Women's understanding of a "normal smear test result": experimental questionnaire based study

ObjectivesTo describe women''s understanding of a negative smear test result when presented using the term “normal smear result,” as required by the NHS cervical screening programme, and to evaluate the impact on understanding of different ways of presenting the residual risk inherent in such a result.DesignExperimental questionnaire based study.InterventionsParticipants were asked to imagine that they had received a normal smear result. The meaning of this result was then presented using different combinations of three different expressions of residual risk of having or developing cervical cancer over the next five years: a verbal probability of absolute risk (low risk), a numerical probability of absolute risk (1 in 5000), or a numerical probability of risk relative to an unscreened woman (five times lower).Participants1027 women aged 20 to 64.ResultsWhen informed only that their smear result was normal, 52% (80 of 153 women) of participants correctly understood that this entailed a residual risk of cervical cancer, compared with 70% (107 of 152) given the additional sentence explaining the meaning of a normal smear result using a verbal probability of absolute risk (difference 18%; 95% confidence interval 7% to 29%). Additionally, explaining the results using a numerical probability of absolute or relative risk did not increase the proportion who correctly understood that there was a residual risk of cervical cancer.ConclusionsNHS policy for reporting normal smears needs to change to make it a definite requirement that the reporting of a “normal smear result” is accompanied by a sentence stating that this means a low risk for having or developing cervical cancer in the next five years.     

The inadequate smear: does it matter?

The objective of this study was to quantify the incidence of underlying cervical intraepithelial neoplasia (CIN) among women referred for colposcopy with three consecutive inadequate smears. The design was a retrospective cohort study analysing data from a regional colposcopy database at Cervical Screening Wales. Women who were referred to all the colposcopy clinics in Wales with three consecutive inadequate smears, the third inadequate smear being taken between 1 April 2001 and 31 March 2002 constituted the study population. The results of the fourth smear taken at the colposcopy clinic after three consecutive inadequate smears, the worst biopsy results from any of the subsequent colposcopies and the relationship between the result of the fourth smear taken at colposcopy clinic and any histology result were the main outcome measures. The accuracy of the colposcopic opinion was also examined. Of the 433 women identified as having been referred because of three consecutive inadequate smears, 302 were linked to either a subsequent smear and/or a biopsy result. An adequate smear result was available for 85% of these women when the smear was taken in the colposcopy clinic; 77% were reported as negative and 8% were abnormal. Of the 347 women seen in the colposcopy clinic, high-grade CIN was seen in 3% and low-grade lesion in 8%. The sensitivity and specificity of the fourth inadequate smear test in predicting underlying CIN were 15% and 84% respectively, with a positive predictive value of 8%. The sensitivity and specificity of colposcopy in predicting histological CIN among patients with three inadequate smears was 70% and 49%, respectively, and the positive predictive value was 44%. This study raises the question as to whether three consecutive inadequate smears should be considered as an indication for colposcopy, or merely for a further smear to be taken in circumstances where there is a greater likelihood getting an adequate result.     

The clinical significance of class III (suspicious) urine cytology

I. Sternberg, R. Rona, S. Olsfanger, S. Lew and I. Leibovitch The clinical significance of class III (suspicious) urine cytology Background: Urine cytology, combined with cystoscopy, is the mainstay of the diagnosis and surveillance of urothelial carcinoma (UC). While classes I and II urine cytology are considered benign and classes IV and V are considered malignant the clinical significance of class III urine cytology is unclear. We evaluated the positive predictive value of class III urine cytology for concurrent and subsequent UC. Methods: The records of all class III urine cytology cases during a 3‐year period were retrospectively reviewed for the presence of concurrent and subsequent UC, determined by cystoscopy and histological confirmation. Results: Of 111 cases, 54 (48.7%) were associated with concurrent UC and 14 (12.6%) with subsequent UC after an initial evaluation negative for malignancy, with a mean time to diagnosis of 10.8 months. Of 27 cases of class III urine cytology with no prior history of UC, 13 (48.1%) had concomitant UC and none had subsequent UC. Of 84 cases of class III urine cytology with a prior history of UC, 41 (48.8%) had a concomitant diagnosis of UC and 14 (16.7%) developed UC during their follow‐up, leading to a total of 55 (65.5%) cases of UC. Conclusions: Patients with class III urine cytology and a prior history of UC should undergo a full initial evaluation of their urinary tract, and should be followed vigorously if this evaluation is negative for malignancy. Patients without a prior diagnosis of UC and class III urine cytology should also undergo a full initial evaluation, while further larger studies are needed to elucidate the need for further follow‐up in such patients.     

Cytophotometric studies in suspicious cervical smears.

Papanicolaou stained smears of various cervical lesions diagnosed as "suspicious" by routine cytology were reviewed with regard to different cell types leading to this diagnosis. The smears were then submitted to Feulgen hydrolysis and redyed by Acriflavin-SO2 for fluorescence-cytophotometry. In nine of 14 cases measured, the DNA content of all types of "suspicious" cells was increased with DNA modes at euploid levels of 2 n, 4 n and 8 n indicating that the "suspicious" cells in those cases are polyploid. However, in five cases aneuploid DNA-distribution patterns were found similar to those observed in carcinoma in situ or severe dysplasia. Since polyploidization may be considered as a cellular response to higher functional requirement (i.e. inflammation or regeneration) a "suspicious" cervical smear with a polyploid DNA-distribution pattern may reverse to normal cervical epithelium after normal conditions are restored. However, a "suspicious" smear with an aneuploid DNA-distribution pattern should be considered more seriously as being related to a precancerous lesion requiring immediate surgical treatment.     

The buccal smear: Reassessment of its usefulness.

Over a 7-year period 43 patients who underwent sex-chromatin and cytogenetic studies in the investigation of a disorder related to reproductive function were found to have abnormalities of the sex or autosomal chromosomes that could not have been detected by routine buccal smear. Therefore, testing for sex chromatin is of no value to the clinician, because full chromosome analysis must be performed irrespective of the findings from the buccal smear. However, the sex-chromatin test is an aid to the cytogeneticist in interpreting the chromosome analysis. In addition to those with amenorrhea and oligospermia or aspermia, persons with hypospadius and those to be treated with fertility drugs should undergo cytogenetic studies.