The adequacy of management of women with CIN 2 and CIN 3 Pap smear abnormalities

Abstract

To assess the adequacy of management of Sydney women with Papanicolaou (Pap) smears showing cervical intraepithelial neoplasia (CIN) grades two and three. A prospective descriptive study of patient management. All 206 general practitioners (GPs) who sent Pap smears which were reported as CIN 2 or CIN 3 to three Sydney laboratories between January and June 1990 were included in the sample. The GPs were contacted and management details for the women collected. The adequacy of management was evaluated by comparing it with management guidelines constructed for the study. Management steps were: notification of results, referral for colposcopy, biopsy, treatment and follow-up. The number of women reaching each step, expressed as a proportion of those women who should have reached that step according to the management guidelines, was calculated. The points where management was inadequate were established and the reasons explored. All GPs provided management information about their patients. Ninety-nine per cent of women (95% confidence intervals [CI], 98%-100%) were informed of their Pap smear result and 94% (CI, 90%-97%) of the total sample subsequently underwent colposcopy. Ninety-three per cent (CI, 88%-97%) of the 160 women definitely requiring histological diagnosis had this and 98% (CI, 94%-100%) of the 140 women definitely needing treatment were treated. Following treatment (or equivalent if not indicated) 80% of women (CI, 74%-86%) were known to have had a follow-up Pap smear but only 31% (CI, 24-38%) of women needing follow-up colposcopy were known to have had it. At the time of the study (on average, 17 months after the index Pap smear) only 60% (CI, 54%-67%) of women were still being followed up. Virtually all women with the more severe cytological abnormalities are being referred by their GPs for further investigation and treatment. However, follow-up after treatment is often inadequate. The responsibility for this follow-up needs to be clarified, as well as communication about it between women, their GPs and gynaecologists. A cytology registry could increase the proportion of Sydney women known to be receiving follow-up.