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The potential harms of over screening

O’Connor et al. report adverse psychological outcomes associated with colposcopy and related procedures in women with cervical dysplasia. In their review of the scientific literature, the authors report anxiety in particular, but also depression, distress, worries about future fertility/ cancer and sexual dysfunction experienced by women after procedures. These findings may persist months to years beyond the initial encounter for colposcopy. The authors present their conclusions based on the methodology of a systematic review. The substance of a systematic review is based on available scientific literature and the breadth of search criteria. The authors used high quality studies representing a variety of settings. Unfortunately, heterogeneity between studies and the variety of psychological concerns measured by differing scales limit the authors’ ability to make definitive conclusions on factors that may predispose women to having psychological distress. The search criteria in this study were extensive but categorised colposcopy as equivalent to excisional procedures such as the loop electrosurgical excision procedures (LEEP). It is unclear whether these procedures can or should be equated. The indications for the LEEP procedure are frequently more serious (diagnosis of a precancerous lesion). A LEEP also usually occurs after a series of anxiety-provoking encounters which may lead to an accumulation of distress after multiple medical interactions. The authors recommend a standardised approach to studying this topic and long-term outcome research. Colposcopic examination is standard follow up after abnormal cervical cytology smear screening. In the USA, for example, guidelines for cervical cancer screening have been revised over the past decade from the notion of the ‘annual Pap smear’ to less frequent screening. These guideline changes have been based on an accumulation of clinical evidence demonstrating the slow transformation time between initial HPV infection and the development of cervical cancer. Clinical studies have consistently demonstrated that a yearly cervical cytology screening smear does not decrease either cervical cancer incidence or mortality (Kulasingam SL, et al. Agency for Healthcare Research and Quality, 2011). Furthermore, a higher screening frequency inherently leads to unnecessary procedures (colposcopy, biopsy, excision), which in turn can lead to long-term morbidity such as preterm delivery or physical discomfort and emotional distress as described in this study. (Bevis KS, Biggio JR. Am J Obstet Gynecol 2011;205:19–27) As gynecologists, we are in the position to help patients understand and balance the risks of over screening. Provider acceptance of current screening guidelines that lengthen screening intervals through interventions such as highly sensitive HPV co-screening may not only enhance cervical cancer prevention efforts but also decrease the incidence of colposcopy-related stress. The balance between harms and benefits is always a tension when making public health recommendations. The summative data presented by O’Connor and colleagues illustrate an aspect of screening tests that is often overlooked and needs further attention. Research on the psychological impact of abnormal cervical cytology management pathways, the advent of HPV testing, and identification of risk factors for psychological distress are needed to improve the gynaecological care of women.