Can default rates in colposcopy really be reduced?

Attendance at early recall and colposcopy in routine cervical screening with human papillomavirus testing

Attendance at early recall and colposcopy is crucial to attaining the benefits of primary high-risk human papillomavirus (HR-HPV)-based screening. Within the English HPV pilot, we analysed deprivation- and age-related patterns of attendance at colposcopy and 12- and 24-month early recall of HR-HPV positive women screened in 2013 to 2015 (N = 36 466). We fitted logistic regression models for adjusted odds ratios (OR). Despite high overall attendance, area deprivation had a small but significant impact at both early recalls, for example, attendance at 24 months was 86.3% and 83.0% in less vs more deprived areas, respectively (ORadj : 0.76; 95% CI: 0.67-0.87). Older women (≥30 years) were more likely to attend early recall than younger women (<30 years), for example, attendance at 24 months was 86.1% vs 82.3%, respectively (ORadj : 1.32, 95% CI: 1.16-1.51). Most women attended colposcopy following a baseline referral, with 96.9% attendance among more deprived and 97.8% among less deprived areas (ORadj : 0.70; 95% CI: 0.55-0.88). Differences in colposcopy attendance by deprivation level at 12 and 24 months were of approximately the same magnitude. In conclusion, attendance at early recall and colposcopy was reassuringly high. Although there were statistically significant differences by deprivation and age group, these were small in absolute terms.

Understanding the role of oncogenic human papillomavirus (HPV) status on adherence behaviors among women with abnormal cervical cytology

BACKGROUND

With the introduction of oncogenic Human Papillomavirus (HPV) testing into cervical screening there is a renewed focus on primary prevention among high-risk groups. To date, little is known about the effectiveness of this program, and the extent to which individual-level factors, such as psychosocial health and agency, may play a role. In particular, it is unclear if knowledge of one's oncogenic HPV status impacts on adherence behaviors amongst women with screening abnormalities. The purpose of this study was to identify if clinical, demographic or psychosocial factors predict non-adherence with recommended colposcopy follow-up.

METHODS

This prospective pilot study included 145 women referred to a large Toronto colposcopy clinic between December, 2013 and September, 2014. Demographic, clinical and psychosocial characteristics were collected at three points in time: (1) at initial colposcopy consultation; (2) 4-6 weeks following initial consultation, and; (3) at time of follow-up appointment (within 12 months of initial consultation).

RESULTS

Overall, 13% (n = 145) of the women were classified as non-adherent. Older women (OR = 0.73, p < 0.01) and those with higher-grade lesions (OR = 0.10, p < 0.01) were less likely to be non-adherent, whereas current smokers (OR = 22.46, p < 0.01) were more likely to be non-adherent. While not statistically significant, variation in rates of non-adherence amongst the various HPV status groups (untested; 15.3%, HPV positive; 5.3%, HPV negative; 6.7%) warrants further study.

CONCLUSION

Findings of this study indicate that younger women, those with higher-grade lesions and current smokers were more likely to be non-adherent to recommended colposcopy follow-up. While HPV status did not reach statistical significance, the direction of this finding suggests that testing for HPV may have a positive reinforcing role on adherence to follow-up. The direction of this finding warrants further study, and potentially a practical clinical goal as HPV testing for women becomes standard of care.

Post-colposcopy Management of ASC-US and LSIL Pap Tests (PALS Trial): Pilot RCT

OBJECTIVE

Evidence supporting optimal follow-up of women with atypical squamous cells of undetermined significance (ASC-US) or low-grade squamous intraepithelial lesion cytology found to have low-grade disease or normal findings at initial colposcopy is weak. Surveillance options include continued colposcopy, discharge with Pap testing, or HPV testing at 12 months. This study was a pilot RCT comparing these three follow-up policies. The objectives were to determine the feasibility of an RCT and to compare the incidence of greater than or equal to high-grade squamous intraepithelial lesion (≥HSIL) in each of the follow-up policies.

METHODS

A total of 133 women referred with ASC-US or low-grade squamous intraepithelial lesion cytology between June and August 2012 underwent initial colposcopy where incident ≥HSIL histology was ruled out. Of these women, 125 were randomly assigned to colposcopic surveillance, Pap testing, or HPV testing. Patients with high-risk results at any point were treated according to standard of care. Patient recruitment and adherence to follow-up were calculated using descriptive statistics. Accuracy of the three follow-up arms was calculated (Canadian Task Force Classification: IC).

RESULTS

Recruitment rates were 80%, and adherence to protocol was 85% to 100%. Nine of 125 (7.2%) patients overall were found to have ≥HSIL histology at exit: one of 43 in the reference colposcopy group, and six of 41 and three of 41 in Pap and HPV arms, respectively. One early cancer was detected in the HPV arm. Sensitivity and specificity (CI) for each arm, respectively, were as follows: colposcopy N/A, 100% (88.1%-100%); Pap, 100% (47.8%-100%) and 85.7% (63.7%-97%); and HPV, 66.7% (9.4%-99.2%) and 68% (46.5%-85.1%).

CONCLUSION

This pilot study demonstrated the operational and safety feasibility of an RCT in this patient population. Validation of clinical findings is necessary.

Colposcopy attendance and deprivation: A retrospective analysis of 27,193 women in the NHS Cervical Screening Programme

Background:

Attendance for cervical screening is socially graded, but little is known about patterns of attendance for colposcopy following an abnormal screening result.

Methods:

Logistic regression was used to regress colposcopy attendance status for 27 193 women against age and area-level deprivation, adjusting for ethnicity.

Results:

Colposcopy attendance was high at 8 weeks (89%) and 4 months post-referral (94%) but women living in the most deprived areas were significantly less likely to attend.

Conclusions:

The high overall attendance rates at colposcopy are encouraging but lower attendance among women in the most income-deprived areas indicates that even when these women attend primary cervical screening, they remain at higher risk of missing out on the benefits of the programme.

Improving the Rate of Colposcopy in an Urban Population of Patients With Known Abnormal Pap Smears

This project was designed to improve the colposcopy rate in an urban patient population with known abnormal Pap smears within 75 days of the test to rapidly identify and treat premalignant lesions. Using Plan-Do-Study-Act cycles, Lean techniques, and the electronic health record, the authors created a protocol to verify all Pap smears, then created a process whereby a phone-triage team contacted patients with abnormal Pap smears to educate them and schedule colposcopy. As a result, 100% of Pap smears were verified, compared with 95% prior to plan implementation. The mean time from Pap to colposcopy was 38.5 days, with 85% of patients having colposcopy performed after plan implementation, compared with 50% prior-a 70% improvement. If patients with medical contraindications were excluded, the percentage rose to 91%-an 82% improvement. Patient and provider satisfaction improved, staff and provider workload did not increase, and there was the potential for substantial economic savings.

Cytologic surveillance versus immediate colposcopy for women with a cervical smear diagnosis of low-grade squamous intraepithelial lesion in a poor setting in Nigeria

Background

Ideally, all patients with abnormal Papanicolaou smear cytology results should undergo colposcopic examination of the cervix, but low-grade squamous intraepithelial lesions (LSILs) can also be followed up with further Papanicolaou smear surveillance. The aim of this study was to evaluate the outcome of cytologic surveillance versus immediate colposcopy in women with a cervical smear diagnosis of LSIL.

Methods

This was a prospective comparative study of 240 eligible consenting women consecutively grouped into cervical surveillance for 6 months versus immediate colposcopy at a ratio of 1:1. Free cervical smear cytology, colposcopy, and biopsy, as well as histology, were provided for all study participants.

Results

The regression, persistence, and progression rates with 6 months of cytologic surveillance of LSIL were 46.1%, 43.4%, and 3.9%, respectively. The difference between the proportions of women who had an eventual histologic diagnosis of cervical intraepithelial neoplasia 2+ in both groups was not statistically significant (4.9% versus 8.7%; P=0.68). The default rates among women on cytologic surveillance and immediate colposcopy were 37% and 12.5%, respectively (P=0.0002).

Conclusion

Although the progression rate of LSIL is low, a high persistence rate and higher default rate from cytologic surveillance highlight the need to consider immediate referral for colposcopy, where available, for all women with a Papanicolaou smear diagnosis of LSIL in this environment.

Domestic violence is a leading risk factor in default from colposcopy services

AIM

Domestic violence is common in women and is associated with poorer health-care outcomes. However, no causal pathway has been identified to explain this observation. We have followed a cohort of women to determine whether poorer outcomes can be explained by high rates of default and loss to follow-up.

MATERIAL AND METHODS

A prospective cohort study was performed. Institutional ethics approval was obtained. Participants were consecutive patients attending colposcopy clinics at a major metropolitan hospital in Australia. Following ascertainment of domestic violence status, appointment outcomes for colposcopy services were tracked for a 3-year period. Multivariate analysis was undertaken to determine demographic factors associated with default from care and loss to follow-up.

RESULTS

Of 581 women approached, consent was obtained from 574 women (99%). Domestic violence status was obtained from 566 women, of whom 187 (33%) had a recent history of exposure. Women exposed to violence were more likely to default from colposcopy once (26.2% vs 7.4%; P < 0.0001), twice (11.2% vs 3.2%, P = 0.0001), or thrice (10.7% vs 2.4%, P < 0.0001). They were more likely to be lost to follow-up (8.0% vs 1.1%, P < 0.0001). In multivariate analysis, exposure to domestic violence remained significantly associated with default and loss to follow-up.

CONCLUSION

Domestic violence is a risk factor for default from attendance and loss to follow-up at colposcopy services. This may explain the mechanism behind adverse health-care outcomes seen. Screening and targeted appointment intervention programs may improve clinical compliance.

Predictors of default from follow-up care in a cervical cancer screening program using direct visual inspection in south-western Nigeria

Background

Increasingly evidence is emerging from south East Asia, southern and east Africa on the burden of default to follow up care after a positive cervical cancer screening/diagnosis, which impacts negatively on cervical cancer prevention and control. Unfortunately little or no information exists on the subject in the West Africa sub region. This study was designed to determine the proportion of and predictors and reasons for default from follow up care after positive cervical cancer screen.

Method

Women who screen positive at community cervical cancer screening using direct visual inspection were followed up to determine the proportion of default and associated factors. Multivariate logistic regression was used to determine independent predictors of default.

Results

One hundred and eight (16.1%) women who screened positive to direct visual inspection out of 673 were enrolled into the study. Fifty one (47.2%) out of the 108 women that screened positive defaulted from follow-up appointment. Women who were poorly educated (OR: 3.1, CI: 2.0 – 5.2), or lived more than 10 km from the clinic (OR: 2.0, CI: 1.0 – 4.1), or never screened for cervical cancer before (OR: 3.5, CI:3:1–8.4) were more likely to default from follow-up after screening positive for precancerous lesion of cervix . The main reasons for default were cost of transportation (48.6%) and time constraints (25.7%).

Conclusion

The rate of default was high (47.2%) as a result of unaffordable transportation cost and limited time to keep the scheduled appointment. A change from the present strategy that involves multiple visits to a “see and treat” strategy in which both testing and treatment are performed at a single visit is recommended.

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

OBJECTIVE

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

STUDY DESIGN

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

RESULTS

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

CONCLUSION

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

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Effect of Patient Education on Postcolposcopy Follow-Up

The purpose of this study was to investigate the effects of patient education on human papillomavirus (HPV) infection and abnormal Pap smears for women scheduled for colposcopy and their compliance to treatment recommendations. A convenience sample of 60 women was included in the study. The experimental group included 30 women scheduled for colposcopy who received education prior to procedure. Thirty patients in the control group were women referred for colposcopy the year before the study. Both groups were similar in age, ethnicity, insurance status, and histological findings. Recall rates were analyzed between the two groups and results demonstrated a statistical difference in the return rate of the experimental group. Patient education increased compliance to treatment recommendations post colposcopy. Findings provide important information on the importance of educating patients with abnormal Pap results regarding HPV and sequelae of infection.