Volume 185 - Issue 3
Do women in rural and remote areas need different guidelines for management of low-grade abnormalities found on cervical screening?
Author: Stewart Bryant
Med J Aust 2006; 185 (3): 182-183. || doi: 10.5694/j.1326-5377.2006.tb00522.x
Published online: 7 August 2006
Published online: 7 August 2006
To the Editor: We read with interest the letter by Breeze et al on management of abnormalities detected on cervical screening.1 Their study identifies a universal and fundamental feature of the Pap smear — namely, that it is an imperfect predictor of underlying abnormalities in the cervical epithelium.
For smears reported as a low-grade squamous intraepithelial lesion (LSIL) (atypical squamous cells of uncertain significance) or possible LSIL, Breeze and colleagues have shown that underestimation of the extent of the underlying abnormality is greater in infrequently screened women than in frequently screened women. They claim that following the latest National Health and Medical Research Council (NHMRC) guidelines for cervical screening2 will put women in rural and remote areas with cytologically detected low-grade lesions at risk of developing high-grade lesions that go undetected through lack of timely follow-up. I contend that following the new NHMRC guidelines presents a significant risk to all women with LSIL or possible LSIL reported on smears, regardless of ethnicity, locality or social class. The risk is merely greater for women living in rural and remote areas.
In addition to delays in diagnosis of high-grade lesions, data from cervical cytology registries indicate that there will be delays in diagnosis for the 30–50 women each year whose smears show changes only of LSIL or possible LSIL but who are shown on biopsy to have cervical cancer.3
The problem of women defaulting on clinic appointments or being lost to follow-up is a phenomenon commonly encountered in cervical screening programs in general, but in Far North Queensland the risks of inadequate follow-up are magnified.
For these and other reasons, the Royal College of Pathologists of Australasia, other learned societies and individuals have consistently and strenuously opposed the latest NHMRC guidelines during the period of their development and during the consultation period of many months.
Rather than advocate a separate set of guidelines for women in rural and remote areas, it would be better to have a universally accepted safe set of guidelines that conforms to international best practice and applies to all Australian women. Using the guidelines that were in use until 20054 and that have served us so well in the past is one option. Another option, which is backed by first class scientific evidence,5 is to use human papillomavirus DNA testing for triage of women with smears reported as possible LSIL.
References
- Breeze C, de Costa CM, Jagusch M. Do women in rural and remote areas need different guidelines for management of low-grade abnormalities found on cervical screening? Med J Aust 2006; 184: 307-308. 0_CBBFABEE
- National Health and Medical Research Council. Screening to prevent cervical cancer: guidelines for the management of asymptomatic women with screen detected abnormalities. Canberra: Commonwealth of Australia, 2005. http://www.nhmrc.gov.au/publications/_files/wh39.pdf (accessed Jul 2006).
- Mitchell H. Outcome after a cervical cytology report of low-grade squamous abnormality in Australia. Cancer 2005; 105: 185-193. 0_i1091789
- National Health and Medical Research Council. Screening to prevent cervical cancer: guidelines for management of asymptomatic women with screen detected abnormalities. Canberra: Commonwealth of Australia, 1994. http://www.csp.nsw.gov.au/downloads/wh16.pdf (accessed Jul 2006).
- Schiffman M, Solomon D. Findings to date from the ASCUS-LSIL Triage Study (ALTS). Arch Pathol Lab Med 2003; 127: 946-949. 0_i1091793