Management of the low-grade abnormal Pap smear: What are women’s preferences?

,

Original Research

Management of the low-grade abnormal Pap smear: What are women’s preferences?

J Fam Pract. 2002 October;51(10):849-855

PDF Download

References

1. Woolf SH. Screening for cervical cancer. In: Goldbloom RB, Lawrence RS, eds. Preventing disease: beyond the rhetoric. New York: Spring-Verlag, 1990:319–23.

2. Kurman RJ, Henson DE, Herbst AL, Noller KL, Schiffman MH. Interim guidelines for management of abnormal cervical cytology. The 1992 National Cancer Institute Workshop. JAMA 1994;271:1866-69.

3. Miller AB, Anderson G, Brisson J, Laidlaw J, Le Pitre N, Malcolmson P, et al. Report of a national workshop on screening for cancer of the cervix. Can Med Assoc J 1991;145:1301-25.

4. American College of Obstetricians and Gynecologists. Cervical cytology: evaluation and management of abnormalities. ACOG technical bulletin no. 183. Washington, DC: American College of Obstetricians and Gynecologists, 1993.

5. Melnikow J, Nuovo J, Willan AR, Chan BK, Howell LP. Natural history of cervical squamous intraepithelial lesions: A meta-analysis. Obstet Gynecol 1998;92:727-34.

6. Wright TC, Cox TJ, Massad LS, Twiggs LB, Wilkonson EJ. Consensus guidelines for the management of women with cervical cytological abnormalities. JAMA 2002;287:2120-29.

7. Drummond MF, O’Brien BJ, Stoddart GL, Torrance GW, eds. Methods for the economic evaluation of health care programs. 2nd edition. New York: Oxford University Press, 1997.

8. Torrance G. Measurement of health state utilities for economic appraisal: A review. J Health Econ., 1986;5:1-30.

9. Furlong W, Feeny D, Torrance GW, Barr R, Horsman J. Guide to design and development of health state utility instrumentation. Centre for Health Economics and Policy Development. Working Paper Series # 90-9. Hamilton, McMaster University, 1990.

10. Melnikow J, Nuovo J, Paliescheskey M, Stewart GK, Howell L, Green B. Detection of high grade cervical dysplasia: Impact of age and Bethesda system-related follow-up criteria. Diagnostic Cytopathol 1997;17:321-25.

11. Fink A, Kosecoff J, Chassin M, Brook RH. Consensus methods: Characteristics and guidelines for use. Am J Pub Health 1984;74:979-83.

12. Nease RF, Kneeland T, O’Connor GT, Sumner W, Lumpkins C, Shaw L, et al. Variation in patient utilities for outcomes of the management of chronic stable angina. JAMA 1995;273:1185-90.

13. Ferris DG, Kriegel D, Cole L, Litaker M, Woodward L. Women’s triage and management p for cervical cytologic reports demonstrating atypical squamous cells of undetermined significance and low grade squamous intraepithelial lesions. Arch Fam Med 1997;6:348-53.

14. Meana M, Steward DE, Lickrish GM, Murphy J, Rosen B. Patient preference for the management of midly abnormal Papanicolaou smears. J Women’s Health and Gender Based Medicine 1999;8:941-7.

15. Kuppermann M, Nease RF, Learman LA, Gates E, Posner SF, Washington AE. How do women value Down syndrome-affected birth and miscarriage? The thirty-five-year-old question. Decis Making 1998;18:468.-

16. Solomon D, Schiffman M, Tarone R. Comparison of three management strategies for patients with atypical squamous cells of undetermined significance: baseline results from a randomized trial. J Natl Cancer Inst 2001;93(4):252-3.

17. The atypical squamous cells of undetermined significance/low grade squamous intraepithelial lesions triage study (ALTS) group. Human papillomavirus testing for triage of women with cytologic evidence of low-grade squamous intra-epithelial lesions: baseline data from a randomized trial. J Natl Cancer Inst,. 2000;92:397-402.

18. Kuppermann M, Shiboski S, Feeny D, Elkin E, Washington AE. Can preference scores for discrete states be used to derive preference scores for an entire path of events? An application to prenatal diagnosis. Med Decis Making 1997;17:42-55.

19. Kassirer JP, Pauker SG. The toss up. N Engl J Med 1981;305:1457-9.

20. Kaplan SH, Greenfield S, Ware JE, Jr. Assessing the effects of physician patient interactions on the outcomes of care. Med Care 1989;27 (Suppl 3):S110-27.

Strengths of our study include the diversity of the subjects, the formal process for preference assessment, and the paired scenarios, which allow assessment of preferences for a single management decision, in which 2 separate paths lead to an equivalent ultimate outcome. Our findings are consistent with previous work showing that the sequence of events leading to an outcome will influence utilities for the outcome.¹⁸

Application to clinical practice

How might our findings be translated into clinical practice? In clinical situations where different approaches to management are unlikely to result in substantial outcome differences (a “toss-up”), patient preferences are a key aspect of the decision-making process.¹⁹ For women with lowgrade Pap abnormalities, several diagnostic options are available and no single option is strongly supported by evidence to offer better outcomes. Our study indicates that no single option is preferred by most women. Under these conditions, engaging the patient in the decision-making process may produce better health outcomes.²⁰ Clinicians should anticipate highly varied preferences, and will need to adopt a flexible approach. Not all patients will want to be actively involved in the decision process, but the desire for information is nearly universal. Flexible use of the questions in Table 4 may help patients to define their preferences and will likely improve their satisfaction and adherence to the treatment plan.

TABLE 4

Questions for patients with an abnormal Pap smear

What is your understanding of what it means for you to have an abnormal Pap smear showing _____________?
There are different options for the next step. Would you like to be involved in deciding which option is preferred for your case?
What questions do you have about these options?
How important is it to you to have a definite answer as soon as possible?
How do you feel about undergoing colposcopy?
Would you prefer to have a follow-up Pap smear in ____ months, which might avoid a colposcopy, or would you prefer to have a colposcopy sooner?

· Acknowledgments ·

The authors thank the staff of Planned Parenthood Mar Monte East for their assistance with subject recruitment and interviews.