Speculoscopy

Abstract

To the Editors:I read the August 1998 review of cervical screening adjuncts (Spitzer M. Cervical screening adjuncts: Recent advances. Am J Obstet Gynecol 1998;179:544-56), and I believe that Spitzer’s review of the subject was inaccurate with respect to speculos-copy. I will take this opportunity to fill in some of the blanks.Spitzer’s referral to “flawed” methodology centers around his review of only 2 articles on speculoscopy. One report featured women with a previously abnormal Papanicolaou test result and the other featured women with atypical smears. He is correct when he states that these were not “screening” populations; in fact, neither study purported to be performed for the purpose of screening patients. Although Spitzer correctly states that to properly evaluate speculoscopy it would be necessary to subject healthy women to this examination in a prospective study, preferably with examiners who were not colposcopists, it is surprising that he did not review any of the 3 published studies with such a population.Mann et al1Mann W Lonky N Massad S Scotti R Blanco J Vasilev S Papanicolaou smear screening augmented by a magnified chemiluminescent exam.Int J Gynaecol Obstet. 1993; 43: 289-296Abstract Full Text PDF PubMed Scopus (34) Google Scholar studied speculoscopy in a screening population of 243 patients. Although that study was conducted largely by colposcopists, in the study of Edwards et al2Edwards G Rutkowski C Palmer C Cervical cancer screening with Papanicolaou smear plus speculoscopy by nurse practitioners in a health maintenance organization.J Lower Genital Tract Dis. 1997; 1: 141-147Crossref Scopus (12) Google Scholar speculoscopy was performed by nurse practitioners who were not colposcopists on a screening population of 689 healthy patients. Wertlake et al3Wertlake P Francus K Newkirk G Parham G Effectiveness of the Papanicolaou smear and speculoscopy as compared with the Papanicolaou smear alone: a community-based clinical trial.Obstet Gynecol. 1997; 90: 421-427Crossref PubMed Scopus (25) Google Scholar published the data from a community-based study of 5692 women in Southern California, and these women were examined by physicians and nurse practitioners who were not colposcopists. In each of these studies cervical biopsy served as the gold standard for determination of the presence or absence of cervical abnormality. It thus would appear that precisely the data that Spitzer said should be available to evaluate speculoscopy as a screening adjunct are in fact available. They simply were not reviewed by Spitzer in the preparation of his review.Spitzer also suggested that the lack of variable magnification and of a system for differentiation of tissue pathology is a drawback for speculoscopy. In deference to this opinion, speculoscopy is not a derivative of either colposcopy or cervicography. The use of acetic acid and magnification to assist with visualization is simply an application of long known principles for the recognition of potentially abnormal cervical tissue. Speculoscopy is, as a screening test should be, a test designed to assist in population triage.This letter is intended as a reminder to the Journal’s readers that because Spitzer’s review of speculoscopy was deficient in failing to review these applicable studies his conclusions regarding this technology should not be considered even remotely valid. Readers are urged to review these studies and draw their own conclusions regarding the potential contribution of speculoscopy to cervical screening, particularly as an adjunct to the conventional Papanicolaou test. To the Editors:I read the August 1998 review of cervical screening adjuncts (Spitzer M. Cervical screening adjuncts: Recent advances. Am J Obstet Gynecol 1998;179:544-56), and I believe that Spitzer’s review of the subject was inaccurate with respect to speculos-copy. I will take this opportunity to fill in some of the blanks.Spitzer’s referral to “flawed” methodology centers around his review of only 2 articles on speculoscopy. One report featured women with a previously abnormal Papanicolaou test result and the other featured women with atypical smears. He is correct when he states that these were not “screening” populations; in fact, neither study purported to be performed for the purpose of screening patients. Although Spitzer correctly states that to properly evaluate speculoscopy it would be necessary to subject healthy women to this examination in a prospective study, preferably with examiners who were not colposcopists, it is surprising that he did not review any of the 3 published studies with such a population.Mann et al1Mann W Lonky N Massad S Scotti R Blanco J Vasilev S Papanicolaou smear screening augmented by a magnified chemiluminescent exam.Int J Gynaecol Obstet. 1993; 43: 289-296Abstract Full Text PDF PubMed Scopus (34) Google Scholar studied speculoscopy in a screening population of 243 patients. Although that study was conducted largely by colposcopists, in the study of Edwards et al2Edwards G Rutkowski C Palmer C Cervical cancer screening with Papanicolaou smear plus speculoscopy by nurse practitioners in a health maintenance organization.J Lower Genital Tract Dis. 1997; 1: 141-147Crossref Scopus (12) Google Scholar speculoscopy was performed by nurse practitioners who were not colposcopists on a screening population of 689 healthy patients. Wertlake et al3Wertlake P Francus K Newkirk G Parham G Effectiveness of the Papanicolaou smear and speculoscopy as compared with the Papanicolaou smear alone: a community-based clinical trial.Obstet Gynecol. 1997; 90: 421-427Crossref PubMed Scopus (25) Google Scholar published the data from a community-based study of 5692 women in Southern California, and these women were examined by physicians and nurse practitioners who were not colposcopists. In each of these studies cervical biopsy served as the gold standard for determination of the presence or absence of cervical abnormality. It thus would appear that precisely the data that Spitzer said should be available to evaluate speculoscopy as a screening adjunct are in fact available. They simply were not reviewed by Spitzer in the preparation of his review.Spitzer also suggested that the lack of variable magnification and of a system for differentiation of tissue pathology is a drawback for speculoscopy. In deference to this opinion, speculoscopy is not a derivative of either colposcopy or cervicography. The use of acetic acid and magnification to assist with visualization is simply an application of long known principles for the recognition of potentially abnormal cervical tissue. Speculoscopy is, as a screening test should be, a test designed to assist in population triage.This letter is intended as a reminder to the Journal’s readers that because Spitzer’s review of speculoscopy was deficient in failing to review these applicable studies his conclusions regarding this technology should not be considered even remotely valid. Readers are urged to review these studies and draw their own conclusions regarding the potential contribution of speculoscopy to cervical screening, particularly as an adjunct to the conventional Papanicolaou test. I read the August 1998 review of cervical screening adjuncts (Spitzer M. Cervical screening adjuncts: Recent advances. Am J Obstet Gynecol 1998;179:544-56), and I believe that Spitzer’s review of the subject was inaccurate with respect to speculos-copy. I will take this opportunity to fill in some of the blanks. Spitzer’s referral to “flawed” methodology centers around his review of only 2 articles on speculoscopy. One report featured women with a previously abnormal Papanicolaou test result and the other featured women with atypical smears. He is correct when he states that these were not “screening” populations; in fact, neither study purported to be performed for the purpose of screening patients. Although Spitzer correctly states that to properly evaluate speculoscopy it would be necessary to subject healthy women to this examination in a prospective study, preferably with examiners who were not colposcopists, it is surprising that he did not review any of the 3 published studies with such a population. Mann et al1Mann W Lonky N Massad S Scotti R Blanco J Vasilev S Papanicolaou smear screening augmented by a magnified chemiluminescent exam.Int J Gynaecol Obstet. 1993; 43: 289-296Abstract Full Text PDF PubMed Scopus (34) Google Scholar studied speculoscopy in a screening population of 243 patients. Although that study was conducted largely by colposcopists, in the study of Edwards et al2Edwards G Rutkowski C Palmer C Cervical cancer screening with Papanicolaou smear plus speculoscopy by nurse practitioners in a health maintenance organization.J Lower Genital Tract Dis. 1997; 1: 141-147Crossref Scopus (12) Google Scholar speculoscopy was performed by nurse practitioners who were not colposcopists on a screening population of 689 healthy patients. Wertlake et al3Wertlake P Francus K Newkirk G Parham G Effectiveness of the Papanicolaou smear and speculoscopy as compared with the Papanicolaou smear alone: a community-based clinical trial.Obstet Gynecol. 1997; 90: 421-427Crossref PubMed Scopus (25) Google Scholar published the data from a community-based study of 5692 women in Southern California, and these women were examined by physicians and nurse practitioners who were not colposcopists. In each of these studies cervical biopsy served as the gold standard for determination of the presence or absence of cervical abnormality. It thus would appear that precisely the data that Spitzer said should be available to evaluate speculoscopy as a screening adjunct are in fact available. They simply were not reviewed by Spitzer in the preparation of his review. Spitzer also suggested that the lack of variable magnification and of a system for differentiation of tissue pathology is a drawback for speculoscopy. In deference to this opinion, speculoscopy is not a derivative of either colposcopy or cervicography. The use of acetic acid and magnification to assist with visualization is simply an application of long known principles for the recognition of potentially abnormal cervical tissue. Speculoscopy is, as a screening test should be, a test designed to assist in population triage. This letter is intended as a reminder to the Journal’s readers that because Spitzer’s review of speculoscopy was deficient in failing to review these applicable studies his conclusions regarding this technology should not be considered even remotely valid. Readers are urged to review these studies and draw their own conclusions regarding the potential contribution of speculoscopy to cervical screening, particularly as an adjunct to the conventional Papanicolaou test.