The new evidence-based guidelines for the management of abnormal Pap smears resulted from a tremendous collaborative effort (see related story, p. 878). But a study presented at the annual meeting of the American Society of Clinical Oncology suggested that the bigger challenge will be to get patients and doctors to adhere to the guidelines.
The retrospective study found that only 21% of women whose Pap smears showed atypical squamous cells of undetermined significance (ASCUS) and 17.5% of women with low-grade squamous intraepithelial lesions (LSIL) had a repeat Pap test within 5 to 7 months, the recommended follow-up interval for such diagnoses. Overall, there was no record of repeat Pap testing in 40% of the women who had a first-time diagnosis of a low-grade abnormality such as ASCUS or LSIL.
Rachel Kupets, M.D., of the Division of Gynecologic Oncology at the University of Toronto, used a central database of the results of Pap smears ordered by family physicians and gynecologists in Ontario to calculate these compliance rates for the management of low-grade lesions. Of the more than 1 million Pap smears performed in Ontario in 1999, about 29,000 tests showed a first-time diagnosis of ASCUS or LSIL.
Kupets then sorted the data by physician to determine how well physicians complied with guideline recommendations. She found that half of the family physicians and gynecologists in the database never complied with guidelines for follow-up and that the physicians most likely to follow repeat screening recommendations were those who perform the fewest number of Pap smears per year.
"What this study shows is that physicians are not following guidelines and that patients are being overtreated or undertreated, or simply inappropriately treated," Kupets said.
Kupets noted that there was no way to tell whether the 40% of women for whom no repeat Pap test was available were lost to follow-up or went on to have a colposcopy. which by some guidelines is recommended after multiple abnormal Pap smears. However, she noted that some women who may have had a colposcopy were probably overtreated because in the majority of cases, a colposcopy does not find any evidence of cancer in women with low-grade lesions.
"When you have limited resources, such access to colposcopy clinics, patients with high-grade lesions are competing with patients with low-grade lesions to get to colposcopy for management," she said. "In terms of resources utilization, you may be increasing the waiting times for women with high-grade lesions on their Pap smears who actually have something on their cervix. When youre sharing small resources, its very important to keep guidelines like this in mind."
A recent survey found that there is some disagreement among physicians about how best to manage a diagnosis of ASCUS. The survey found that one quarter of physicians would refer a patient with a first-time diagnosis of ASCUS for colposcopy, while the other respondents said that they would repeat a Pap test. Of those who would repeat the Pap test, 23.5% said that they would repeat it in less than 3 months, much sooner than many guidelines recommend. (Am J Obstet Gynecol 185:5516). The authors noted that several factors influence how a doctor chooses to manage a patient, including patient preference, a physicians agreement with the guidelines, and medical and legal concerns.
The recently published guidelines for the management of abnormal Pap smears concede that there is some room for interpretation: "It is also important to recognize that these guidelines should never be a substitute for clinical judgment. Clinicians need to practice clinical discretion when applying a guideline to an individual patient since it is impossible to develop guidelines that apply to all situations."
But Kupets pointed out that such guidelines are based on the best available evidence and should always be used as a starting point for determining patient care.
"A lot of people think that guidelines are cookbook medicine, they dont like to be told what to do, and they disagree with [the guidelines]," Kupets said. "I think its important for physicians to change their attitudes toward guidelines and really use them as a tool for continuing education so they can continue to improve the delivery of health care to patients beyond their training years."
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