of Reproductive and Developmental Biology (IRDB), Surgery and Cancer, Imperial College London, IRDB Building, 3rd floor, Hammersmith Campus, Du Cane Road, London, UK, W12 0HS
| | - Sadaf Ghaem-Maghami
- West London Gynaecological Cancer Centre, Queen Charlotte's & Chelsea, Hammersmith Hospital, Imperial NHS Healthcare Trust, Du Cane Road, London, UK, W12 0NN
- The Institute of Reproductive and Developmental Biology (IRDB), Surgery and Cancer, Imperial College London, IRDB Building, 3rd floor, Hammersmith Campus, Du Cane Road, London, UK, W12 0HS
| | - Pierre Pl Martin-Hirsch
- Gynaecological Oncology Unit, Royal Preston Hospital, Lancashire Teaching Hospital NHS Trust, Sharoe Green Lane, Fullwood, Preston, Lancashire, UK, PR2 9HT
| | - Margaret Cruickshank
- Obstetrics and Gynaecology, Aberdeen Royal Infirmary, Foresterhill, Aberdeen, UK, AB25 2ZD
| | - Marc Arbyn
- Unit of Cancer Epidemiology, Belgian Cancer Centre, Scientific Institute of Public Health, Juliette Wytsmanstreet 14, Brussels, Belgium, B-1050
| | - Evangelos Paraskevaidis
- Department of Obstetrics and Gynaecology, Ioannina University Hospital, Ioannina, Greece, 45001
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Kyrgiou M, Kalliala I, Mitra A, Ng KYB, Raglan O, Fotopoulou C, Martin-Hirsch P, Paraskevaidis E, Arbyn M. Immediate referral to colposcopy versus cytological surveillance for low-grade cervical cytological abnormalities in the absence of HPV test: A systematic review and a meta-analysis of the literature. Int J Cancer 2016; 140:216-223. [PMID: 27603593 DOI: 10.1002/ijc.30419] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Revised: 07/24/2016] [Accepted: 08/24/2016] [Indexed: 01/20/2023]
Affiliation(s)
- Maria Kyrgiou
- Department of Surgery & Cancer; IRDB, Imperial College; London United Kingdom
- West London Gynaecological Cancer Center; Queen Charlotte's & Chelsea-Hammersmith Hospital, Imperial Healthcare NHS Trust; London United Kingdom
| | - Ilkka Kalliala
- Department of Surgery & Cancer; IRDB, Imperial College; London United Kingdom
| | - Anita Mitra
- Department of Surgery & Cancer; IRDB, Imperial College; London United Kingdom
| | - Ka Ying Bonnie Ng
- Human Development and Health Academic Unit, Faculty of Medicine; University of Southampton; Southampton United Kingdom
| | - Olivia Raglan
- Department of Surgery & Cancer; IRDB, Imperial College; London United Kingdom
| | - Christina Fotopoulou
- Department of Surgery & Cancer; IRDB, Imperial College; London United Kingdom
- West London Gynaecological Cancer Center; Queen Charlotte's & Chelsea-Hammersmith Hospital, Imperial Healthcare NHS Trust; London United Kingdom
| | - Pierre Martin-Hirsch
- Department of Gynaecologic Oncology; Lancashire Teaching Hospitals; Preston United Kingdom
- Department of Biophysics; University of Lancaster; Lancaster United Kingdom
| | | | - Marc Arbyn
- Unit of Cancer Epidemiology/Belgian Cancer Centre; Scientific Institute of Public Health; Brussels Belgium
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O'Connor M, O'Leary E, Waller J, Gallagher P, D'arcy T, Flannelly G, Martin CM, McRae J, Prendiville W, Ruttle C, White C, Pilkington L, O'Leary JJ, Sharp L. Trends in, and predictors of, anxiety and specific worries following colposcopy: a 12-month longitudinal study. Psychooncology 2016; 25:597-604. [PMID: 26392040 DOI: 10.1002/pon.3980] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Revised: 08/18/2015] [Accepted: 08/19/2015] [Indexed: 02/11/2024]
Abstract
OBJECTIVE Little is known about which women are at greatest risk of adverse psychological after-effects following colposcopy. This study examined time trends in, and identified predictors of, anxiety and specific worries over 12 months. METHODS Women attending two hospital-based colposcopy clinics for abnormal cervical cytology were invited to complete psychosocial questionnaires at 4, 8 and 12 months following colposcopy. General anxiety and screening-specific worries (about cervical cancer, having sex and future fertility) were measured. Generalised estimating equations were used to assess associations between socio-demographic, lifestyle and clinical variables and risk of psychological outcomes. RESULTS Of 584 women initially recruited, 429, 343 and 303 completed questionnaires at 4, 8 and 12 months, respectively. Screening-specific worries declined significantly over time but were still relatively high at 12 months: 23%, 39% and 18% for worries about cervical cancer, fertility and having sex, respectively. Anxiety remained stable (20%) over time. Risks of cervical cancer worry and anxiety were both almost double in women without private health insurance (cervical cancer worry: OR = 1.80, 95% CI 1.25-2.61; anxiety: OR = 1.84, 95% CI 1.20-2.84). Younger women (<40 years) had higher risk of fertility worries. Non-Irish women had higher risk of anxiety (OR = 2.13, 95% CI 1.13-4.01). CONCLUSIONS Screening-specific worries declined over time but anxiety remained stable. Notable proportions of women still reported adverse outcomes 12 months following colposcopy, with predictors varying between outcomes. Women in socio-demographically vulnerable groups were at greatest risk of adverse psychological outcomes. This information could inform development of interventions to alleviate psychological distress post-colposcopy.
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Affiliation(s)
| | - Eamonn O'Leary
- National Cancer Registry Ireland, Kinsale Road, Cork, Ireland
| | - Jo Waller
- Health Behaviour Research Centre, University College London, London, UK
| | - Pamela Gallagher
- School of Nursing and Human Sciences, Dublin City University, Dublin, Ireland
| | - Tom D'arcy
- Coombe Women and Infants University Hospital, Dublin 8, Ireland
| | | | - Cara M Martin
- Coombe Women and Infants University Hospital, Dublin 8, Ireland
| | - Judith McRae
- National Cancer Registry Ireland, Kinsale Road, Cork, Ireland
| | | | - Carmel Ruttle
- Coombe Women and Infants University Hospital, Dublin 8, Ireland
| | | | | | - John J O'Leary
- Coombe Women and Infants University Hospital, Dublin 8, Ireland
| | - Linda Sharp
- Institute of Health and Society, Newcastle University, UK
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9
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O'Connor M, Gallagher P, Waller J, Martin CM, O'Leary JJ, Sharp L. Adverse psychological outcomes following colposcopy and related procedures: a systematic review. BJOG 2016; 123:24-38. [PMID: 26099164 DOI: 10.1111/1471-0528.13462] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/02/2015] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
- M O'Connor
- National Cancer Registry Ireland, Cork, Ireland
| | - P Gallagher
- School of Nursing and Human Sciences, Dublin City University, Dublin, Ireland
| | - J Waller
- Department of Epidemiology and Public Health, Health Behaviour Research Centre, University College London, London, UK
| | - C M Martin
- Coombe Women and Infants University Hospital, Dublin, Ireland
| | - J J O'Leary
- Coombe Women and Infants University Hospital, Dublin, Ireland
| | - L Sharp
- Institute of Health &/ Society, Newcastle University, Newcastle, UK
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O'Connor M, Waller J, Gallagher P, Martin CM, O'Leary JJ, D'Arcy T, Prendiville W, Flannelly G, Sharp L. Understanding Women's Differing Experiences of Distress after Colposcopy: A Qualitative Interview Study. Womens Health Issues 2015; 25:528-34. [PMID: 26189936 DOI: 10.1016/j.whi.2015.05.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2015] [Revised: 04/26/2015] [Accepted: 05/15/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Women who have an abnormal cervical cytology test may be referred for a colposcopy. Accumulating evidence suggests some women may experience distress after colposcopy. This exploratory study examined women's differing experiences of post-colposcopy distress with the aim of identifying factors that are predictive of, or protective against, distress. METHODS We carried out semistructured, qualitative interviews with 23 women who had undergone colposcopies. Interviews were transcribed verbatim, coded, and analyzed thematically. The Framework Approach was used to summarize and organize the data and identify emerging higher order themes. RESULTS Two forms of post-colposcopy distress emerged: 1) short term and 2) long term. Short-term distress was experienced immediately after the colposcopy and in the days afterward, and was usually related to the physical experience of the colposcopy. Long-term distress typically persisted over time and was related to concerns about fertility, cervical cancer, and sexual intercourse. The drivers of short-term and long-term distress differed. Factors related to short-term distress were feeling unprepared for the procedure, having a negative experience of the procedure, and attending the clinic alone. Factors related to long-term distress were future intentions to have (more) children, having physical after-effects of the procedure that impacted on the woman's life, and being under on-going clinic surveillance. Absence of these factors (e.g., being accompanied to the clinic) was protective against short- and long-term distress. CONCLUSIONS Colposcopy can lead to short- and long-term post-procedural distress for some women. We identified a range of factors, some potentially modifiable, that seem to influence the chances of experiencing distress. These results may inform the development of strategies or interventions aimed at preventing or minimizing distress after colposcopy and related procedures.
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Affiliation(s)
- Mairead O'Connor
- Department of Research, National Cancer Registry Ireland, Cork Airport Business Park, Cork, Ireland.
| | - Jo Waller
- Health Behaviour Research Centre, University College London, London, UK
| | - Pamela Gallagher
- Department of Nursing and Human Sciences, Dublin City University, Dublin, Ireland
| | - Cara M Martin
- Department of Pathology, Coombe Women and Infants University Hospital, Dolphin's Barn, Dublin, Ireland
| | - John J O'Leary
- Department of Pathology, Coombe Women and Infants University Hospital, Dolphin's Barn, Dublin, Ireland
| | - Tom D'Arcy
- Department of Obstetrics and Gynaecology, Coombe Women and Infants University Hospital, Dolphin's Barn, Dublin, Ireland
| | - Walter Prendiville
- Department of Obstetrics and Gynaecology, Coombe Women and Infants University Hospital, Dolphin's Barn, Dublin, Ireland
| | - Grainne Flannelly
- Department of Obstetrics and Gynaecology, National Maternity Hospital, Dublin, Ireland
| | - Linda Sharp
- Department of Research, National Cancer Registry Ireland, Cork Airport Business Park, Cork, Ireland
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Ghani MA, Brown SE, Khan F, Wickersham JA, Lim SH, Dhaliwal SK, Kamarulzaman A, Altice FL. An exploratory qualitative assessment of self-reported treatment outcomes and satisfaction among patients accessing an innovative voluntary drug treatment centre in Malaysia. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2015; 26:175-82. [PMID: 25577322 PMCID: PMC4291539 DOI: 10.1016/j.drugpo.2014.10.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2013] [Revised: 08/29/2014] [Accepted: 10/19/2014] [Indexed: 01/17/2023]
Abstract
BACKGROUND In Malaysia, compulsory drug detention centres (CDDCs) hold suspected drug users for two years without adjudication. Acute detoxification without healthcare access has been documented. CDDCs are criticized globally due to ineffectiveness in treating addiction and human rights violations. In response, the Malaysian government began transitioning these facilities into voluntary drug treatment centres known as "Cure and Care" (C&C) centres that embrace a holistic treatment-based approach to drug addiction rehabilitation. METHODS An explorative qualitative study was undertaken to explore patient perspectives and satisfaction regarding treatment and services at the new Cure and Care centre in Kota Bharu, Malaysia. A convenience sample of 20 patients was recruited to participate in semi-structured in-depth interviews. Content analysis was used to identify the salient themes. RESULTS Patients identified methadone treatment, psychosocial programs, religious instruction, and recreational activities as important factors contributing to treatment success for addressing both health and addiction needs. Though many had previously been in a CDDC, adherence to treatment in the C&C centre was perceived to be facilitated by the degree of social support, the voluntary nature and the array of new programs available for selection. CONCLUSION C&Cs represents a dramatic shift in the Malaysian government's approach to drug addiction. Our findings demonstrate positive patient experiences associated with the holistic treatment-based approach of these centres. This exploratory study provides additional evidence to document this ongoing policy transition and may guide continued expansion of new holistic drug treatment programs across the country.
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Affiliation(s)
- Mansur A Ghani
- Yale University School of Medicine, Department of Medicine, Section of Infectious Diseases, AIDS Program, New Haven, Connecticut, USA
| | - Shan-Estelle Brown
- Yale University School of Medicine, Department of Medicine, Section of Infectious Diseases, AIDS Program, New Haven, Connecticut, USA
| | - Farrah Khan
- Yale University School of Medicine, Department of Medicine, Section of Infectious Diseases, AIDS Program, New Haven, Connecticut, USA
| | - Jeffrey A Wickersham
- Yale University School of Medicine, Department of Medicine, Section of Infectious Diseases, AIDS Program, New Haven, Connecticut, USA
| | - Sin How Lim
- Centre of Excellence for Research in AIDS (CERiA), Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | | | - Adeeba Kamarulzaman
- Yale University School of Medicine, Department of Medicine, Section of Infectious Diseases, AIDS Program, New Haven, Connecticut, USA; Centre of Excellence for Research in AIDS (CERiA), Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Frederick L Altice
- Yale University School of Medicine, Department of Medicine, Section of Infectious Diseases, AIDS Program, New Haven, Connecticut, USA; Centre of Excellence for Research in AIDS (CERiA), Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia.
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Sharp L, Cotton S, Little J, Gray NM, Cruickshank M, Smart L, Thornton A, Waugh N, Walker L. Psychosocial impact of alternative management policies for low-grade cervical abnormalities: results from the TOMBOLA randomised controlled trial. PLoS One 2013; 8:e80092. [PMID: 24386076 PMCID: PMC3875419 DOI: 10.1371/journal.pone.0080092] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2012] [Accepted: 10/05/2013] [Indexed: 11/18/2022] Open
Abstract
Background Large numbers of women who participate in cervical screening require follow-up for minor cytological abnormalities. Little is known about the psychological consequences of alternative management policies for these women. We compared, over 30-months, psychosocial outcomes of two policies: cytological surveillance (repeat cervical cytology tests in primary care) and a hospital-based colposcopy examination. Methods Women attending for a routine cytology test within the UK NHS Cervical Screening Programmes were eligible to participate. 3399 women, aged 20–59 years, with low-grade abnormal cytology, were randomised to cytological surveillance (six-monthly tests; n = 1703) or initial colposcopy with biopsies and/or subsequent treatment based on colposcopic and histological findings (n = 1696). At 12, 18, 24 and 30-months post-recruitment, women completed the Hospital Anxiety and Depression Scale (HADS). A subgroup (n = 2354) completed the Impact of Event Scale (IES) six weeks after the colposcopy episode or first surveillance cytology test. Primary outcomes were percentages over the entire follow-up period of significant depression (≥8) and significant anxiety (≥11; “30-month percentages”). Secondary outcomes were point prevalences of significant depression, significant anxiety and procedure-related distress (≥9). Outcomes were compared between arms by calculating fully-adjusted odds ratios (ORs) for initial colposcopy versus cytological surveillance. Results There was no significant difference in 30-month percentages of significant depression (OR = 0.99, 95% CI 0.80–1.21) or anxiety (OR = 0.97, 95% CI 0.81–1.16) between arms. At the six-week assessment, anxiety and distress, but not depression, were significantly less common in the initial colposcopy arm (anxiety: 7.9% vs 13.4%; OR = 0.55, 95% CI 0.38–0.81; distress: 30.6% vs 39.3%, OR = 0.67 95% CI 0.54–0.84). Neither anxiety nor depression differed between arms at subsequent time-points. Conclusions There was no difference in the longer-term psychosocial impact of management policies based on cytological surveillance or initial colposcopy. Policy-makers, clinicians, and women themselves can be reassured that neither management policy has a significantly greater psychosocial cost. Trial Registration Controlled-Trials.com ISRCTN 34841617
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Affiliation(s)
- Linda Sharp
- National Cancer Registry Ireland, Cork Airport Business Park, Kinsale Road, Cork, Ireland
- * E-mail:
| | - Seonaidh Cotton
- Obstetrics & Gynaecology, University of Aberdeen, Polwarth Building, Foresterhill, Aberdeen, Scotland
| | - Julian Little
- Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Nicola M. Gray
- Centre of Academic Primary Care, University of Aberdeen, Polwarth Building, Foresterhill, Aberdeen, Scotland
| | - Margaret Cruickshank
- Obstetrics & Gynaecology, University of Aberdeen, Polwarth Building, Foresterhill, Aberdeen, Scotland
| | - Louise Smart
- Department of Pathology, Aberdeen Royal Infirmary, Aberdeen, Scotland
| | - Alison Thornton
- Centre of Academic Primary Care, University of Aberdeen, Polwarth Building, Foresterhill, Aberdeen, Scotland
| | - Norman Waugh
- Medical School, University of Warwick, Coventry, England
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SOUTTER WILLIAMPATRICK, MOSS BRONWEN, PERRYMAN KAREN, KYRGIOU MARIA, PAPAKONSTANTINOU KATERINA, GHAEM-MAGHAMI SADAF. Long-term compliance with follow-up after treatment for cervical intra-epithelial neoplasia. Acta Obstet Gynecol Scand 2012; 91:1103-8. [DOI: 10.1111/j.1600-0412.2012.01477.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Davies P. Public awareness and cervical cancer screening. Cytopathology 2012; 23:143-5. [DOI: 10.1111/j.1365-2303.2012.00984.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Affiliation(s)
- H C Kitchener
- Department of Gynaecological Oncology, St Mary's Hospital, University of Manchester, Oxford Road, Manchester, UK
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Galaal K, Bryant A, Deane KH, Al-Khaduri M, Lopes AD. Interventions for reducing anxiety in women undergoing colposcopy. Cochrane Database Syst Rev 2011; 2011:CD006013. [PMID: 22161395 PMCID: PMC4161490 DOI: 10.1002/14651858.cd006013.pub3] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
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.
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Affiliation(s)
- Khadra Galaal
- Gynaecological Oncology, Northern Gynaecological Oncology Centre, Queen Elizabeth Hospital, Gateshead, Tyne and Wear, UK, NE9 6SX
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Frederiksen ME, Lynge E, Rebolj M. What women want. Women’s preferences for the management of low-grade abnormal cervical screening tests: a systematic review. BJOG 2011; 119:7-19. [DOI: 10.1111/j.1471-0528.2011.03130.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Sharp L, Cotton S, Thornton A, Gray N, Whynes D, Smart L, Waugh N, Duncan I, Cruickshank M, Little J. Which women default from follow-up cervical cytology tests? A cohort study within the TOMBOLA trial. Cytopathology 2011; 23:150-60. [PMID: 21366734 DOI: 10.1111/j.1365-2303.2011.00848.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To identify factors associated with default from follow-up cervical cytology tests. METHODS A cohort study was conducted involving 2166 women, aged 20-59, with recent low-grade cervical cytology taken within the NHS Cervical Screening Programmes in Scotland and England, and managed by 6-monthly cytology in primary care. For the first (6-month) and second (12-month) surveillance cytology tests separately, women were categorized as 'on-time attendees' (attended ≤6 months of test being due), 'late attendees' (attended greater than 6 months after test was due) or 'non-attendees' (failed to attend). Multivariate odds ratios (ORs) were computed for factors associated with late and non-attendance. RESULTS For the first surveillance test, risk of non-attendance was significantly higher in younger women, those without post-secondary education, and non-users of prescribed contraception. Factors significantly associated with late attendance for the first test were the same as for non-attendance, plus current smoking and having children. The most important predictor of non-attendance for the second surveillance test was late attendance for the first test (OR = 9.65; 95% CI, 6.60-16.62). Non-attendance for the second test was also significantly higher among women who were younger, smokers and had negative cytology on the first surveillance test. Late attendance for the second surveillance test was higher in women who were younger, smokers, had children and attended late for the first test. CONCLUSIONS Women at highest risk of default from follow-up cytology tend to be young, smoke, lack post-secondary education, and have defaulted from a previous surveillance appointment. Tackling default will require development of targeted strategies to encourage attendance and research to better understand the reasons underpinning default.
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Affiliation(s)
- L Sharp
- National Cancer Registry Ireland, Cork, Ireland.
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Elit L, Levine MN, Julian JA, Sellors JW, Lytwyn A, Chong S, Mahony JB, Gu C, Finch T, Zeferino LC. Expectant management versus immediate treatment for low-grade cervical intraepithelial neoplasia. Cancer 2010; 117:1438-45. [DOI: 10.1002/cncr.25635] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2010] [Revised: 08/03/2010] [Accepted: 08/04/2010] [Indexed: 11/10/2022]
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McCaffery KJ, Turner R, Macaskill P, Walter SD, Chan SF, Irwig L. Determining the Impact of Informed Choice. Med Decis Making 2010; 31:229-36. [DOI: 10.1177/0272989x10379919] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background. The Rucker 2-stage randomized trial (RCT) design and method allows treatment, preference, and selection effects to be estimated separately in clinical trials. Objective. To understand the effect of patient choice on patient outcomes, the authors applied the Rucker design and analysis method. Design. They used data from a trial of management strategies for women with atypical cells of undetermined significance (ASCUS) detected at routine cervical screening, in which informed choice using a decision aid was compared to no choice. Setting. Women’s health clinics across Australia. Patients. Women aged 18 to 70 years (n = 314) with ASCUS. Intervention. Women were randomized to either an informed choice of human papillomavirus (HPV) triage testing or repeat Pap testing or to no choice with random allocation to management by either option. Measurements. Health-related quality of life (SF36) and satisfaction were measured over the course of management and up to 1 year after triage. Results. Using the Rucker analysis, patients who received their choice had higher quality of life scores than those who did not choose (SF36 MCS, 6% higher, 6.0; 95% confidence interval: −0.6 to 12.9; P = 0.07; effect size 0.61 [moderate]). In contrast, the traditional RCT analysis suggested there was little difference in quality of life between the choice and no-choice trial arms. Limitations. The Rucker method assumes that the declared preferences for treatment in the choice arm are representative of the preferences that would have been observed in the no-choice arms if choice was available. Conclusions. The Rucker method should be used to estimate treatment, preference, and selection effects in randomized trials, as it adds to our understanding of the effect of choice on patient outcomes.
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Affiliation(s)
- Kirsten J. McCaffery
- Screening and Test Evaluation Program, School of Public Health, University of Sydney, Sydney, Australia (KJM, RT, PM, SFC, LI)
- Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada (SDW)
| | - Robin Turner
- Screening and Test Evaluation Program, School of Public Health, University of Sydney, Sydney, Australia (KJM, RT, PM, SFC, LI)
- Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada (SDW)
| | - Petra Macaskill
- Screening and Test Evaluation Program, School of Public Health, University of Sydney, Sydney, Australia (KJM, RT, PM, SFC, LI)
- Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada (SDW)
| | - Stephen D. Walter
- Screening and Test Evaluation Program, School of Public Health, University of Sydney, Sydney, Australia (KJM, RT, PM, SFC, LI)
- Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada (SDW)
| | - Siew Foong Chan
- Screening and Test Evaluation Program, School of Public Health, University of Sydney, Sydney, Australia (KJM, RT, PM, SFC, LI)
- Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada (SDW)
| | - Les Irwig
- Screening and Test Evaluation Program, School of Public Health, University of Sydney, Sydney, Australia (KJM, RT, PM, SFC, LI)
- Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada (SDW)
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McCaffery KJ, Irwig L, Turner R, Chan SF, Macaskill P, Lewicka M, Clarke J, Weisberg E, Barratt A. Psychosocial outcomes of three triage methods for the management of borderline abnormal cervical smears: an open randomised trial. BMJ 2010; 340:b4491. [PMID: 20179125 PMCID: PMC2827716 DOI: 10.1136/bmj.b4491] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To assess which of three triage strategies for women with borderline abnormal cervical smear results in the best psychosocial outcomes. DESIGN Pragmatic, non-blinded, multicentre, randomised controlled trial. SETTING 18 family planning clinics across Australia, covering both urban and rural areas, between January 2004 and October 2006. PARTICIPANTS Women aged 16-70 years (n=314) who attended routine cervical screening and received a borderline cervical smear. INTERVENTIONS Patients were randomly assigned to human papillomavirus (HPV) DNA testing (n=104), a repeat smear test at six months (n=106), or the patient's informed choice of either test supported by a decision aid (n=104). Psychosocial outcomes were assessed at multiple time points over 12 months by postal questionnaire. MAIN OUTCOME MEASURES We assessed health related quality of life (SF36 mental health subscale), cognitive effects (such as perceived risk of cervical cancer, intrusive thoughts), affective outcomes (general anxiety [state-trait anxiety inventory]), specific anxiety about an abnormal smear (cervical screening questionnaire), and behavioural outcomes (sexual health behaviour and visits to the doctor) over 12 months of follow-up. RESULTS At two weeks, some psychosocial outcomes were worse for women allocated to HPV testing compared with those in the smear testing group (SF36 vitality subscale: t=-1.63, df=131, P=0.10; intrusive thoughts chi(2)=8.14, df=1, P<0.01). Over 12 months, distress about the abnormal smear was lowest in women allocated to HPV testing and highest in the repeat smear testing group (t=-2.89, df=135, P<0.01). Intrusive thoughts were highest in patients allocated to HPV testing (25%, compared with 13% in the informed choice group; difference=12%, 95% CI -1.1% to 25.1%). Women in the HPV DNA group and the informed choice group were more satisfied with their care than women allocated to repeat smear testing. CONCLUSIONS Although the psychosocial effect was initially worse for women allocated to HPV triage, over the full year of follow-up this intervention was better for women's psychosocial health than repeat smear testing. Offering informed choice could have a small advantage for cognitive outcomes, but in view of the additional effort and logistical complexity that this intervention requires, HPV testing alone can be justified for most women. TRIAL REGISTRATION actr.org.au Identifier: 12605000111673.
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Affiliation(s)
- Kirsten J McCaffery
- Screening and Test Evaluation Program, School of Public Health, University of Sydney, NSW 2006, Australia.
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Cytological surveillance compared with immediate referral for colposcopy in management of women with low grade cervical abnormalities: multicentre randomised controlled trial. BMJ 2009; 339:b2546. [PMID: 19638646 PMCID: PMC2718083 DOI: 10.1136/bmj.b2546] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVES To examine the effectiveness of cytological surveillance in primary care compared with immediate referral for colposcopic examination in women with low grade abnormal results on cervical cytology tests. DESIGN Multicentre individually randomised controlled trial. SETTING NHS cervical screening programmes in Grampian, Tayside, and Nottingham. PARTICIPANTS 4439 women, aged 20-59, with a cytology result showing borderline nuclear abnormalities or mild dyskaryosis, October 1999-October 2002. INTERVENTIONS Cytological screening every six months in primary care (n=2223) or referral for colposcopy and related interventions (n=2216). All women were followed for three years, concluding with an exit appointment at which colposcopic examination was undertaken. Colposcopists assessing outcome at this appointment were blinded to randomisation. MAIN OUTCOME MEASURES Primary end point: cumulative incidence of cervical intraepithelial neoplasia grade II or more severe disease. Other end points: cervical intraepithelial neoplasia grade III or worse, clinically significant anxiety and depression, other self reported after effects, and rates of non-attendance. Analysis was by intention to treat; all those randomised were included. RESULTS The cumulative incidence of cervical intraepithelial neoplasia grade II or worse was 79 per 1000 person years in the colposcopy arm and 58 per 1000 person years in the cytological surveillance arm (relative risk 1.37, 95% confidence interval 1.19 to 1.57). This difference was less marked for cervical intraepithelial neoplasia grade III or more severe disease, but the incidence was still higher in the colposcopy arm (relative risk 1.26, 1.04 to 1.53). Among women randomised to immediate colposcopy, 79% (74.9% to 82.5%) of cases of cervical intraepithelial neoplasia grade II or worse were diagnosed at the time of the immediate colposcopy, while among women randomised to cytological surveillance, 77% (72.1% to 81.2%) of cases were detected by surveillance cytology and related interventions. Similar proportions of women were anxious or depressed in the two arms. A higher proportion of women in the colposcopy arm reported after effects, and these were of longer duration and more severe. Non-attendance was low in both arms. CONCLUSION The more marked difference between the arms in the occurrence of cervical intraepithelial neoplasia grade II or worse than in the occurrence of grade III or worse can probably be accounted for by the spontaneous regression of some cases of grade II neoplasia. Compared with cytological surveillance, a policy of immediate colposcopy detects more cervical intraepithelial neoplasia grade II or worse, and some more grade III or worse, but might lead to overtreatment. Such a policy is associated with a higher rate of reported after effects, which are more severe and of longer duration than those associated with cytological surveillance. TRIAL REGISTRATION ISRCTN 34841617.
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Whynes DK, Woolley C, Philips Z. Management of low-grade cervical abnormalities detected at screening: which method do women prefer? Cytopathology 2008; 19:355-62. [DOI: 10.1111/j.1365-2303.2008.00565.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Vist GE, Bryant D, Somerville L, Birminghem T, Oxman AD. Outcomes of patients who participate in randomized controlled trials compared to similar patients receiving similar interventions who do not participate. Cochrane Database Syst Rev 2008; 2008:MR000009. [PMID: 18677782 PMCID: PMC8276557 DOI: 10.1002/14651858.mr000009.pub4] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Some people believe that patients who take part in randomised controlled trials (RCTs) face risks that they would not face if they opted for non-trial treatment. Others think that trial participation is beneficial and the best way to ensure access to the most up-to-date physicians and treatments. This is an updated version of the original Cochrane review published in Issue 1, 2005. OBJECTIVES To assess the effects of patient participation in RCTs ('trial effects') independent both of the effects of the clinical treatments being compared ('treatment effects') and any differences between patients who participated in RCTs and those who did not. We aimed to compare similar patients receiving similar treatment inside and outside of RCTs. SEARCH STRATEGY In March 2007, we searched The Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, The Cochrane Methodology Register, SciSearch and PsycINFO for potentially relevant studies. Our search yielded 7586 new references. In addition, we reviewed the reference lists of relevant articles. SELECTION CRITERIA Randomized studies and cohort studies with data on clinical outcomes of RCT participants and similar patients who received similar treatment outside of RCTs. DATA COLLECTION AND ANALYSIS At least two review authors independently assessed studies for inclusion, assessed study quality and extracted data. MAIN RESULTS We identified 30 new non-randomized cohort studies (45 comparisons): no new RCTs were found. This update now includes five RCTs (yielding 6 comparisons) and 80 non-randomized cohort studies (130 comparisons), with 86,640 patients treated in RCTs and 57,205 patients treated outside RCTs. In the randomised studies, patients were invited to participate in an RCT or not; these comparisons provided limited information because of small sample sizes (a total of 412 patients) and the nature of the questions they addressed. When the results of RCTs and non-randomized cohorts that reported dichotomous outcomes were combined, there were 98 comparisons; there was also heterogeneity (P < 0.00001, I(2) = 42.2%) between studies. No statistical significant differences were found for 85 of the 98 comparisons. Eight comparisons reported statistically significant better outcomes for patients treated within RCTs, and five comparisons reported statistically significant worse outcomes for patients treated within RCTs. There was significant heterogeneity (P < 0.00001, I(2) = 58.2%) among the 38 continuous outcome comparisons. No statistically significant differences were found for 30 of the 38 comparisons. Three comparisons reported statistically significant better outcomes for patients treated within RCTs, and five comparisons reported statistically significant worse outcomes for patients treated within RCTs. AUTHORS' CONCLUSIONS This review indicates that participation in RCTs is associated with similar outcomes to receiving the same treatment outside RCTs. These results challenge the assertion that the results of RCTs are not applicable to usual practice.
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Affiliation(s)
- Gunn Elisabeth Vist
- Department of Evidence-Based Health Services, Norwegian Knowledge Centre for Health Services, PO Box 7004, St Olavs Plass, Oslo, Norway, 0130.
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KITCHENER H, FLETCHER I, ROBERTS C, WHEELER P, ALMONTE M, MAGUIRE P. The psychosocial impact of human papillomavirus testing in primary cervical screeninga study within a randomized trial. Int J Gynecol Cancer 2008; 18:743-8. [DOI: 10.1111/j.1525-1438.2007.01113.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Rebolj M, Bais AG, van Ballegooijen M, Boer R, Meerding WJ, Helmerhorst TJM, Habbema JDF. Human papillomavirus triage of women with persistent borderline or mildly dyskaryotic smears: Comparison of costs and side effects of three alternative strategies. Int J Cancer 2007; 121:1529-35. [PMID: 17565745 DOI: 10.1002/ijc.22838] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
The conventional direct referral to colposcopy of persistent borderline or mildly dyskaryotic (BMD) smears in cervical cancer screening leads to considerable unnecessary referrals and associated anxiety and costs. This may be improved by including testing for oncogenic human papillomavirus (HPV) in the triage. We assessed costs and side effects (referrals, treatments and time in follow-up) for 3 possible HPV triage strategies (immediate HPV testing, a 6-month delay in HPV testing, a 2-stage combination of both) and compared them with the conventional strategy. The assessments are based on recent Dutch data from various national databases and trials. We estimated that the referral rate could be reduced by 49, 58 and 58% with immediate, delayed and 2-stage HPV testing, respectively. As a consequence, the average length of follow-up, as well as average costs, also decrease. Therefore, we advocate including HPV testing before referring to colposcopy. Among the 3 HPV strategies, analysis of additional aspects favors implementation of immediate HPV testing.
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Affiliation(s)
- Matejka Rebolj
- Department of Public Health, Erasmus MC, Rotterdam, the Netherlands.
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Ahmed AS, Goumalatsos G, Akbar N, Lawton FG, Savvas M. Outcome analysis of 4 years' follow-up of patients referred for colposcopy with one smear showing mild dyskaryosis. Cytopathology 2007; 19:94-105. [PMID: 17937774 DOI: 10.1111/j.1365-2303.2007.00478.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To assess the 4-year outcome of patients after one smear showing mild dyskaryosis with respect to smear regression rate, prevalence of cervical intraepithelial neoplasia (CIN) and the effect of age. METHODS Retrospective analysis of patients diagnosed with initial mildly dyskaryotic smear during the year 2000 with a follow-up period of 48 months. These women had not had any previous abnormal smears. SETTINGS Cytopathology Department and Colposcopy Unit, King's College Hospital, London, UK. RESULTS We identified 524 patients of whom 375 patients with complete follow-up data are included. The age range was 19-67 years with a median of 29 years. There were 207 patients aged 35 years or less (55%). At 6 months, 258 smears were performed and 47.8% of them were negative (95% CI: 41.6-54.0%). The total number of negative follow-up smears in the first year was 198 out of a total of 397 smears performed (50%). This proportion has significantly increased between 1 and 4 years' follow-up to 67.5% (RR: 1.24; 95% CI: 1.14-1.35). Over the 4-year period, 791 smears were performed and 477 were negative (60.3%; 95% CI: 56.9-63.7%). Of the 477 negative smears there were only 61 smears (12.8%; 95% CI: 10-16%), in 54 patients (14%; 95% CI: 11-18%) that reverted back to low-grade cytological abnormality. In only one case the repeat smear showed high-grade abnormality after initial negative follow-up; however, on biopsy, histology showed CIN I. Out of the 375 patients, 70 required treatment with excisional biopsy (19%; 95% CI: 15.0-22.9%). Histology confirmed high-grade CIN in only 41 cases giving a prevalence of 11% (95% CI: 8.1-14.5%). There were no cases of microinvasive or invasive cancer detected. Age (< or =35 years versus >35 years) did not significantly affect either cytological or histological outcome. CONCLUSION Sixty per cent of follow-up smears after initial mild dyskaryosis subsequently became negative; of them 87.2% remained negative over the 4 year follow-up. Treatment was only required in 19% of patients, with 11% prevalence of high-grade CIN. Age did not affect the outcome. These results are reassuring and indicate that colposcopic referral may not be necessary after only one mildly dyskaryotic smear.
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Affiliation(s)
- A S Ahmed
- Gynaecology Dept, King's College Hospital, London, UK.
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Kyrgiou M, Koliopoulos G, Martin-Hirsch P, Kehoe S, Flannelly G, Mitrou S, Arbyn M, Prendiville W, Paraskevaidis E. Management of minor cervical cytological abnormalities: A systematic review and a meta-analysis of the literature. Cancer Treat Rev 2007; 33:514-20. [PMID: 17658693 DOI: 10.1016/j.ctrv.2007.05.002] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2007] [Accepted: 05/28/2007] [Indexed: 10/23/2022]
Abstract
BACKGROUND A significant number of women are diagnosed with a low grade cytological abnormality on cervical screening. Many authorities recommend surveillance as spontaneous regression might occur. However, protracted attendance for cytological follow-up decreases with time and might put some women at risk of developing invasive disease. The aim of this review was to assess management options for women with minor cervical disease. METHODS An electronic literature search was conducted. All randomised controlled studies comparing immediate colposcopy to cytological surveillance in women with cervical atypia/borderline nuclear changes or low-grade lesions were included. The main outcomes studied were the default rates from the colposcopy clinic and the histological status of biopsies within immediate management protocols compared to biopsies taken on completion of surveillance. Pooled relative risks and 95% confidence intervals were calculated using a random-effect model and inter-study heterogeneity was assessed with Cochrane's Q-test. RESULTS Three randomised controlled trials identified from the literature search with different surveillance periods were combined. The analysis revealed that compliance with follow-up declines over time and reaches significance at the end of 24 months of surveillance (RR: 74.10 [10.36, 529.79]). There was a significantly higher incidence of HPV and CIN 1 in those women referred to immediate colposcopy/treatment compared to those at the end of 24 months surveillance period (32% vs 21%) (RR 1.49, 95% CI 1.17-1.90) and (21% vs 8%) (RR 2.58, 95% CI 1.69-3.94), respectively, possibly explained by spontaneous regression of clinically non-important lesions. Finally, there was no significant difference in the incidence of CIN2 or worse at initial colposcopy compared with the observation group (24 months) (RR 1.72, 95% CI 0.85-3.48). CONCLUSION Cytological surveillance puts women at risk as many show poor compliance and such women might have occult high grade abnormalities. A general policy should be immediate colposcopy for all women after a single low grade cervical smear.
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Affiliation(s)
- M Kyrgiou
- Department of Obstetrics and Gynaecology, Victoria Hospital, Blackpool FY3 8NR, UK.
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Galaal KA, Deane K, Sangal S, Lopes AD. Interventions for reducing anxiety in women undergoing colposcopy. Cochrane Database Syst Rev 2007:CD006013. [PMID: 17636821 DOI: 10.1002/14651858.cd006013.pub2] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Before cervical cancer develops the cells of the cervix become abnormal. Following an abnormal cervical smear colposcopy is performed. 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 STRATEGY The Cochrane Central Register of Controlled Trials (CENTRAL), (Cochrane Library, Issue 1, 2006) MEDLINE (1951-2006), EMBASE (1980-2006), CINAHL (1982-2006), Psych Lit and CancerLit, NHMRC Clinical Trials Register, UKCCCR Register of Cancer Trials, Meta-Register and Physician Data Query Protocols. SELECTION CRITERIA Randomised and quasi randomised controlled trials of interventions to reduce anxiety during colposcopic examination. DATA COLLECTION AND ANALYSIS One author searched the citations and reference lists. Studies that appeared to meet inclusion criteria were retrieved and assessed independently by the remaining three authors. The methodological quality of included studies was assessed using the Cochrane Collaboration Back Review Group's methodological quality criteria (van Tulder 2003). MAIN RESULTS Eleven trials were included, these trials used various interventions to reduce anxiety. These examined 1441 women's anxiety levels after different types of intervention. These included: Information leaflets - (proved not to be associated with anxiety reduction). Counselling: pre-colposcopic counselling was not associated with anxiety reduction. Information leaflets and information video and pre-colposcopy counselling was not associated with a reduction in anxiety levels. Listening to music during colposcopy: this intervention was associated with reduction in anxiety levels (p < 0.002). Video colposcopy was associated with reduction in anxiety levels, and the reduction in anxiety was significant (p < 0.0002). Information using graphs and verbal information and information video versus information only when sought: There was no significant reduction in the level of anxiety in the intervention group. Information leaflets and information video versus information leaflets only: There was a reduction in anxiety levels in the intervention group compared to the control group (p < 0.00001). AUTHORS' CONCLUSIONS Anxiety appears to be reduced by playing music during colposcopy, showing information videos prior to colposcopy and viewing video colposcopy during the procedure. Although information leaflets did not reduce anxiety levels, they did increase knowledge levels and so are useful in obtaining clinical consent to the colposcopic procedure.
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Affiliation(s)
- K A Galaal
- Queen Elizabeth Hospital, Northern Gynaecology Oncology Centre, Queen Elizabeth Avenue, Sherriff Hill, Gateshead, Tyne & Wear, UK, NE7 7XA.
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Abstract
Although the incidence rate of cervical cancer has decreased over the last several years, low-income ethnic minority women remain at increased risk for morbidity and mortality from cervical cancer. We conducted a pilot study to examine the feasibility and acceptability of mindfulness-based stress reduction (MBSR) program among multiethnic low-income women with abnormal Pap smears. Spanish- and English-speaking women recruited through convenience sampling participated in MBSR classes 2 hours each week over 6 consecutive weeks. State anxiety and self-compassion were measured before and after the MBSR program. Focus groups and surveys were used to evaluate the program. Although 51 women were initially recruited, pre- and post-MBSR data were available only for 8 women. There was a significant reduction in anxiety and a trend toward increased self-compassion in this group of women. The participants evaluated the MBSR program very positively. The high attrition rate highlights the challenges of conducting MBSR research with this demographic of women. Potential strategies for improving recruitment and retention of low-income multiethnic women are discussed.
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Waller J, McCaffery K, Kitchener H, Nazroo J, Wardle J. Women's experiences of repeated HPV testing in the context of cervical cancer screening: a qualitative study. Psychooncology 2007; 16:196-204. [PMID: 16858719 DOI: 10.1002/pon.1053] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To evaluate the psychosocial impact of taking part in repeated testing for human papillomavirus (HPV) in the context of cervical cancer screening. METHODS In-depth interviews were carried out with 30 women who were HPV positive with normal cytology at trial baseline, and attended for a repeat HPV test 12 months later. Interview transcripts were analysed qualitatively using Framework Analysis to identify emergent themes. RESULTS Although women often experienced serious negative emotional consequences at the time of their first positive result, these did not generally last during the year between tests once questions about HPV had been resolved. The emotional impact of testing positive a second time was greater for many women, sometimes causing them to overcome their embarrassment about having a sexually transmitted infection in order to disclose their result and seek support. Among the women interviewed there was an overwhelming preference for immediate colposcopy rather than continued surveillance for persistent HPV. This was associated with the desire for a speedy resolution, and fears about progression to cancer. CONCLUSIONS Although most women did not appear to suffer on-going anxiety while waiting for a second HPV test, this seemed contingent on their information needs being met. Women appeared to be more distressed by a second HPV positive result than a single one, and expressed a clear preference for immediate colposcopy over continued surveillance. This finding might have implications for the way in which HPV testing could be used in cervical cancer screening programmes.
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Affiliation(s)
- Jo Waller
- Cancer Research UK, Health Behaviour Unit, Department of Epidemiology and Public Health, UCL, 2-16 Torrington Place, London WC1E 6BT, UK.
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Adamson J, Cockayne S, Puffer S, Torgerson DJ. Review of randomised trials using the post-randomised consent (Zelen's) design. Contemp Clin Trials 2006; 27:305-19. [PMID: 16455306 DOI: 10.1016/j.cct.2005.11.003] [Citation(s) in RCA: 101] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2004] [Revised: 11/10/2005] [Accepted: 11/14/2005] [Indexed: 11/24/2022]
Abstract
BACKGROUND In 1979, Zelen described a trial method of randomising participants before acquiring consent in order to enhance recruitment to clinical trials. The method has been criticised ethically due to lack of consent and scientifically due to high crossover rates. This paper reviews recent published trials using this method and describes the reasons authors gave for using the method, examines the crossover rates, and looks at the quality of identified trials. METHODS Literature review searching for all citations to the relevant Zelen's papers of trials published since 1990 plus inclusion of trials from personal knowledge. RESULTS We identified 58 relevant trials. The most common justification for the use of Zelen method was to avoid the introduction of bias (e.g., to avoid the Hawthorne effect). Few trialists had explicitly used the design to enhance participant recruitment. Most trials (n=41) experienced some crossover from one group to the other (median crossover=8.9%, mean=13.8%, IQR 2.6% to 15%) although this was usually within acceptable limits. CONCLUSION The most important reason stated by authors for using Zelen's method was to limit bias. Zelen's method, if carefully used, can avoid 'resentful demoralisation' and the Hawthorne effect biasing a trial. Unlike a previous review, we found that crossover was not a problem for most trials.
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Affiliation(s)
- Joy Adamson
- York Trials Unit, Department of Health Sciences, University of York, York YO10 5DD, UK
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Kitchener HC, Castle PE, Cox JT. Chapter 7: Achievements and limitations of cervical cytology screening. Vaccine 2006; 24 Suppl 3:S3/63-70. [PMID: 16950019 DOI: 10.1016/j.vaccine.2006.05.113] [Citation(s) in RCA: 149] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2006] [Accepted: 05/15/2006] [Indexed: 10/24/2022]
Abstract
This chapter reviews the contribution of cervical cytology, what makes it successful, the management of screen positives and how technological advances may affect its use in the future. Cervical screening has saved hundreds of thousands of lives but has not been available to women in the poorest countries. In countries where wide coverage has been achieved and quality assurance is in place, incidence and death rates have fallen by over 50% even though cervical cytology is logistically complex. The management of high-grade cervical intraepithelial neoplasia (CIN) is very effective, but low-grade cytological abnormalities require care to avoid over-treatment. The increasing rate of human papillomavirus (HPV) testing and the prospect of prophylactic vaccination will change the way cervical cytology is used, possibly giving way to HPV testing as the primary test in secondary prevention.
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Affiliation(s)
- Henry C Kitchener
- Academic Unit of Obstetrics & Gynaecology, University of Manchester, St. Mary's Hospital, Whitworth Park, Manchester, UK.
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Bentley E, Cotton SC, Cruickshank ME, Duncan I, Gray NM, Jenkins D, Little J, Neal K, Philips Z, Russell I, Seth R, Sharp L, Waugh N. Refining the Management of Low-Grade Cervical Abnormalities in the UK National Health Service and Defining the Potential for Human Papillomavirus Testing: A Commentary on Emerging Evidence. J Low Genit Tract Dis 2006; 10:26-38. [PMID: 16378029 DOI: 10.1097/01.lgt.0000192695.93172.75] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Elaine Bentley
- University of Nottingham Medical School at Derby, Derby City General Hospital, UK
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Smith JHF. Can the management of mild dyskaryosis be refined? Cytopathology 2005; 16:273-6. [PMID: 16303039 DOI: 10.1111/j.1365-2303.2005.00305.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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