Effect of nurse colposcopists on a hospital-based service

Evaluation of 'see-see and treat' strategy and role of HIV on cervical cancer prevention in Uganda

Background

There is scant information on whether Human Immunodeficiency Virus (HIV) seropositivity has an influence on the outcome of treatment of precancerous cervical lesions using cryotherapy. We studied the prevalence of cervical abnormalities detectable by visual inspection and cervical lesions diagnosed by colposcopy according to HIV serostatus and described the outcomes of cryotherapy treatment.

Methods

Trained nurses examined women not previously screened for cervical cancer using visual inspection with acetic acid (VIA) and Lugol's iodine (VILI) in two family planning/post natal clinics in Kampala, Uganda, from February 2007 to August 2008. Women with abnormal visual inspection findings were referred for colposcopic evaluation and HIV testing. Women with precancerous cervical lesions detected at colposcopy were treated mainly by cryotherapy, and were evaluated for treatment outcome after 3 months by a second colposcopy.

Results

Of the 5 105 women screened, 834 presented a positive screening test and were referred for colposcopy. Of these 625 (75%) returned for the colposcopic evaluation and were tested for HIV. For the 608 (97.5%) women in the age range 20-60 years, colposcopy revealed 169 women with cervical lesions: 128 had inflammation, 19 had low grade squamous intraepithelial lesion (LGSIL), 13 had high grade squamous intraepithelial lesion (HGSIL), 9 had invasive cervical cancer and 2 had inconclusive findings. Detection rates per 1 000 women screened were higher among the older women (41-60 years) compared to women aged 20-40 years. They were accordingly 55% and 20% for inflammation, 10% and 2% for LGSIL, 5% and 2% for HGSIL, 6% and 1% for invasive cervical cancer.

Of the 608 women, 103 (16%) were HIV positive. HIV positivity was associated with higher likelihood of inflammation (RR = 1.7; 95% CI: 1.2-2.4).

Conclusions

Detection rates were higher among older women 41-60 years. Visual inspection of the cervix uteri with acetic acid (VIA) and Lugol's iodine (VILI) used as a sole method for cervical cancer screening would entail significant false positive results. HIV seropositivity was associated with a higher prevalence of inflammatory cervical lesions. In view of the small numbers and the relatively short follow up time of 3 months, we could not make an emphatic conclusion about the effect of HIV serostatus on cryotherapy treatment outcome.

Women's colposcopy experience and preferences: a mixed methods study

BACKGROUND

The colposcopy service is a key component in the UK Cervical Screening Programme. Over 120,000 women are referred to the service annually, however up to 25% of women fail to attend their appointment. Little is known about patients' preferences for colposcopic investigation and treatment. This study aims to investigate women's experience of colposcopy, to identify patients' preferences for aspects of appointments within the colposcopy service, and to make suggestions for service improvement.

METHODS/DESIGN

This study has been designed as a two stage, mixed method project. Stage one will involve in-depth interviews with new colposcopy patients to ascertain their experience of colposcopy services. This qualitative stage will generate factors thought to be important by service users in their experience. Stage two will utilise a choice based quantitative technique to identify women's preferences and determine the representativeness of factors generated through the interviews. The initial stage of in-depth interviews will be conducted with patients who are newly referred to colposcopy clinics to investigate the experience that they have of the referral process and appointment attendance. The outcome of these interviews will be analysed qualitatively using Framework analysis. Factors found to be important in women's experience will be extracted and used to construct a choice based questionnaire. The discrete choice experiment (questionnaire) will apply a best-worst technique through scenario-based questions to find women's relative preferences for different aspects of the service. It will be offered to women attending follow-up appointments at two colposcopy clinics in the West Midlands. Women will complete the questionnaire whilst they wait for their appointment, or, if they prefer, will take it home to complete in private. Women who do not attend their appointment will be posted the research information and questionnaire. The questionnaire analysis will use a weighted least squares regression technique for each best/worst pair. The accept/reject 'would you attend this appointment' question will be analysed using a random effects logit model.

DISCUSSION

Colposcopy is a common procedure and one that is associated with raised anxiety among women experiencing the service. Little is known about women's experience of the service or their preferences for service delivery. The outcomes of the study will comprise a description of women's experience of colposcopy and establishing their preferences for how aspects of the service should be provided. Women's preferences will be fed back to service providers to enable improvements to the service to be made.

Effectiveness, safety and acceptability of 'see and treat' with cryotherapy by nurses in a cervical screening study in India

We evaluated a ‘see and treat’ procedure involving screening, colposcopy, biopsy and cryotherapy by trained nurses in one-visit in field clinics in a cervical screening study in South India for its acceptability, safety and effectiveness in curing cervical intraepithelial neoplasia (CIN). Women positive on visual inspection with acetic acid (VIA) were advised colposcopy, directed biopsies and cryotherapy if they had colposcopic impression of CIN in one visit by nurses in field clinics supervised by a doctor. Side effects and complications were assessed and cure rates were evaluated with VIA, colposcopy and biopsy if colposcopic abnormalities were suspected. Cure was defined as no clinical or histological evidence of CIN at ⩾6 months from treatment. Of the 2513 women offered ‘see and treat’ procedure, 1879 (74.8%) accepted. Of the 1397 women with histologically proved CIN treated with cryotherapy, 1026 reported for follow-up evaluation. Cure rates were 81.4% (752 out of 924) for women with CIN 1; 71.4% (55 out of 77) for CIN 2 and 68.0% (17 out of 25) for CIN 3. Minor side effects and complications were documented in less than 3% of women. ‘See and treat’ with cryotherapy by nurses under medical supervision is acceptable, safe and effective for cervical cancer prevention in low-resource settings.

Number of cervical biopsies and sensitivity of colposcopy

OBJECTIVE

To examine the influence that type of medical training and number of biopsies have on sensitivity of colposcopically guided biopsies.

METHODS

Among 408 women with an adequate enrollment colposcopy and a diagnosis of cervical intraepithelial neoplasia (CIN) 3 or cancer (CIN 3+) over 2 years in the Atypical Squamous Cells of Undetermined Significance/Low-Grade Squamous Intraepithelial Lesions (ASCUS-LSIL) Triage Study, we evaluated factors influencing the sensitivity of the enrollment colposcopic procedure. We used contingency table analysis to examine confounding variables and chi(2) tests to ascertain statistical significance.

RESULTS

Overall, 69.9% of women with a cumulative diagnosis of CIN 3+ had a "true-positive" enrollment colposcopically guided biopsy result of CIN 2 or worse (CIN 2+), the threshold that would trigger excisional therapy. The sensitivity of the procedure did not vary significantly by type of colposcopist. However, the sensitivity was significantly greater when the colposcopists took two or more biopsies instead of one (P<.01), a pattern observed across all types of colposcopists. Independent of the severity of the colposcopic impression, the frequency with which colposcopists took two or more biopsies instead of one varied (in descending order) from nurse practitioners to general gynecologists to gynecologic oncology fellows to gynecologic oncologists (P<.01).

CONCLUSION

Colposcopy with guided biopsy or biopsies detects approximately two thirds of CIN 3+. Although the sensitivity of the procedure does not differ significantly by type of medical training, it is greater when two or more biopsies are taken.