Performance characteristics of visualising the cervix in symptomatic young females: a review of primary care records in females with and without cervical cancer

Abstract

BackgroundThe current strategy for timely detection of cervical cancer in young females centres on visualising the cervix when females present with gynaecological symptoms, but is based on expert opinion without an evidence base. AimTo assess visualising the cervix in primary care in young females with gynaecological symptoms. Design and settingA review of primary care records for females in England aged 20-29 years with cervical cancer (nationwide interview-based study) and in the general population (Clinical Practice Research Datalink database). MethodFrom primary care records the proportion of females was identified with gynaecological symptoms who had documented cervical examination in the year before diagnosis (cancers) and in 1-year age bands (general population). Of these, the proportion was identified that was then referred for suspected malignancy. ResultsOnly 39% of young females with cervical cancer had documented examination at symptomatic presentation. Visualisation resulted in referral for suspected malignancy for 18% of those examined (95% confidence interval = 5% to 40%). Very few (<1.7%) symptomatic females in the general population had documented cervical examination. None were referred for suspected malignancy at the time. ConclusionThe sensitivity of cervical examination to detect cancer is very low, highlighting the need for better triage tools for primary care. Until such tools are identified GPs should continue to consider cervical cancer when symptoms persist and the cervix is not obviously abnormal on clinical examination. Further research on additional triage tools such as cervical cytology used as a diagnostic aid is needed urgently. cervix/bleeding on contact), or a 'suspicious cervix'. The proportion referred urgently to colposcopy on the basis of abnormal examination findings was identified. KeywordsThe second dataset comprised anonymous electronic medical records obtained from the Clinical Practice Research Datalink (www.cprd.com) database. 5 The CPRD holds data from more than 600 primary care practices in the UK. The sample included consultation records for 45 484 females aged 20-29 years during the years 1990-2010. Consultation data were provided as medical codes. To protect anonymity, only the year of birth was supplied; 1 July was assigned to estimate the date of birth. Estimates were made of the proportion of females who presented with a gynaecological symptom when aged 20-29 years in 1-year age bands; the proportion of these who had codes for cervical examination within 14 days after presenting; and, of these females, the proportion referred to colposcopy. Analyses were carried out in Stata (version 13). RESULTSPrimary care record data were available for 107 (84%) of the 128 females recruited to the nationwide interview-based study (age range 22-29 years). Fifty-two per cent (56 of 107) of young females with cervical cancer had gynaecological symptoms recorded in their primary care records in the year before diagnosis (a much higher percentage, 89%, reported symptoms...

Recognizing Gynecological Cancer in Primary Care: Risk Factors, Red Flags, and Referrals

“…Women reporting high-risk symptoms should undergo an adequate genital examination with visualization of the cervix and a full diagnostic workup including an infection screen. In one study, only 39% of patients who were referred and subsequently diagnosed with CC had a documented cervical examination in primary care [ 65 ]. While a visualized lesion is obviously an important finding and warrants urgent referral on a suspected cancer pathway, a normal cervical exam does not exclude cervical cancer, which can be microscopic at presentation.…”

The use, quality and effectiveness of pelvic examination in primary care for the detection of gynaecological cancer: a systematic review

“…National and international guidelines on management of suspected gynaecological cancers are clear in their recommendation to perform PE (abdominal palpation, bimanual palpation ± visualization of the cervix) when women present with symptoms suggestive of a gynaecological cancer, but there is little evidence offered to support this recommendation(3,4,24). Pre-referral visualization of the cervix by GPs had low sensitivity and may lead to delayed diagnosis due to incorrect interpretation of examination findings (19,25). In the diagnosis of ovarian cancer, bimanual examination was found to have marked limitations when examining adnexal masses, regardless whether the clinician was a specialist or a generalist (26).…”

Cytology in the diagnosis of cervical cancer in symptomatic young women: a retrospective review

“…A substantial proportion of young women with cervical cancer stand to benefit. The majority (89%) retrospectively report having symptoms in the year before diagnosis,15 and, according to primary care records, 52% present with gynaecological symptoms 14…”

“…However, this is based on expert opinion and lacks empirical evidence. The authors recently demonstrated that cervical examination missed the majority of cervical cancers, including stage 1B or worse 14. Furthermore, microinvasive cancers are not visible to the naked eye and are potentially symptomatic,15 and it is at this early stage that physicians would like to be able to diagnose cancers.…”