Can high-grade cervical lesions be managed in a single clinic visit?

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Abstract

BACKGROUND

In the US, women from low-income backgrounds and minority groups, particularly those of Latin American origin, have a high incidence of cervical cancer. Attendance for Papanicolaou ('Pap') smear testing and follow-up is low among these populations. A simplified screening program entailing a single clinic visit could increase the number of women who receive screening and treatment for cervical abnormalities.

OBJECTIVES

To determine the feasibility and acceptability of a single-visit approach to cervical cancer screening and treatment in under-resourced communities, and to compare treatment and follow-up rates with those of women receiving standard care.

DESIGN

Enrollment for this randomized, controlled trial took place between January 1999 and April 2002. During the first half of the study, women were recruited through registries of community health clinics in Orange County, CA. After December 1999, media recruitment was predominantly employed. Women were eligible for enrollment if they were over 18 years of age, had no history of cervical malignancy, were not pregnant, and had not undergone a cervical screening procedure within the past 12 months.

INTERVENTION

Participants were randomized to one of two treatment groups. In the standard-care group, women were discharged after their Pap test to await the outcome by post and seek further evaluation in the event of an abnormal result. In the single-visit group, women remained in the clinic after their test and received the results on the same day. An immediate cervical loop electrosurgical excision procedure was performed on women in the single-visit group who were found to have high-grade squamous intraepithelial lesions (HGSIL), atypical glandular cells of undetermined significance (AGUS), or suspicion of carcinoma.

OUTCOME MEASURES

The primary outcome measures were 6-month treatment rates for women with HGSIL and AGUS, and follow-up rates at 6 months for lower grade lesions and 12 months for all women.

RESULTS

The rate of cervical abnormalities among all participants (standard care n = 1,805; single visit n = 1,716) was 4.1%, with 1% of tests showing HGSIL or AGUS. The percentage of women who received definitive treatment for these high-grade lesions within 6 months of screening was significantly higher in the single-visit group (88%) than in the standard-care group (53%; P = 0.04). Among all participants, the percentage who returned for follow-up screening 1 year after their initial Pap test did not differ between the two treatment groups (36%). Among the subset of women diagnosed with HGSIL or AGUS, however, more from the single-visit group returned for follow-up testing at 12 months than in the standard-care group (P = 0.02). In the single-visit group, the period of time spent waiting for Pap test results was deemed acceptable by 76% of the participants, and 95% stated that they would request this treatment approach again.

CONCLUSION

The single-visit approach to cervical cancer screening was feasible and acceptable to women in this under-resourced population and resulted in improved treatment and follow-up rates for high-grade abnormalities.

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