Do women with high-grade cervical intraepithelial neoplasia prefer a see and treat option in colposcopy?
Dr J Tidy, G18, Royal Hallamshire Hospital, Glossop Road, Sheffield S10 2JF, UK. Email email@example.com
Objective To compare women’s experiences of either see and treat (ST) or defer and treat (DT) at first visit to colposcopy following abnormal cytology.
Design A prospective postal questionnaire survey.
Setting Colposcopy clinics of a University Hospital.
Sample A total of 272 women with high-grade cervical intraepithelial neoplasia (CIN) referred to colposcopy.
Methods A total of 136 women receiving ST and a matched sample of women receiving DT (N= 136) were sent a postal questionnaire 7 days after first appointment at colposcopy to assess evaluations of their experience, psychological distress and relief. Subsequent appointment keeping was extracted from medical records.
Main outcome measures Anxiety and subsequent behaviour.
Results Women undergoing ST were significantly less anxious and more relieved than those undergoing DT. They also evaluated their first appointment as more motivationally congruent. While women undergoing ST were less likely than DTs to keep their second appointment, there was no overall difference in did not attend (DNA) rates at 15-month follow up.
Conclusions ST is psychologically beneficial and may be preferred by women with CIN2/3.
Cancer of the cervix is the second commonest cancer affecting women and poses a major threat to women’s health throughout the world. It affects 471 000 women per year and has an associated mortality of 233 300.1 In England and Wales, there were 2700 new cases, with the incidence of cancer falling from 16 per 100 000 in 1986 to 9.3 per 100 000 in 1997.2 Cervical cancer is potentially preventable by screening and by treatment in the precancerous phase, cervical intraepithelial neoplasia (CIN). Screening programmes use exfoliative cytology, and the national cervical screening programme offers screening to all women aged 25–64 years. Uptake in England is now 80.3% in the target population and in 2004/2005, 3.6 million women were screened, of whom 3.4% were referred to a colposcopy clinic.3
Women with high-grade smears may be offered two management options at their first colposcopy visit. In the defer and treat (DT) management option, biopsies of colposcopically suspicious areas are taken, with further management depending on histology. In see and treat (ST), treatment, large loop excision of the transformation zone (LLETZ), is offered at the initial colposcopy visit if the colposcopist is convinced that the cervical lesions are consistent with CIN2 or worse. Considerable debate exists in the literature regarding the relative advantages and disadvantages of these two management options, but there has been no previous research on patient’s perspective on the available management options. Our aim therefore was to conduct a study to provide an insight into how management type might alter the emotional significance of the colposcopy visit, examine the psychological impact of ST and DT and test our hypothesis that women prefer ST to DT.
A number of previous studies using relatively small samples have examined emotional reactions of women at different stages of the cervical screening cycle (Table 1).4–10 These studies suggest that women receiving abnormal smear results experience elevated levels of anxiety compared with those receiving normal smear results. Although some of the studies are limited by sample size, taken overall, evidence suggests that women experience anxiety, first on receiving the abnormal smear result following which anxiety levels seem to subside. Levels of anxiety peak again immediately prior to colposcopy and also just prior to treatment, to decline to normal levels about 24–36 weeks after colposcopy. It is therefore evident that an abnormal smear result and a colposcopy clinic appointment have considerable emotional impact on women.
Table 1. Anxiety at different stages of the cervical screening cycle
|Wardle et al.4||1 week after receipt of abnormal smear result||14||48.6|
|Marteau et al.5||8–16 weeks before colposcopy||15||46.2|
|Gath et al.6||4 weeks before colposcopy||102||36.5|
|Marteau et al.7||Immediately before colposcopy||30||51.2|
|Marteau et al.5||Immediately before colposcopy||64||49.1|
|Wilkinson et al.8||Immediately before colposcopy||31||49.59|
|Richardson et al.9||Immediately before colposcopy||109||45.2|
|Richardson et al.9||Immediately after colposcopy||109||40.9|
|Wilkinson et al.8||Immediately after colposcopy||31||33.35|
|Orbell et al.10||1 week after colposcopy||1095||40.91|
|Gath et al.6||4 weeks after colposcopy||99||32.91|
|Richardson et al.9||Immediately pre-treatment||109||48.4|
|Richardson et al.9||24 weeks after colposcopy||109||39.2|
|Gath et al.6||36 weeks after colposcopy||96||30.90|
Appraisal is an evaluation of what one’s relationship to the environment implies for personal wellbeing and in our context, what the colposcopy clinic visit means to the individual woman. Appraisals are commonly used as one of the most reliable means of distinguishing between human emotions and are measured in our study to determine women’s perception of their colposcopy visit. According to Lazarus11 and Smith and Lazarus12 primary appraisal determines whether the situation is personally important; and secondary appraisal evaluates a person’s resources and options for coping with the encounter. The components of primary appraisal are motivational relevance (which identifies the degree to which the situation is relevant to personal goals) and motivational congruence/incongruence (which identifies the extent to which the situation is compatible/incompatible with personal goals). The four components of secondary appraisals are accountability (determines who or what is to receive the credit or blame), future expectancy (which assesses the likelihood of things changing for the better or worse), problem-focused coping potential (which assesses options for influencing the situation by one’s direct action), emotion-focused coping potential (which evaluates personal ability to adjust emotionally to the situation).13 A more detailed description of the role of appraisals in explaining emotion can be found in the article published by Orbell et al.10
Women were recruited to the study as part of a larger study examining women’s reaction to colposcopy.10,14 Recruitment to the study were from two colposcopy clinics in Sheffield. One of the two clinics routinely offered women referred with moderate or severe dyskaryosis a ST option and treatment was proceeded with at the same visit only if the woman consented to it. Women who did not want treatment at the same visit had a colposcopy and cervical biopsy performed. The other clinic’s usual practice was DT for women referred with any grade of abnormal smear. ST was offered at this clinic if requested or if felt appropriate by the colposcopist. All women undergoing treatment at either clinic were reviewed in the colposcopy clinic 6 months after treatment. Women were eligible for inclusion in the study if they were attending their first appointment at a colposcopy clinic, having been referred with an abnormal cervical smear result.
Women attending their first colposcopy appointment were informed of the study during their colposcopy appointment. A research officer with an NHS contract extracted contact information from medical records. Women were initially sent a letter explaining the purpose of the study, reinforcing the verbal information already given together with a short questionnaire to their home address within 7 days of their first attendance. A prepaid reply envelope was enclosed with the questionnaire. If a completed questionnaire was returned, the woman was deemed to have consented and was recruited into the study. If no reply was received within 14 days, the woman was contacted by telephone by the research officer and a second copy of the letter, and questionnaire was posted to her if required. If a completed questionnaire was not returned after this reminder, the woman was assumed not to have consented to participate and was not contacted again. The local medical ethics committee approved the protocol.
The questionnaire assessed women’s perceptions and emotional reactions following the colposcopy visit. The most commonly used psychometric method of assessing anxiety is the Spielberger State–Trait Anxiety Inventory.15 This gives a score of 20–80, a high score denoting greater levels of anxiety. Additional measures to assess anger, sadness, guilt, embarrassment (negative emotions) and relief (positive emotion) were also used. The scales used are well validated, and validation of these scales has been published by Orbell et al.10 For example, embarrassment was assessed by three statements: ‘I feel embarrassed’, ‘I feel humiliated’ and ‘I feel disgraced’. Similarly, three items assessed guilt: ‘I feel sorry’, ‘I feel guilty’ and ‘I feel regretful’. Appropriate items also assessed anger, sadness and relief. All items were scored on 4-point scales (not at all—very much so). Appraisals were measured using items scored by a 7-point response scale. An open-ended question asked the participants to write down any desirable or undesirable aspects of their colposcopy visit. Further information on the psychological theories of appraisal and emotion and the use of the above items in measuring emotions can be found in articles published by Smith and Lazarus11,12 and Orbell et al.10
We also wanted to ascertain what sources of information women used to obtain information about colposcopy and if being aware prior to the visit changed their perception of their visit to colposcopy. The questionnaire thus included three questions, ‘Did you receive a leaflet before you attended the colposcopy clinic?’, ‘Did you read the leaflet about colposcopy?’ and ‘Did the GP explain about the colposcopy clinic?’.
Data concerning colposcopic diagnosis, name, address, date of birth, colposcopist seen at first visit, treatment received at first visit and subsequent attendance/nonattendance at follow-up appointments were extracted from medical records.
Social deprivation index scores based on calculations by Carstairs and Morris16 were subsequently acquired from Mimas and merged into the data set using postal code information.
As part of a large study examining women’s reactions to colposcopy, 1541 women underwent DT and 211 women underwent ST. A questionnaire was sent out to all women a week after colposcopy. A total of 136 of the 211 women (64.5%) who had ST and 949 of the 1541 women (61.6%) who had DT returned the questionnaire. Response rates were similar (chi-square  = 0.65, not significant [ns]). Nonresponders were slightly younger than responders and had higher deprivation indexes.
The main aim of this study was to compare the psychological impact of a ST management strategy with a DT management strategy. To compare these two groups, we drew a sample of DT participants matched to the ST cases in terms of severity of abnormalities, age and deprivation category. Controlling for these variables was important to compare the impact of management type per se. Matching proceeded as follows. All the women who received ST had high-grade CIN colposcopically. We therefore first drew a sample of all CIN2/3 women (N= 320) treated by DT. We then drew, for each woman having ST (n= 136), the first available age-matched woman having DT with a Carstairs score within ±1.0. T-tests confirmed the success of our matching procedure. There were no differences between our matched samples in terms of age (means ST versus DT = 32.43 versus 32.48, t=−0.046, ns). Carstairs indexes were also equivalent for the ST and DT groups (means = 2.52 and 2.55, respectively, t=−06, ns). We conducted one further preliminary check on our data. Since ST and DT patients were unequally distributed across colposcopists, we undertook a preliminary comparison of women with high-grade CIN treated by DT to ensure that there were no differences in appraisal or emotion according to colposcopist. Multivariate analysis of variance confirmed that there was no significant main effect of colposcopist (F [2, 278] = 1.24, ns).
Eighty-three percent of women reported receiving and reading the leaflet prior to colposcopy, and 68% of women went to their GP for more information prior to their colposcopy visit. Women who reported receiving and reading the leaflet had lower motivational relevance than women who did not receive or read a leaflet (P < 0.05). This could be due to the fact that women who did not read the leaflet perceived their colposcopy visit as being more important and relevant following the result of an abnormal smear. Women who did read the leaflet reported more feelings of relief (P < 0.05). Women to whom the GP explained about the colposcopy visit showed no differences in either emotions or appraisals.
Emotion and appraisal
Table 2 summarises mean responses to emotion and appraisal measures according to management type. As hypothesised, women undergoing ST reported significantly lower anxiety (mean = 41.08) days after their first colposcopy than those undergoing DT (mean = 43.98, P < 0.05). Women who underwent ST were also less embarrassed than women who underwent DT (means = 1.18 versus 1.28, respectively, P < 0.05) and reported feeling significantly more relieved (means = 2.68 versus 2.11, respectively, P < 0.01). Significant differences between the two groups also emerged for motivational congruence and problem-focused coping potential. Women undergoing ST found their first colposcopy visit more in keeping with what they had desired would happen, i.e. more motivationally congruent (means = 4.99 and 4.62, P < 0.05). There was a positive correlation seen between motivational congruence and relief, patients for example commenting, ‘Got the treatment over and done with’. ST participants also perceived that they were more in control during their visit (greater problem-focused coping potential). This may be because they felt involved in the decision-making process and have made a decision to have the treatment performed at the same visit (means = 4.47 versus 4.06, P < 0.05). The increased problem-focused coping potential as seen with ST was associated with lower anxiety and embarrassment.
Table 2. Emotion and appraisal 7 days after the first colposcopy visit among matched samples (N= 136) of women with CIN2 or three undergoing see and treat or defer and treat
|State anxiety (Spielberger)||41.08 (11.76)||43.98 (14.88)||−1.76*|
|Guilt||1.29 (0.49)||1.35 (0.63)||−0.82|
|Anger||1.22 (0.48)||1.27 (0.56)||−0.84|
|Sadness||1.49 (0.67)||1.65 (0.85)||−1.62|
|Embarrassment||1.18 (0.36)||1.28 (0.56)||−1.74*|
|Relief||2.68 (1.02)||2.11 (0.10)||4.52**|
|Motivational relevance||6.19 (1.70)||6.30 (1.27)||−0.57|
|Motivational incongruence||3.29 (1.85)||3.08 (1.72)||0.96|
|Motivational congruence||4.99 (1.86)||4.62 (1.69)||1.68*|
|Emotion-focused coping potential||4.57 (1.64)||4.59 (1.64)||−0.10|
|Problem-focused coping potential||4.47 (1.61)||4.06 (1.51)||2.16*|
|Self-accountability||3.68 (2.18)||3.56 (1.51)||0.51|
|Other accountability||2.92 (2.09)||2.94 (1.82)||−0.09|
|Expectation||4.43 (1.59)||4.39 (1.35)||0.23|
Responses to the open-ended question concerning the nature of desirable/undesirable aspects of the colposcopy visit were examined. A total of 79 (58%) ST and 64 (47%) DT participants provided qualitative responses to this question. Content analysis by two independent coders (kappa = 0.98) identified three categories of positive comment, shown in Table 3. Comments from the open-ended questions were grouped into broad categories depending on the content and any disagreement between the investigators was resolved by discussion. If a woman commented on two aspects that fell into different categories of the coding, it was counted as two separate thoughts for purposes of analysis. Women undergoing both procedures were more likely to make positive comments regarding the quality of procedural explanation offered by clinic staff and the sympathetic way in which they were treated while at the clinic. Six women particularly commented on the use of monitors in the clinic, which enabled them to observe their cervix. Women undergoing ST also made positive comments about the advantages of receiving treatment during their first visit. Perceived advantages of early treatment included (a) the perception that they had been treated without delay (i.e. no waiting list), (b) the psychological benefits of getting the treatment procedure ‘over and done with’ and not having to endure anxiety while anticipating this and (c) the perception that because everything was performed at the one visit, they would not have to take the time and trouble to return to the clinic again. Women undergoing DT were more likely to comment on the confirmation of diagnosis they received during their clinic visit (e.g. ‘They told me why I had to go to the hospital because I didn’t know’).
Table 3. Desirable aspects of colposcopy experience reported by women
|Procedural explanation and respect||33||27|
|‘I was treated with dignity and my questions were answered honestly.’|
|‘I managed to watch everything on TV which made me more comfortable, understanding and supportive staff explained during the procedure.’|
|‘To get it over and done with and abnormal cells removed.’|
|‘Treatment done straight away—no waiting and worrying.’|
|‘Attended to on the day of my appointment, did not have to return, I was grateful.’|
|‘They told me why I had to go to the hospital and what is wrong with me because I didn’t know.’|
|‘Being told immediately that there wasn’t any cancer cells.’|
Several women in both groups noted that to be confirmed as having CIN2 or CIN3 was undesirable as was the very thought of needing treatment either at the same visit or subsequently. Content analysis of the undesirable happenings listed by women, shown in Table 4, showed only two comments from ST patients about the unexpectedness of being offered treatment immediately; ‘thought I was having just a colp, not any treatment’, while 17% of women who had DT commented on the stress and inconvenience of coming back for treatment, ‘treatment could not be carried out that day’, ‘didn’t want to have to go back’. Thus, most comments made regarding the ST management strategy were favourable.
Table 4. Undesirable aspects of colposcopy experience
|‘Pain when having biopsy.’|
|‘Didn’t want any injections or have my womb cut.’|
|‘Thought I was just having a colp not any treatment.’|
|‘Told I was having treatment when I got there.’|
|‘Treatment could not be carried out that day.’|
|‘Didn’t want to have to go back.’|
When follow-up visits were analysed according to management strategy, interestingly we found that 14% of women who had ST did not attend their subsequent visit as compared with only 2.9% of the DT group (P < 0.001). This could be because women who had ST considered their problem already treated and, hence, did not consider their follow-up appointment important. However, when overall did not attend (DNA) rates were analysed at the end of 15 months, it was seen that both ST and DT had similar DNA rates (12.7 versus 11.7%), so treatment strategies per se did not seem to influence follow-up rates long term.
Through its association with cancer, the diagnosis of CIN is threatening, and women find the diagnosis of CIN traumatic.17 Orbell et al. have, in fact, shown that following colposcopy, women who were discharged to their GP were far less anxious than those receiving a diagnosis of CIN2/3, which would require treatment and further visits to colposcopy.10 Data for our study were collected as part of a much larger study on colposcopy of the cervix. It might be argued that comparison of management types conducted here was less than optimal, since women were not assigned at random to the two approaches. Nonetheless, we believe the matching procedures used here have effectively controlled for differences in socio-economic status, age and disease severity. As recruitment to the study was completed only on returning the questionnaire, colposcopists were quite unaware as to which of the women would finally be recruited to the study thus removing any element of bias. There was also no evidence that individual colposcopists influenced outcome measures. Any prospective study always raises a query about the impact of surveillance itself on results—the Hawthorne effect. O’Sullivan et al. in their large study on the uptake of faecal occult blood testing screening showed that there was no statistically significant difference in screening uptake among people invited or not invited to complete a questionnaire, indicating that the Hawthorne effect may not play a very significant role in health services research.18
In our study, women undergoing ST reported a higher perception of control and had significantly lower anxiety levels than those undergoing DT. It is possible that women offered ST perceived a greater sense of control due to their participation in the decision-making process to go ahead with the treatment at the same visit and consequently felt they were actively involved in the management of the diagnosed CIN. Increased problem-focused coping potential was negatively associated with anxiety and embarrassment. Both of these emotions are anticipatory and arise from uncertainty.11 The decreased anxiety could be explained by the fact that the initial colposcopy visit in these women not only provided diagnosis following the abnormal smear but also offered treatment, and thus bringing continuing uncertainty to a close.
The most significant finding of our study was that women found ST more in line with their goals and motives in that situation (motivationally congruent). Motivational congruence was also significantly associated with feelings of relief after the appointment. Analysis of qualitative data showed that women preferred immediate treatment for three reasons. First, some women commented that they had been treated promptly, perhaps implying that they had not encountered a delay or a waiting list for treatment. Second, some women noted that they did not have to endure ongoing anxiety while waiting for treatment. Third, some women pointed to the advantages of getting the treatment over and done with at the same visit, so they would not have to take the time and the trouble to return again.
Although the conservative treatment of CIN by LLETZ is highly successful, women treated for CIN still carry a five-fold risk of invasive cancer and recurrence of CIN. Cytological and colposcopic follow up is therefore essential.19 We monitored follow up of our cohorts of women to see if management strategies would influence follow up long term. We found that 14% of women who had undergone ST did not attend their subsequent appointment compared with only 2.9% of the DT group. Following LLETZ, women may be unaware of the importance of follow up, may consider their treatment completed and hence think it unimportant to attend follow-up visits. It should, however, be noted that women in the DT group following LLETZ, also defaulted follow-up appointments leading to very similar DNA rates at 15 months of 12.7% for ST and 11.7% for the DT groups (Table 5). Bornstein and Bahat-Sterensus, in their study on noncompliance with follow up after treatment with LLETZ in the DT group, reported noncompliance rates as high as 52% and concluded that DNAs after treatment may be much higher than expected.20
Table 5. Colposcopy attendance over 15 months for ST and DT women (%)
Considerable work has been performed on the clinical and economic aspects of ST. Since only a single visit is required for diagnosis and treatment, ST has been found to be most cost effective with enormous cost savings to clinics and patients.21,22 It improves patient compliance making it more convenient to patients with only one disruption to daily schedule.23,24 Patient satisfaction with the ST strategy has also been acceptable.25 One of the main criticisms of the ST approach, however, is the risk of overtreatment. If ST is restricted to women with high-grade disease on both referral smear and colposcopy, then the range of overtreatment narrows down to 4.0–23.5% for those with normal pathology.26 Das and Elias, however, reported that there was no difference between the ST and DT groups in the complication rate, the rate of overtreatment or in the need for subsequent treatment.27 Our study sheds light on women’s perceptions and their preference of management strategies currently available and answers the question of what women want in the management of high-grade CIN.
ST has now become internationally accepted. It decreases patient anxiety, increases patient compliance and has proved to be more cost effective than the conventional DT. Its cost effectiveness makes it appealing, especially in settings with limited health resources. Our study adds yet another important piece of information, i.e. women appear to perceive ST as more in keeping with their motives and goals during the colposcopy visit. They perceive themselves as being more in control and report feeling relieved and less anxious following ST. Women thus appear to prefer and benefit psychologically from a ST management strategy as compared with the conventional DT strategy in the management of high-grade CIN. ST management strategy, however, does not alter DNA rates long term.
The research reported in this paper was supported by Cancer Research UK (CP1048/0101). We also thank Julietta Patnick for her support for this project. We are grateful to Janet Williams for extracting medical data and to Craig Smith for providing details of his measures of cognitive appraisal.