Discussion
Although our 9% referral rate differs little from the 14% reported by Pfenninger, the reasons for the referrals have changed. For example, half the referrals by Pfenninger were for cold cone biopsies. In contrast, many LEEP procedures performed in the Cervical Dysplasia Clinic were LEEP cones. Referral for cold knife conization was limited to patients with glandular atypia on biopsy or endocervical curretage, or colposcopic impression of glandualr atypia. Pregnancy and the inability to visualize the entire transformation zone were 2 common reasons for referral in the series by Pfenninger, but they did not account for any referrals in our study. Patients with unsatisfactory colposcopy underwent diagnostic LEEP conization. The 3 pregnant patients in the study cohort were followed through pregnancy without referral. Biopsy of one of these patients showed cervical intraepithelial neoplasia - grade 3; the other 2 were not biopsied because of benign colposcopic findings and ASCUS cytology.
Our study supports the conclusions of Pfenninger and Spoelhof that the majority of colposcopic care for women can be provided by family physicians. Our finding of low referral rates may be surprising because of significant patient preselection. The Cervical Dysplasia Clinic serves a statewide population of uninsured patients who have a high prevalence of cytologic and histologic abnormalities, including high-grade lesions. However, despite a patient population with more severe disease than that seen by the majority of family physicians, referral rates remained relatively low. Despite recent data confirming the safety and efficacy of cryotherapy,4 the use of LEEP for large and severe lesions has greatly expanded the family physician’s ability to manage lesions for which cryotherapy remains an unsatisfactory treatment.
Conclusions
Many of the reasons for referral before LEEP was developed are no longer impediments to definitive primary care management. Nonetheless, well-trained family physicians need to be aware of which lesions lie outside the scope of their skills and require referral.5 Learning to recognize the boundaries between generalist and specialist management should be one of the major goals of family medicine procedural training. In comparison with cryotherapy, LEEP is more demanding and should be performed only by physicians thoroughly trained in cognitive and technical aspects of electrosurgery. Family physicians lacking extensive LEEP experience should refer appropriately to colleagues skilled in this procedure.