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The Unintended Consequences of Cervical Screening: Distress in Women Undergoing Cytologic Surveillance

Sharp, Linda PhD1; Cotton, Seonaidh PhD2; Cruickshank, Margaret MD2; Gray, Nicola M. PhD3; Harrild, Kirsten MSc4; Smart, Louise MD5; Walker, Leslie G. PhD6; Little, Julian PhD7on behalf of the TOMBOLA Group

Journal of Lower Genital Tract Disease: April 2014 - Volume 18 - Issue 2 - p 142–150
doi: 10.1097/LGT.0b013e31829c97d8
Original Articles

Objective It is well known that receipt of an initial abnormal cervical cytology test can trigger considerable anxiety among women. Less is known about the impact of follow-up by repeat cytology tests. We quantified prevalence, and identified predictors, of distress after repeat cytologic testing in women with a single low-grade test.

Methods Within the framework of the TOMBOLA randomized controlled trial of alternative managements, 844 women aged 20 to 59 years with a single routine cytology test showing borderline nuclear abnormalities (BNA; broadly equivalent to atypical squamous cells of undetermined significance) were assigned to follow-up by repeat cytology in primary care (the first test was due 6 months after the initial BNA result). Women completed sociodemographic and psychosocial questionnaires at recruitment and the Impact of Event Scale (IES) 6 weeks after their first follow-up cytology test. Factors associated with significant psychologic distress (IES ≥ 9) were identified using logistic regression.

Results The response rate was 74% (n = 621/844). Of all the respondents, 39% scored in the range for significant distress. Distress varied by follow-up cytology result: negative, 36%; BNA or mild dyskaryosis, 42%; other (including high grade and inadequate), 55%. After adjusting for the cytology result, risk of distress was significantly raised in women who had significant anxiety at recruitment, reported experiencing pain after the follow-up cytology, had children, or were dissatisfied with support they had received after their initial BNA test.

Conclusions Substantial proportions of women experience surveillance-related psychologic distress after a follow-up cytology test, even when the result is negative. This is an important, albeit unintended, consequence of cervical screening. Strategies to alleviate this distress merit attention.

A substantial proportion of women with a single cervical cytology test showing borderline nuclear abnormalities (broadly equivalent to atypical squamous cells of undetermined significance) experience surveillance-related psychologic distress after follow-up cytology, even when the result is negative.

1National Cancer Registry Ireland, Cork Airport Business Park, Cork, Ireland; 2Obstetrics and Gynaecology and 3Centre of Academic Primary Care, University of Aberdeen, Foresterhill, Aberdeen, Scotland; 4Medical Statistics Team, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, Scotland; 5Department of Pathology, Aberdeen Royal Infirmary, Aberdeen, Scotland; 6University of Hull, Hull, England; and 7Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, Ontario, Canada

Reprint requests to: Linda Sharp, PhD, National Cancer Registry Ireland, Building 6800, Cork Airport Business Park, Kinsale Road, Cork, Ireland. E-mail:

Linda Sharp and Seonaidh Cotton contributed equally to this work.

This study, and the TOMBOLA trial, was funded by the Medical Research Council (Grant Number G9700808) and the NHS in England and Scotland.

The authors declare that they are not aware of any conflict of interest that would have materially affected the work reported in the article.

Copyright © 2014 by the American Society for Colposcopy and Cervical Pathology