Comparing the effect of referral intervals on the severity of dysplasia at the colposcopy clinic

Abstract

Background: Cervical cancer is the most common cancer in black South African women. Cervical cancer screening was initiated in South Africa in 2001, but limited infrastructure in the public health service result in a long delay between initial screening and colposcopy and treatment for women with abnormal Pap smears. Objective: To determine the effect of the time interval between cervical cytology screening and histology at treatment on the grade of cervical disease in women at a colposcopy clinic, Chris Hani Baragwanath Hospital. Methods: Women with cytological abnormalities were referred to the colposcopy clinic according to National Guidelines for referral. Data extracted from the colposcopy clinic database were analyzed to determine whether early (up to 180 days) or late (more than 180 days) referral and treatment had an impact on the grade of dysplasia of the cervical lesion from the time of initial diagnosis on cervical cytology to the definitive treatment at colposcopy. Results: In the early (7 to 180 days) referral group 213 (13.43%) women compared to 201 (14.63%) in the late (181 to 1702 days) referral group had upgrading of cervical dysplasia (p=0.35). The number of women with down-grading of dysplasia or no change in grade of dysplasia was 1373 (86.57%) and 1173 (85.37%) in the early and the late referral groups respectively (p=0.35). In the univariate analysis, risk factors for up-grading of dysplasia were HIV (OR=1.63, p=0.00) and condom use (OR=1.30, p=0.02). There were 4 cases (0.68%) of invasion in the LSIL group and 50 cases (2.11%) in the HSIL group that were not detected by cervical cytology. Risk factors for invasive disease on histology were age (OR=1.09 per year, p=0.00), parity (OR=1.32 per pregnancy, p=0.00) and HSIL on cervical cytology compared to LSIL (OR=3.17, p=0.03). Conclusion: There was no difference in up or down-grading of cervical dysplasia between patients that were referred to colposcopy clinic within 180 days compared to those that arrived after 180 days. With the present restrictive infra-structure, older women, HIV positive women, those of higher parity, and especially those with HSIL on cervical cytology should be referred sooner. HIV positive women should be prioritised by grade of dysplasia but not by CD4 until its effect on cervical dysplasia has been clarified. Ideally all women should be seen at a colposcopy clinic at least within 180 days and even sooner because of other factors such as anxiety, loss to follow up and cases of invasion being missed by cytology.