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Sir,

Wiener, Sweetnam and Jones (1992) in their recent paper conclude that ‘the risk of vaginal carcinoma after hysterectomy for pre-invasive carcinoma of the cervix is similar to the incidence of pre-invasive carcinoma of the cervix in the general population.’ On this basis alone, they recommended that ‘screening for carcinoma of the vagina should be at the same frequency as that for cervical carcinoma in the general population.’ Can I suggest that their simple conclusion may not take a sufficiently full account of the generally accepted criteria for the evaluation of any individual screening programme. In particular screening can only be justified where not only has the test been shown to be adequately specific and sensitive, but also only when it has been clearly demonstrated that available treatment will effectively halt the progress of the disease sought, and where ‘the test is acceptable to those tested’ (Wilson & Junger 1968).

Whilst routine screening of a generally healthy population for an eminently treatable disease must be commendable, regularly reminding anxious, and sometimes very frightened women, that their cancer may not have been fully cured, cannot, I suggest, be so universally advised. Indeed, my own interest in post hysterectomy screening resulted from the recognition of the sometimes quite unacceptable levels of anxiety too often found in this particular subgroup of women, typified by a patient who said ‘I get all worked up for the week before my annual check-up. My head pounds and I get myself in such a state’ (said by a woman who had had ‘a small focus of dysplasia’ in her cervix followed by a pathology free hysterectomy eight years before). Further work may be needed to quantify the level of stress caused, but mean-while are we not under an obligation to demonstrate much more clearly than has so far been achieved that early detection of vaginal problems will significantly result in effective early treatment. Certainly in my own study of 4304 women years of follow-up, the one late recurrence revealed by all that activity did not seem to lead to any improvement in that patient's ultimate prognosis. (Fawdry 1984).

Our actions will always speak more loudly than our words and our words and our verbal reassurance that ‘it was only car-cinoma-in-situ’ (a meaningless term for most lay people) will rarely be sufficient to overcome the fear of recurrence of cancer, especially if our patient feels that ‘my cancer was so bad that I had to have a hysterectomy’. In such a situation the inevitable false positives will cause even more devastating effects.

Having again confirmed in their study that the rate of vaginal carcinoma after hysterectomy is extremely low, indeed hardly higher than the general population risk of cervical problems, I would suggest that, for the sake of the overall health of our patients, it is still not unreasonable to continue to recommend one or two years of follow up to ensure complete removal. At the end of that time we should then very firmly reassure our hysterectomised women that ‘we have removed your uterus and you can no longer die from cancer of the cervix. You no longer need cervical cytology screening; indeed that would be impossible. Naturally we cannot guarantee that the rest of your body will always remain free of problems, and if you are at all worried go and see your doctor but you can now forget about cervical cancer’.

If professionally we still feel the need to offer at least some of our patients a fresh screening programme for vaginal neoplasia, we will only be fair to them if we make it quite clear that such screening is: optional, not mandatory; and for a quite different disease with very different possibilities for treatment.

References

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  2. References
  • Fawdry R. D. S. (1984) Carcinoma in situ of the cervix: is post hysterectomy cytology worthwhile Br J Obstet Gynaecol 99, 907910.
  • Wiener J. J., Sweetnam P. M. & Jones J. M. (1992) Long term follow up of women after hysterectomy with a history of pre-invasive cancer of the cervix. Br J Obstet Gynaecol 99, 907910.
  • Wilson J. M. G. & Junger G. (1968) Principles and practice of screening for disease. Public Health Paper, no. 34, World Health Organisation, Geneva .