Direct notification of cervical cytology results to women improves follow-up in cervical cancer screening - A cluster-randomised trial

Bettina Kjær Kristiansen, Berit Andersen, Flemming Bro, Hans Svanholm, Peter Vedsted, Bettina Kjær Kristiansen, Berit Andersen, Flemming Bro, Hans Svanholm, Peter Vedsted

Abstract

Up to half of all women do not receive follow-up as recommended after cervical cytology testing and are thus at increased risk of dysplasia progression. Women from lower social positions are at increased risk of not receiving follow-up. Sample takers, often general practitioners, convey results to women, but communication problems constitute a challenge. We aimed to investigate the effect of direct notification of cervical cytology results on follow-up rates. In a 1:1 cluster-randomised controlled trial, we assessed if having the pathology department convey cervical cytology results directly to the investigated women improved timely follow-up, compared with conveying the results via the general practitioner as usual. All women with a cervical cytology performed in a general practice in the Central Denmark Region (2013-2014) and receiving follow-up recommendation were included (n = 11,833). The proportion of women without timely follow-up was lower in the group with direct notifications than in the control group of women receiving usual care, regardless of age, educational status, cohabitation status and ethnicity. Among the women with the most severe cervical cytology diagnoses who are recommended gynaecological follow-up within 3 months, the percentage without timely follow-up was 15.1% in the intervention group and 19.5% in the control group (prevalence difference: -0.04 (95%CI: -0.07; -0.02)). Improved timely follow-up was also observed for women with a recommendation to have follow-up performed at 3 and 12 months. Cervical cytology results conveyed directly by letter to women increased the proportion of women with timely follow-up without raising inequality in follow-up measured by social position. Trial registration: ClinicalTrials.gov (TRN: NCT02002468) 29 November 2013.

Keywords: AGC, Atypical Glandular Cells; AIS, adenocarcinoma in situ; ASC-H, atypical squamous cells cannot exclude HSIL; ASC-US, Atypical Squamous Cells of Undetermined Significance; CCU, cancer of the cervix uteri; CDR, Central Denmark Region; DPDB, Danish National Pathology Registry and Data Bank; Early detection of cancer; GP, general practitioner; General practice; HSIL, High-grade Squamous Intraepithelial Lesion; ICC, intra-cluster correlation coefficient; LSIL, Low-grade Squamous Intraepithelial Lesion; Mass screening; PD, prevalence differences; PR, prevalence ratio; Quality of health care; SNOMED, Systematized Nomenclature of Medicine; Socioeconomic factors; Uterine cervical dysplasia; hrHPV-pos., high-risk Human Papilloma Virus positive.

Figures

Fig. 1
Fig. 1
Flow chart for cervical cytologies1 obtained in general practice in the Central Denmark Region with a follow-up recommendation from 7 January 2013 to 1 June 2014 for women aged 23–64 years. Clusters consisted of general practices at the same address (N = number of cervical cytologies). 1Samples with topography SNOMED codes: T8X210, T8X310, T8X311, T8X312, T8X320, or T8X330. 2One intervention practice did not wish to participate; these women received usual care, but the analysis was performed as intention to treat. 3Other organisms or non-neoplastic findings, for example herpes. 4Ambiguous SNOMED coding, unprecise follow-up recommendation or uncommon topography (i.e. T8X210, T8X311, T8X312, T8X320, or T8X330). 5Observation period ended four months after GP reminder date. 6Seven general practices did not obtain cervical cytologies.
Fig. 2
Fig. 2
Proportions of women without follow-up among women receiving usual care (control (blue)) or direct notification by letter (intervention (red)), stratified by follow-up recommendation1. Observation of effect stopped 4 months after the GP reminder was generated. 1Time point 0 represents the date that the cervical cytology was obtained. The first vertical line is the time point for recommended timely follow-up. The second vertical line is the time point at which a reminder is generated by the screening programme and sent to the GP, if the woman has not had follow-up. A GP reminder is generated 4 months after the initial cervical cytology if follow-up is recommended within 3 months, and after 6, 9, or 15 months, if follow-up is recommended in 3, 6, or 12 months, respectively.

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