Loss to follow-up of cervical smears without endocervical columnar cells is not disturbing

Objective: To investigate the six-month recommended follow-up after mass screening of Pap smears because of the absence of endocervical columnar cells (ECC-) or ECC+ smears with atypical squamous or glandular cells of undetermined origin (ASCUS/AGUS) or low-grade squamous or glandular intraepithelial lesions (LSIL/LGIL) in a Dutch mass screening cervical cancer programme.

Methods: Data were extracted from computerised medical records of national representative Dutch general practices. We have studied the attendance at and the outcome of the subsequent Pap smears after a 6-month recommendation.

Results: The six-month follow-up was linked to 8.7% of the Pap smears (n = 1,002); 77.6% were without endocervical columnar cells (ECC-). Clear differences were found between the follow-up of ECC+ and ECC- smears; after 36 weeks of follow-up of 43.5% the women had an ECC- smear and 66.9% had other conditions. For initial ECC- Pap smears, 84.1% had no abnormalities in the subsequent Pap smear; for initial ECC+ Pap smears, in about 64% of the cases no abnormalities were found (p < 0.0001).

Conclusions: Repeating ECC- smears has a low follow-up rate but also lacks evidence-based necessity. However, for the other 6-month recommended Pap smears, one in five women had still not responded within one year, so improvement is necessary.

Mass screening; Cervical screening; Follow-up; ECC- smears

[1] Crane L.A.: "Social support and adherence behavior among women with abnormal Pap smears". J. Cancer Educ., 1996, 11, 164.

[2] Boyle P., Maisonneuve P., Autier P.: "Update on cancer control in women". Int. J. Gynaecol. Obstet., 2000, 70, 263.

[3] Walsh J.M.: "Cervical cancer: developments in screening and evaluation of the abnormal Pap smear". West. J. Med., 1998, 169, 304.

[4] Day N.E.: "Screening for cancer of the cervix". J. Epidemiol Comm. Health, 1989, 43, 103.

[5] Sigurdsson K.: "Effect of organized screening on the risk of cervical cancer. Evaluation of screening activity in Iceland, 1964-1991". Int. J. Cancer, 1993, 54, 563.

[6] Austoker J.: "Cancer prevention in primary care: screening for cervical cancer". Br. Med. J., 1994, 309, 241.

[7] Coleman D., Day N., Douglas G., Farmery E., Lynge E., Philip J et al.: "European guidelines for quality assurance in cervical cancer screening. Europe against cancer programme". Eur. J Cancer, 1993, 29A (suppl. 4), Sl.

[8] Marcus A.C., Crane L.A., Kaplan C.P., Reading A.E., Savage E., Gunning J. et al.: "Improving adherence to screening follow-up among women with abnormal pap smears: results from a large clinic-based trial of three intervention strategies". Med. Care, 1992, 30, 216.

[9] Marcus A.C., Kaplan C.P., Crane L.A., Berek J.S., Bernstein G., Gunning J.E. et al.: "Reducing loss-to-follow-up among women with abnormal Pap smears. Results from a randomized trial testing an intensive follow-up protocol and economic incentives". Med. Care, 1998, 36, 397.

[10] Michielutte R., Dignan M., Bahnson J., Wells H.B.:'The Forsyth County Cervical Prevention Project-11. Compliance with screening follow-up of abnormal cervical smears". Health Educ. Res., 1994, 9, 421.

[11] Holowaty P., Miller A.B., Rohan T., To T.: "Natural history of dysplasia of the uterine cervix". J. Natl. Cancer Inst., 1999, 91, 252.

[12] Bos A.B., van Ballegooijen M., van den Akker-van Marie E.M., Hanselaar A.G., van Oortmarssen G.J., Habbema J.D.: "Endocervical Status is not predictive of the incidence of cervical cancer in the years after negative smears". Am. J. Clin. Pathol., 2001, 115, 851.

[13] Mitchell H., Medley G.: "Influence of endocervical status on the cytologic prediction of cervical intraepithelial neoplasia". Acta Cytol., 1992, 36, 875.

[14] Mitchell H., Medley G.: "Cytological reporting of cervical abnormalities according to endocervical status". Br. J. Cancer, 1993, 67, 585.

[15] Mitchell H.S.: "Longitudinal analysis of histologic high-grade disease after negative cervical cytology according to endocervical status". Cancer Cytopathology, 2001, 93, 237.

[16] Ballegooijen van M., Hermens R.: "Cervical cancer screening in the Netherlands". Eur. J. Cancer, 2000, 36, 2244.

[17] Solomon D., Davey D., Kurman R., Moriarty A., O'Connor D., Prey M. et al.: "T he 2001 Bethesda System; terminology for reporting results of cervical cytology". JAMA, 2002, 287, 2114.

[18] Kavanagh A.M., Broom D.H.: "Women's understanding of abnormal cervical smear test results: a qualitative interview study". Br. Med. J., 1997, 314, 1388.

[19] Wilkinson C., Jones J.M., McBride J.: "Anxiety caused by abnormal result of cervical smear test: a controlled trial". Br. Med. J., 1990, 300, 440.

[20] Stewart D.E., Lickrish G.M., Sierra S., Parkin H.:''The effect of educational brochures on knowledge and emotional distress in women with abnormal Papanicolaou smears". Obstet. Gynecol., 1993, 81,280.

[21] Somerset M., Peters T.J.: "Intervening to reduce anxiety for women with mild dyskaryosis: do we know what works and why?". J. Adv. Nurs., 1998, 28, 563.

[22] Tacken M.A.J.B., Braspenning J.C.C., Berende A., Hak E., Bakker D.H., de Groenewegen P.P. et al.: "Vaccination of high-risk patients against influenza: impact on primary care contact rates during epidemics. Analysis of routinely collected data". Vaccine, 2004, 22, 2985 .

[23] Tacken M., Braspenning J., Spreeuwenberg P., van den Hoogen H., van Essen G., de Bakker D. et al.: "Patient characteristics determine differences in the influenza vaccination rate more so than practice features". Prev. Med., 2002, 35,401 .

[24] Kaplan E.L., Meier P.: "Nonparametric estimation from incomplete observation". J. Am. Stat. Assoc., 1958, 53, 457.

[25] Kalbfleisch J.D., Prentice L .: "The Statistical Analysis of Failure Time Data". New York: Wiley, 1980.

[26] Geijer R.M.M.: "Addendum NHG-Standaard Cervixuitstrijken, Herhalingsadvies vervalt bij uitstrijk zonder endocervicale cellen [Addendum NHG guidelines cervical cancer screening: the follow-up recommendation lapses for ECC- smears]". Huisarts Wet., 2002, 45, 133.

[27] McKee D.: "Improving the follow-up of patients with abnormal Papanicolaou smear results". Arch. Fam. Med., 1997, 6, 574 .

[28] McKee M.D.,L urio J.,M arantz P.,B urton W.,M ulvihill M.:" Barriers to follow-up of abnormal Papanicolaou smears in an urban community health center". Arch. Fam. Med., 1999, 8, 129 .

[29] Tjalma W.A.A., van Dam P.A., Makar A.P., Cruickshank D.J.: "The clinical value and the cost-effectiveness of follow-up in endometrial cancer patients". Int. J. Gynecol. Cancer, 2004, 14, 931.

[30] Sawaya G.F., Kerlikowske K ., Lee N.C., Gildengorin G., Washington A.E.: "Frequency of cervical smear abnormalities within 3 years of normal cytology". Obstet. Gynecol., 2000, 96, 219 .

[31] Siebers A.G., de Leeuw H., Verbeek A.L.M., Hanselaar A.G.J.M.: "Prevalence of squamous abnormalities in women with a recent smear without endocervical cells is lower as compared to women with smears with endocervical cells". Cytopathology, 2003, 14, 58 .

[32] Wee! C. van, Knottnerus J.A.: "Evidence-based interventions and comprehensive treatment". Lancet, 1999, 353, 916.