Summary Eighty-three women, mean age 45 years, successfully treated by surgery (S) (Weijmer Schultz et al., 1991;Corney et al., 1993). Outcome has generally been assessed in terms of the effect on sexual intercourse ignoring such potentially crucial intervening variables as the impact of the disease and treatment on the woman's emotional status and her relationship with her partner. In a pilot study (Van de Wiel et al., 1990) found that men experienced serious difficulties in supporting their partners through treatment for gynaecological cancer, as well as in their sexual relationship. Clearly more attention needs to be given to the wider needs of these patients and their partners.Often the psychological concerns of cancer patients go undetected and unrelieved (Maguire, 1985). Certainly it may be as difficult for cancer patients as for their doctors to open the discussion about sexual matters in a routine consultation (Auchincloss, 1989). It has variously been suggested that improved information and counselling in routine care could enhance post treatment outcome (Capone et al., 1980;Auchincloss, 1989) and that for some patients psychotherapy is indicated (Bos-Branolte et al., 1987)
Following publication of a report in Health Technology Assessment the NHS is running a pilot scheme screening women for human papillomavirus if they have a mildly dyskaryotic or borderline smear.1 How reliable is testing for human papillomavirus as a marker for high grade disease in those with mildly abnormal smears?
Participants, methods, and resultsThree hundred and thirty three consecutive new patients (aged 17 to 61 years, median 30 years) referred for colposcopy with persistent borderline or mildly dyskaryotic smears and who consented to the study were tested for human papillomavirus (high risk types only) with the Digene Hybrid Capture assay HC II (Abbott Laboratories, Maidenhead), by using cervical brush specimens placed in Digene transport medium, and were treated by large loop excision of the transformation zone.The
CommentA proportion of patients with mildly abnormal smears will harbour high grade disease. 3 Identifying this subgroup to target appropriate management is an important clinical issue. Colposcopy itself does not identify high grade disease reliably and we asked whether testing for human papillomavirus might improve diagnostic accuracy. We found that testing for human papillomavirus had a higher overall sensitivity (93% [1 pg/ml cut off] to 85% [4 pg/ml]) than specificity (55% [1 pg/ml] to 62% [4 pg/ml]) in detecting those with high grade disease, thus limiting its usefulness as a surrogate marker (table). This differential was greater for younger women, for those with mild dyskaryosis, and at 1 pg/ml cut off (table). Testing performed best with negative predictive values (prevalence adjusted) of 96% in older women and 94% overall (1 pg/ml).The report in Health Technology Assessment concludes that "the clearest role for HPV testing at the moment is in the management of women with borderline or mildly dyskaryotic smears. In particular, those aged above 30 years who test positive for high risk types could be referred immediately for colposcopy, while those younger than 30 years who test negative could receive less-intensive surveillance." The report supports limited introduction of testing for human papillomavirus, which should be carefully monitored, and encourages further research, including assessing the safety of returning to routine screening women with borderline or mild smears who test negative for human papillomavirus. Extrapolating our results to these guidelines would mean that 55% of those aged 30 years or over who test positive and are referred would have high grade disease but such disease might be missed in a small proportion of those testing negative and not referred (4% for older subjects, 11% for younger ones), this being more significant for younger women if they then face less intensive surveillance. We recognise, however, that our study population, with repeated abnormal smears, differs from that at triage for a single abnormal smear when the prevalence of high grade disease would probably be lower.Manos et al report that human papillomavirus testing is useful in triaging...
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