Volume 185 - Issue 3
Do women in rural and remote areas need different guidelines for management of low-grade abnormalities found on cervical screening?
Authors: Gerard V Wain, Ian G Hammond, Penelope I Blomfield, Marion A Saville and Margaret Davy
Med J Aust 2006; 185 (3): 182-183. || doi: 10.5694/j.1326-5377.2006.tb00523.x
Published online: 7 August 2006
Published online: 7 August 2006
In reply: In June 2005, the National Health and Medical Research Council (NHMRC) endorsed new guidelines for managing asymptomatic women with screen-detected abnormalities because they were safe for Australian women and were based on the best available Australian and international evidence.1 The NHMRC accepted that new information about the natural history of human papillomavirus (HPV) infection of the cervix and cervical neoplasia demanded a reassessment of our traditional approach to this disease.
HPV infection of the cervix and associated, potentially neoplastic precursor lesions are very common, but not all of these have malignant potential. Optimal prevention of cervical cancer will depend on timely diagnosis and treatment of lesions that are most likely to progress. Overdiagnosis and treatment of all incident lesions is unnecessary and potentially results in avoidable morbidity. The approach recommended in the latest guidelines moves away from probabilistic prediction and intensive investigation based on a single cytological specimen to an evidence-based program of intermittent cytological surveillance of this chronic viral infection. Intervention is timed to coincide with evidence of persistent and potentially dangerous infection.
Contrary to Bryant’s claim about Australian registry data, there is no evidence that the new guidelines will mean any increase in the diagnosis of cancer, a view that is supported by independent epidemiological expert review (M Clements, Research Fellow, National Centre for Epidemiology and Population Health, Australian National University, personal communication). The experience of Breeze and colleagues in Far North Queensland suggests that the greatest risk factor for any woman to develop cervical cancer is infrequent screening.2 Furthermore, in the unlikely event that the latest guidelines do result in increased cancer incidence, such an increase will immediately be detected by the monitoring program that is integral to the new approach.
Bryant advocates increased pathology testing using HPV DNA tests. We are not aware of any population data demonstrating that such an approach would result in improved cancer prevention, nor that such an approach would be cost-effective. Consequently, the Guidelines Review Group did not recommend the use of HPV DNA testing as part of triage of women with abnormal smears. The approach recommended in the guidelines is also consistent with contemporary international experience3 — namely, that the clinical significance of a single incident measurement of HPV status is not established.
We believe that the latest NHMRC guidelines1 are safe and acceptable for all Australian women and that all women deserve appropriate investigation and treatment of cervical abnormalities in a manner that will protect them from both cervical cancer and unnecessary, potentially harmful interventions.
Finally, to address the concerns of Breeze and colleagues, the guidelines specifically advise that clinical management be tailored to the patient’s individual circumstances.
References
- 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).<eMJA full text>
- 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_CBBCAAAJ
- Bentley E, Cotton SC, Cruickshank ME, et al. Refining the management of low-grade cervical abnormalities in the UK National Health Service and defining the potential for human papillomavirus testing: a commentary on emerging evidence. J Low Genit Tract Dis 2006; 10: 26-38. 0_CBBHGFDB