Psychosocial morbidity in women with abnormal cervical cytology managed by cytological surveillance or initial colposcopy: longitudinal analysis from the TOMBOLA randomised trial.

S Fielding,In Association With The Tombola Group ,K Rothnie,L G Walker,J Little,L Sharp,N M Gray,D Whynes,K Neal,S C Cotton,M E Cruickshank

doi:10.1002/pon.4163

Abstract

ObjectiveTo compare psychosocial outcomes (follow‐up related worries and satisfaction with follow‐up related information and support) over 30 months of two alternative management policies for women with low‐grade abnormal cervical cytology.MethodsWomen aged 20–59 years with low‐grade cytological abnormalities detected in the National Health Service Cervical Screening Programme were randomised to cytological surveillance or initial colposcopy. A total of 3399 women who completed psychosocial questionnaires at recruitment were invited to complete questionnaires at 12, 18, 24 and 30 months. Linear mixed models were used to investigate differences between arms in the two psychosocial outcomes. Each outcome had a maximum score of 100, and higher scores represented higher psychosocial morbidity.ResultsOn average, over 30 months, women randomised to colposcopy scored 2.5 points (95%CI −3.6 to −1.3) lower for follow‐up related worries than women randomised to cytological surveillance. Women in the colposcopy arm also scored significantly lower for follow‐up related satisfaction with information and support (−2.4; −3.3 to −1.4) over 30 months. For both outcomes, the average difference between arms was greatest at 12th‐ and 18th‐month time points. These differences remained when the analysis was stratified by post‐school education.ConclusionsWomen with low‐grade cytology, irrespective of their management, have substantial initial psychosocial morbidity that reduces over time. Implementation of newer screening strategies, which include surveillance, such as primary HPV screening, need to consider the information and support provided to women. © 2016 The Authors. Psycho‐Oncology published by John Wiley & Sons Ltd.

Highlights

Many women have an abnormal cervical screening test, based on cytological and/or human papilloma virus (HPV) testing
The first found no difference at 12 months in mean distress or anxiety scores between those women randomised to a repeat cytology test in 6 months or a choice between repeat cytology and an immediate colposcopy [8]
The second trial found no difference in anxiety or depression (assessed using the Hospital Anxiety and Depression Scale (HADS)) over 30 months of follow-up between women randomised to cytological surveillance or initial colposcopy, anxiety and depression were significantly lower in women in the colposcopy arm at 6 weeks [9]

Summary

Introduction

Many women have an abnormal cervical screening test, based on cytological and/or human papilloma virus (HPV) testing. A range of options exist, the main ones being repeat testing (by cytology and/or HPV) and colposcopy examination. Both are recognised as acceptable in a range of guidelines internationally [1,2,3,4]. Harms include adverse psychosocial sequelae identified across the entire screening process from initial screening, investigation and potentially beyond [5]. The debate about relative levels of anxiety between repeat testing (i.e. surveillance) and colposcopy has been ongoing for at least two decades [6,7], but there are only two randomised trials of women with low-grade cytology. The second trial (known as TOMBOLA) found no difference in anxiety or depression (assessed using the Hospital Anxiety and Depression Scale (HADS)) over 30 months of follow-up between women randomised to cytological surveillance or initial colposcopy, anxiety and depression were significantly lower in women in the colposcopy arm at 6 weeks [9]

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Discussion

Conclusion