Combining speculoscopy (visual examination of the cervix using a blue-white chemiluminescent light source) with Papanicolaou (Pap) smear has been shown to significantly increase the detection of cervical neoplasms. This increased sensitivity, however, may be achieved at the expense of an increase in false-positive results compared with Pap smears alone, thus causing unwarranted distress and expense to women who have no underlying cervical neoplasms. Some of these women have low-grade lesions that may spontaneously resolve, and some have serious lesions that can progress if intervention is delayed. Parham and colleagues reviewed the outcomes in these women by comparing the effects of immediate versus delayed colposcopy.
All asymptomatic women presenting to an Arkansas university clinic for routine gynecologic examination were eligible for the study. Women with a history of cervical neoplasia within the previous two years were excluded from the study. All examiners received standardized training in the testing procedure, and all samples were obtained and processed using the same techniques and facilities. Women with positive Pap smears were scheduled for immediate colposcopy and biopsy. Those with negative Pap smears but positive speculoscopy results were assigned to undergo colposcopy within four weeks (immediate) or after six months (deferred).
Of the more than 800 women screened, 124 had negative Pap smears but positive speculoscopy results. Demographic characteristics of the 57 women who were offered immediate colposcopy were similar to the 67 women in the deferred group. More than 80 percent of the women in the immediate colposcopy group had positive colposcopy results, and 64.9 percent had histologically proven neoplasms. Thirteen (29 percent) lesions in the deferred group reverted to speculoscopy-negative on repeated testing. In lesions that remained positive at six months, biopsy revealed a neoplasm in 90.6 percent of cases. Only 45 of the 67 women in the deferred group returned for follow-up testing; seven of the 22 women who did not return for follow-up were known to have attended other clinics.
The authors conclude that deferring colposcopy for six months increased the diagnostic yield for neoplasm from approximately 65 to 90 percent. They attribute this increased sensitivity to the spontaneous regression of some lesions and the progression to histologically proven status in others. During the deferred period, however, a significant number of women was lost to follow-up testing or sought treatment elsewhere. The authors caution that deferral should be considered only when follow-up testing can be anticipated.
editor's note: So what are we to tell the patient with a negative Pap smear but positive speculoscopy? From this study, the script would appear to be this: “If we wait six months to repeat these tests, there is about a 30 percent chance they will both be negative, and that means your chances of finding even an early cancer are remote. If the results remain positive at six months, there is a 90 percent chance we will find an early cancer on colposcopy.” I suppose it depends on the values of patient and physician, and how the physician communicates the relative risks of the different scenarios. This study highlights the issues involved in an adjunctive test to improve the accuracy of Pap screening. When the tests concur, the advantages are clear, but in one of eight patients, the results are discordant. We have a long way to go in managing the scientific, clinical, emotional and legal implications of such situations. Many patients, including those at highest risk, may choose to go elsewhere or drop out of surveillance altogether.—a.d.w.