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Psychological impact of cervical screening: a consequence of poor understanding and awareness?
- Ranjit Manchanda, Geoff Budden, Consultant Obstetrician and Gynaecologist, Bedford Hospital (8 June 2004)
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Psychological impact of human papillomavirus testing: could management strategy play a role?
- Jo Waller, Kirsten McCaffery, Jane Wardle (10 June 2004)
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Ranjit Manchanda, Specialist Registrar, Obstetrics and Gynaecology Bedford Hospital, Bedford MK42 9DJ, Geoff Budden, Consultant Obstetrician and Gynaecologist, Bedford Hospital
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Psychological impact of cervical screening: a consequence of poor understanding and awareness? Dear Sir, The study by Maissi et al1 hi-lights an extremely relevant issue that has not been adequately addressed. Around 3.7 million women underwent cervical screening in the year 2002-2003 under the NHS cervical screening programme. Out of the 7.6% positive smear results, the majority (80.2%) were borderline or mildly dyskaryotic2. Abnormal test results were associated with a significantly heightened level of anxiety, distress and concern, more so among Human Papilloma Virus (HPV) positive women1. A higher perceived risk of cancer and a poorer understanding of the results were associated with greater anxiety and distress. Although HPV testing does contribute to the level of stress, clearly there is also a larger issue to be addressed. There is a significant amount of stress associated with undergoing the test itself as underscored by levels of anxiety, distress and concern found in women with normal results. Research has shown that even in relatively well educated women awareness and knowledge of HPV is poor3. As pointed out by Maissi1, up to 41% of women did not know what HPV is, and only 70 out of 1376 knew that they did not have cancer. This in turn is likely to have contributed to the anxiety and stress associated with the test. Although the study was adequately powered and results were controlled for differences in age, education, centre and smear history, the written information that accompanied the test result was not uniform and varied according to the result and even across centres. It is difficult to ascertain what impact this had on the results. A subgroup analysis based on the different information leaflets accompanying the results might have been beneficial to indicate the beneficial effect of information provided on the psychological state of the woman. The study clearly reflects the poor understanding among women of cervical screening, cervical cancer and HPV infection. This is probably contributing to a heightened level of stress associated with the procedure. Available data suggests that many UK colposcopy clinics may not be providing women with the information they require to understand their condition and the procedure they are about to undergo4. There seems to be a lack of standardisation among leaflets and difference in the advice given. Women may want to receive information prior to the time of receiving their abnormal smear result4. There is probably a need for better counselling at the time of the initial test. Being better educated and informed about HPV and cervical smears will help reduce anxiety and distress and improve compliance. These are deficiencies that need to be addressed. Larger studies, which are proportionally representative of all communities, are needed to detect the true level of anxiety and distress caused from cervical screening and to evaluate strategies to reduce this. Conflict of interest: We declare no conflict of interest References 1) Maissi E, Marteau TM, Hankins M, Moss S, Legwood R, Gray A. Psychological impact of human papilloma virus testing in women with borderline or mildly dyskaryotic cervical smear test results: cross sectional questionnaire study. BMJ 2004; 328: 1293-96. 2) Lancucki L, Sheerman-Chase D, Medhurst C. Cervical Screening Programme, England: 2002-03. Department of Health Statistical Bulletin 2003/24, October 2003. 3) Waller J, McCaffery K, Forrest S, Szarewski A, Cadman L, Wardle J. Awareness of human papillomavirus among women attending well woman clinic. Sex Transm Infect 2003; 79(4): 320-22. 4) Byrom J, Dunn PD, Hughes GM, Lockett J, Johnson A, Neale J, Redm CW. Colposcopy information leaflets: what women want to know and when they want to receive this information. J Med Screen 2003; 10(3): 143-47. Competing interests: None declared |
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Jo Waller, Research Fellow Cancer Research UK Health Behaviour Unit, UCL, London WC1E 6BT, UK, Kirsten McCaffery, Jane Wardle
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Editor -- We read with interest the findings of Maissi et al (1) highlighting the possible psychological costs of using HPV testing in the management of mild cervical abnormalities. The authors conclude that testing positive for HPV is associated with increased anxiety in this group, but that testing negative does not appear to be reassuring. However, we wonder whether women’s anxiety might also be influenced by the recommended management strategy. Three courses of management were included in the study: standard recall, 6 month recall, and immediate colposcopy. Anxiety increased across these groups, raising the possibility that it is the recommended management that predicts risk perception and anxiety, rather than the result itself. It seems plausible that women take their cues for anxiety from the suggested management rather than from the results per se (especially if the results are poorly understood as indicated in the study sample). This would also explain the lack of a ‘reassurance’ effect among HPV negative women (who were still asked to re-attend after 6 months), and would be consistent with previous findings comparing colposcopy with repeat cytology for women with mildly abnormal smears, where higher anxiety is reported among those referred for colposcopy follow-up (e.g. 2). In relation to the psychological burden of testing positive for HPV, we note that the results letters did not inform women about the sexually transmitted nature of HPV, although we appreciate that this may have been in the information given to women before they were recruited into the study. There is evidence that the sexually transmitted nature of HPV imposes an additional psychosocial burden on women receiving an HPV positive result, especially with respect to their feelings about their sexual relationships (3). At the moment, it seems that most women in this country know little about HPV (4) but once they are better informed about the virus and are aware of its sexually transmitted nature, anxiety about testing positive could be even higher than was found in the present study. The effect of informing women about the meaning of HPV and low grade cytological abnormalities needs to be tested empirically. References 1. Maissi E, Marteau TM, Hankins M, Moss S, Legood R, Gray A. Psychological impact of human papillomavirus testing in women with borderline or mildly dyskaryotic cervical smear test results: cross sectional questionnaire study. BMJ 2004;328:1293. 2. Jones MH, Singer A, Jenkins D. The mildly abnormal cervical smear: patient anxiety and choice of management. J.R.Soc.Med. 1996;89:257- 60. 3. McCaffery K, Waller J, Forrest S, Cadman L, Szarewski A, Wardle J. Testing positive for human papillomavirus in routine cervical screening: examination of the psychosocial impact. BJOG. 2004;In press. 4. Waller J, McCaffery K, Forrest S, Szarewski A, Cadman L, Wardle J. Awareness of human papillomavirus among women attending a well woman clinic. Sex Transm.Infect. 2003;79:320-2. Competing interests: None declared |
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