Commentary: Present system could be improvedBMJ 1994; 308 doi: http://dx.doi.org/10.1136/bmj.308.6941.1414 (Published 28 May 1994) Cite this as: BMJ 1994;308:1414
- C Smith,
- S Adam
This paper raises several important issues about current clinical practice guidelines for the investigation and treatment of women with abnormal cervical smears. Equipment to excise the abnormal cervical transformation zone while preserving specimens for histolog (loop excision, laser miniconisation) is now widely available for outpatient use. Downey et al propose a policy of see and treat for women in prison, but it could be extended to women in whom factors other than imprisonment identify them as being at high risk. Careful examination is needed to establish the costs and benefits of this approach, to define criteria for its use, and to ensure that women and their general practitioners are clear what to expect and which policy is followed by the local service. Four points require comment.
Defining the problem
We assume that the high prevalence of cervical abnormalities in these women is real. It may, however, be exaggerated by the relative frequency of early repeat smears for the comparison group of women in Hampstead with a low risk of abnormality and the three and six monthly early repeat smears for women with abnormal results.
It seems that women who left Holloway before completing their recommended treatment or follow up were expected to return to the Royal Free Hospital. As Holloway is one of only 11 prisons in England for women, however, it is likely that it would be impractical for many women to attend this hospital once they had left prison. The authors have not attempted to identify those women who may have continued treatment or follow up within their local service.
The women's view
The authors seem to have made little attempt to understand why, from the women's perspective, their behaviour may well be rational and thus susceptible to modification. Unless women are enabled to understand the causes and progression of cervical abnormalities, the importance of their abnormal smear result, and the requirement for and availability of continuing care, they are disadvantaged in terms of making informed decisions about their future health care. All women deserve a full and careful explanation of their cytology results and any treatment should be recommended in a context free of judgmental or patronising attitudes. Where appropriate this discussion should be backed up with written information. Women who leave prison during treatment or follow up should be helped to identify where they might go for continuing care and provided with a letter for the next doctor.
Improving the present system
The above arguments could suggest that the problems may not be as great as implied by the authors. Moreover, the proposed approach to giving information and participation in decision making could provide real improvements. Unfortunately, the authors do not give detailed information about the protocols for the present service or for the proposed see and treat regimen or about the understandings and suppositions about the course of cervical disease which underlie the protocols. There is also no definition of operative treatment. Because of this it is difficult to establish the clinical validity of the approach.
We would argue that with better understanding of the women and the context in which they live their lives, together with the provision of a service which takes this into account, the outcome of care could be considerably improved without the need for a see and treat regimen. The potential adverse sequelae of destruction of the cervical transformation zone on the physical, reproductive, and mental health of the women are not discussed; nor is there any proposal to research this important issue. The adverse effects must be considered to understand the cost benefit ratio for treatment.
Treating women in prison different from rest of community
There is a considerable irony in this paper in that NHS doctors seem to be advocating a system of care for women in prison that would be significantly different from that offered to most women. Changes within the prison health care system over the past few years have supported the integration of NHS services with prison health care services - one of the aims being to provide similar services within and outside prisons. It is essential to see women in prison not as female prison inmates but as women.
However, the paper also raises the wider question of how best to provide services for any woman deemed to be at high risk of developing cervical cancer and considered to be unlikely to return for treatment. These women require the very best services available, provided in an appropriate way for them, and not an approach that will stigmatise them and may increase the risk of their not completing an effective course of treatment.