Gynaecological cancer services: time for change.
Explore the source record for details and available documents.
Cancer Care Facilities↗
Biomedical subjects
H C Kitchener
Publications and source records attributed to H C Kitchener.
The case for stopping cervical screening at age 50.
OBJECTIVE: To determine the pattern of abnormal cervical cytology in women aged 50 to 60 years and to determine whether the development of cervical neoplasia in this age group is confined to women who have been inadequately screened. DESIGN: Retrospective case analysis study. POPULATION: An 11-year birth cohort of women in Grampian Region born between 2/10/33 and 1/10/44, and those who had significant cytological abnormalities in the 5 year period 1/10/89 to 30/9/94. MAIN OUTCOME MEASURES: Cytological and histological outcome for women with significant cytological abnormalities between 50 to 60 years of age and the interval between three consecutive smears taken up to 50 years of age for those women. RESULTS: Of 23,440 women aged 50 to 60 years ever screened in Grampian Region, 229 (1%) had significant cytological abnormalities. Seventy had CIN 3 and 15 had invasive disease of the cervix. Among approximately 9000 women with adequate smear histories prior to age 50, one case of CIN 3 and one case of invasion were detected. The prevalence of invasive disease in the whole cohort during this five year period was 59/100,000. Among the previously well screened women the prevalence was 11/100,000. CONCLUSION: The incidence of preinvasive disease of the cervix is low over the age of 50 and is seen almost exclusively in inadequately screened women. There would appear to be little benefit in continuing cervical screening over the age of 50 in women who have had regular negative smears. The release of this low risk group from the cervical screening programme could alleviate anxiety and could enable reallocation of resources to target better high risk women who default from regular screening and to reduce screening intervals where necessary to three years.
Age Factors↗
A pragmatic randomised comparison of transcervical resection of the endometrium with endometrial laser ablation for the treatment of menorrhagia.
OBJECTIVE: To compare endometrial laser ablation (ELA) with transcervical resection of the endometrium (TCRE) in the treatment of menorrhagia. DESIGN: Randomised controlled trial. SETTING: Gynaecology department of a large teaching hospital. PARTICIPANTS: Women with menorrhagia due to dysfunctional uterine bleeding (n = 372) were randomly allocated to ELA (n = 188) or TCRE (n = 184). MAIN OUTCOME MEASURES: Operative complications, post-operative recovery, relief of menstrual and other symptoms, need for further surgical treatment, satisfaction with treatment after 6 and 12 months, and differential resource use. RESULTS: TCRE was significantly quicker, with lower rates of fluid overload. Perioperative morbidity was low and similar in both groups. Outcome at 12 months was also similar: 72 women (45%) had either amenorrhoea or brown discharge in the ELA group compared with 71 (49%) in the TCRE group; 79 (49%) versus 68 (46%) had lighter periods. Thirty (16%) versus 36 (20%) had received further surgical treatment: 9 (5%) compared with 25 (14%) had had a hysterectomy and 21 (11%) versus 11 (6%) had received repeat ablation. Anxiety and depression, dysmenorrhoea and pre-menstrual symptoms were improved by both procedures and bladder symptoms were affected by neither. At 12 months 148 (90%) women in the ELA group and 140 (91%) women in the TCRE group were satisfied with their treatment. The estimated additional cost of ELA was Pound 145 per procedure. CONCLUSIONS: At one year there was no clear difference in clinical outcome between ELA and TCRE. Both procedures were associated with low morbidity. ELA was the more costly procedure. Despite the need for further surgery for about one in six women, satisfaction rates were high following both ELA and TCRE.
Adult↗
Randomised trial comparing hysterectomy with endometrial ablation for dysfunctional uterine bleeding: psychiatric and psychosocial aspects.
OBJECTIVE: To compare in psychiatric and psychosocial terms the outcome of hysterectomy and endometrial ablation for the treatment of dysfunctional uterine bleeding. DESIGN: Prospective randomised controlled trial. SETTING--Obstetrics and gynaecology department of a large teaching hospital. SUBJECTS: 204 women with dysfunctional bleeding for whom hysterectomy would have been the preferred treatment were recruited over 24 months and randomly allocated to hysterectomy (99 women) or to hysteroscopic surgery (transcervical resection (52 women) or laser ablation (53 women). MAIN OUTCOME MEASURES: Mental state, martial relationship, psychosocial and sexual adjustment in assessments conducted before the operation and one month, six months, and 12 months later. RESULTS: Both treatments significantly reduced the anxiety and depression present before the operation, and there were no differences in mental health between the groups at 12 months. Hysterectomy did not lead to postoperative psychiatric illness. Sexual interest after the operation did not vary with treatment. Overall, 46 out of 185 (25%) women reported a loss sexual interest and 50 out of 185 (27%) reported increased sexual interest. Marital relationships were unaffected by surgery. Personality and duration of dysfunctional uterine bleeding played no significant part in determining outcome. CONCLUSIONS: Hysteroscopic surgery and hysterectomy have a similar effect on psychiatric and psychosocial outcomes. There is no evidence that hysterectomy leads to postoperative psychiatric illness.
Adaptation, Psychological↗
Can HPV16 detection rationalise the management of women with mild or moderate dyskaryosis?
Explore the source record for details and available documents.
Cell Nucleus↗
A comparison of bladder and ovarian function two years following hysterectomy or endometrial ablation.
OBJECTIVE: To test the hypothesis that at two years bladder and ovarian function function are no different following either simple hysterectomy or endometrial ablation (transcervical resection/laser ablation). DESIGN: Randomised controlled trial comparing hysterectomy with endometrial ablation. Two years after trial entry bladder and ovarian function were evaluated subjectively by means of questionnaires and objectively by means of cystometry and estimation of serum follicle stimulating hormone respectively. SETTING: Aberdeen Royal Infirmary. PARTICIPANTS: Tow hundred and four women with dysfunctional uterine bleeding who, when recruited to the initial study two years previously, were aged less than 50 years, weighed less than 100 kg, and who would otherwise have undergone hysterectomy. RESULTS: Of the 204 women originally recruited, 101 re-attended the clinic and underwent cystometry and follicle stimulating hormone estimation. These, together with a further 59 women, completed postal questionnaires (79% of original cohort). Rates of stress incontinence (44% vs 44%, 95% CI of difference -16% to +15%), urge incontinence (21% vs 19% 95% CI of difference -11% to +14%), and hot flushes (30% vs 44%, 95% CI of difference -25% to +7%) were similar in the hysterectomy and endometrial ablation groups, respectively. Cystometry revealed 14 (31%) cases of bladder dysfunction after hysterectomy and 17 (35%) after hysteroscopic surgery (95% CI of difference -23% to +15%). Serum follicle stimulating hormone levels > 40 IU/L [corrected] were found in three (6%) women following hysterectomy and five (10%) of women after endometrial ablation. CONCLUSION: This study suggests that in comparison with endometrial ablation, simple hysterectomy for dysfunctional uterine bleeding does not compromise bladder or ovarian function, at least at two years after the operation. Due to lack of power the estimates of any differences are imprecise, and clinically significant effects cannot be ruled out.
Adult↗
Mature results of a randomized trial of two doses of cisplatin for the treatment of ovarian cancer. Scottish Gynecology Cancer Trials Group.
PURPOSE: In 1992, we reported the first results of a randomized study in ovarian cancer, comprising two doses of cisplatin and indicated a significant difference (P = .0008) in median survival. Four years later, we now describe the results of this trial. PATIENTS AND METHODS: After a median follow-up of 4 years and 9 months, 115 of 159 cases of advanced ovarian cancer, originally randomized to receive six cycles of cyclophosphamide 750 mg/m2 and either a high dose (HD) of 100 mg/m2 cisplatin or a low dose (LD) of 50 mg/m2 (LD) cisplatin, have now died. RESULTS: The overall survival for HD and LD patients is 32.4% and 26.6%, respectively, and the overall relative death rate is 0.68 (P = .043). This represents a reduction in overall benefit with longer follow-up compared with the first 2 years (relative death rate of 0.52). Toxicity, particularly neurotoxicity, is still evident in the fourth year (10/31 on HD compared with 1/24 on LD). CONCLUSION: Our recommended dose of cisplatin in combination schedule is therefore 75 mg/m2, representing the optimal balance between efficacy and toxicity.
Antineoplastic Combined Chemotherapy Protocols↗
A prospective randomised study of the effects of prophylactic antibiotics on the incidence of bacteraemia following hysteroscopic surgery.
OBJECTIVE: To study the effect of prophylactic antibiotics on the incidence of bacteraemia following hysteroscopic surgery. DESIGN: Prospective randomized study. SETTING: Aberdeen Royal Infirmary. SUBJECTS: One hundred and sixteen women about to undergo either endometrial laser ablation (ELA) or transcervical resection of the endometrium (TCRE). INTERVENTION: Fifty-five women were randomised to receive 1.2 g of Augmentin (co-amoxiclav) i.v. at induction of anaesthesia. Sixty-one women received no antibiotic prophylaxis. Blood cultures were obtained at the end of the surgical procedure. RESULTS: Incidence of bacteraemia in the non-antibiotic group (16%) was significantly higher than that in the antibiotic group (2%) (95% confidence interval for difference from 5% to 25%). The majority of organisms were of dubious clinical significance and contamination could not be excluded in 7 cases out of 10. CONCLUSION: There is no convincing evidence that antibiotics are of value in this clinical setting.
Amoxicillin↗
Fertility and pregnancy outcome following large loop excision of the cervical transformation zone.
OBJECTIVE: To determine if large loop excision of the transformation zone affects subsequent fertility and pregnancy outcome. DESIGN: A case-control study. SETTING: A teaching hospital serving a regional population. SUBJECTS: One thousand women who had undergone large loop excision of the transformation zone (LLETZ) for the treatment of cervical intraepithelial neoplasia (CIN) between 1989 and 1991. Two controls were matched for each of the 149 women who had a singleton pregnancy progressing beyond 20 weeks of gestation following treatment, with regard to age, parity, height, husband's or partner's social class and smoking habits to account for common independent risk factors for adverse obstetric outcome and cervical intraepithelial neoplasia. MAIN OUTCOME MEASURES: Intention to conceive, number of pregnancies, gestation, low birthweight, mean birthweight, mode of delivery, and duration of labour. RESULTS: Out of a cohort of 1000 women who underwent LLETZ for the treatment of CIN, 653 women replied to a postal questionnaire. When asked up to 54 months after treatment, 130 women (19.9%) had become pregnant and 47 (7.2%) had tried to become pregnant. A total of 199 pregnancies from 178 women was identified from the cohort of women. For the 149 women from the case cohort, the mean birthweight was 3380 g compared with 3373 g in the control group (P = 0.88). The incidence of low birthweights in pregnancies progressing to at least 37 weeks of gestation was 3.1% in the treated group, compared with 3.2% in the control group (P = 0.98). Following LLETZ, 9.4% of deliveries were preterm (< 37 weeks of gestation), compared with 5.0% in the control group (p = 0.12). There was no significant difference in mean gestation, mode of delivery, indication for caesarean section or duration of labour between the women who had undergone LLETZ and the controls. CONCLUSION: When socio-epidemiological factors associated with the development of cervical intraepithelial neoplasia are controlled for, LLETZ does not appear to exert an independent adverse effect on subsequent pregnancy outcome.
Adult↗
The 1993 British Society for Colposcopy and Cervical Pathology/National Coordinating Network United Kingdom Colposcopy Survey. Comparison with 1988 and the response to introduction of guidelines.
OBJECTIVE: To evaluate colposcopic practice over a 12-month period in the UK, April 1993 to March 1994, to compare this with 1988, and to test penetration and acceptance of previously introduced national guidelines. DESIGN: A nationwide survey of colposcopy practice by postal questionnaire, including referral criteria, diagnosis and treatment, follow up, waiting times and information and counselling. SETTING: All gynaecology clinics in the United Kingdom. RESULTS: Returns were obtained from 215 clinics (78%), that saw an average of 434 new women per year. Seventy percent of clinics follow the current national guideline for cytological referral criteria for colposcopy. Diathermy loop excision is now by far the most popular treatment method for CIN. The majority of clinics employ both colposcopy and cytology for follow up. A total of 103 invasive cancers following treatment for CIN were reported during the 12-month period of the survey. Most clinics provide new patients with both information and counselling. CONCLUSIONS: Colposcopy practice has undergone considerable changes in the last five years. There has been a good response to the introduction of a national guideline for referral for colposcopy. While local audits are necessary to identify improvements that need to be made to individual clinical services, this national audit has shown some trends over the past five years, has highlighted the problem of invasive cancer following treatment for CIN and has assessed the impact of a national guideline.
Colposcopy↗
Towards optimal management of the mildly abnormal smear.
Approximately 2-3% of cervical smears will be reported as showing low-grade changes. Many of these smears are in fact associated with high-grade cervical intraepithelial neoplasia requiring treatment, but a significant number will be associated with an absence of cervical intraepithelial neoplasia, where surveillance would enable regression of the cytological abnormality. Pathological, economic and psychosocial considerations all contribute to the ongoing debate as to the optimal management strategy.
Cervix Uteri↗
The management of carcinoma of the vulva: current opinion and current practice among consultant gynaecologists in Scotland.
A postal questionnaire survey of all 126 consultant gynaecologists in Scotland was undertaken in order to obtain an overview of current opinion and current practice in relation to the management of vulval carcinoma. The response rate was 95%. Fifteen suggested criteria for good quality care were validated by a balance of agreement among respondents. There was particularly strong agreement (> 90% of respondents) that vulval carcinoma should be managed by subspecialists rather than generalists, that en bloc radical vulvectomy is not always required, that patients should be informed of their diagnosis and that long-term follow-up is required. There was least agreement (< 50% of respondents) that groin lymphadenectomy may be omitted in selected cases and that follow-up need be at special multidiscipline clinics. An encouraging picture of current practice emerged. Very few consultants who do not profess to be oncology subspecialists would manage cases alone, few perform en bloc radical vulvectomy in all cases and few undertake deep pelvic lymphadenectomy. Most acknowledge the importance of psychosexual issues and all generally inform patients of the nature of their diagnosis. The postal questionnaire approach achieved a good response rate and has provided an informative overview of current opinion and practice on a national basis. This approach may be more valuable than case-note review audit in providing a meaningful picture of contemporary practice for uncommon conditions like vulval cancer.
Clinical Protocols↗
Randomised trial of hysterectomy, endometrial laser ablation, and transcervical endometrial resection for dysfunctional uterine bleeding.
OBJECTIVE: To evaluate the effectiveness and safety of endometrial laser ablation and transcervical resection of the endometrium compared with hysterectomy in the surgical treatment of women with dysfunctional uterine bleeding. DESIGN: Prospective randomised controlled trial. SETTING: Gynaecology department of a large teaching hospital. SUBJECTS: 204 women who would otherwise have been undergoing hysterectomy for menorrhagia were recruited between August 1990 and March 1992 and randomly allocated to hysterectomy (n = 99) or conservative (hysteroscopic) surgery (transcervical resection (n = 52) and laser ablation (n = 53)). MAIN OUTCOME MEASURES: Operative complications, postoperative recovery, relief of menstrual and other symptoms, patient satisfaction with treatment after six and 12 months. RESULTS: Women treated by hysteroscopic surgery had less early morbidity and a significantly shorter recovery period than those treated by hysterectomy (median time to full recovery 2-4 weeks v 2-3 months, P < 0.001). Twelve months later 17 women in the hysteroscopy group had had a hysterectomy, 11 for continuing symptoms; 11 women had had a repeat hysteroscopic procedure; 45 were amenorrhoeic or had only a brown discharge; and 35 had light periods. Dysmenorrhoea and premenstrual symptoms improved in most women in both groups. After 12 months 89% (79/89) in the hysterectomy group and 78% (75/96) in the hysteroscopy group were very satisfied with the effect of surgery (P < 0.05); 95% (85/89) and 90% (86/96) thought that there had been an acceptable improvement in symptoms, and 72% (64/89) and 71% (68/96) would recommend the same operation to others. CONCLUSIONS: Hysteroscopic endometrial ablation was superior to hysterectomy in terms of operative complications and postoperative recovery. Satisfaction after hysterectomy was significantly higher, but between 70% and 90% of the women were satisfied with the outcome of hysteroscopic surgery. Hysteroscopic surgery can be recommended as an alternative to hysterectomy for dysfunctional uterine bleeding.
Endometrium↗
Management of women with mild and moderate cervical dyskaryosis.
OBJECTIVE: To compare the outcomes in women with mild and moderate dyskaryosis after increasing periods of surveillance and thereby to define a rational protocol for managing such women. DESIGN: Prospective study with randomisation of women to one of four treatment groups, each with a different period of surveillance; one group in which the women were given immediate treatment and three other groups in which the women were under surveillance for six, 12, and 24 months. SETTING: A dedicated colposcopy clinic in Aberdeen, Scotland. SUBJECTS: 902 women who presented with a mildly or moderately dyskaryotic smear for the first time. INTERVENTIONS: Cytological and colposcopic examinations at intervals of six months until the allocated period of surveillance was completed, at which time biopsy was performed. Women with severe dyskaryosis were withdrawn from surveillance and a biopsy was performed. MAIN OUTCOME MEASURES: The histological findings after punch biopsy or large loop excision of the transformation zone, and the trends in cytological appearances of serial cervical smears. RESULTS: 793 women completed the study. In all, 769 women had an adequate final smear, of which 197 were normal cytologically, 328 were still mildly or moderately dyskaryotic, and 244 were severely dyskaryotic. Seventeen of the 67 (25%) women with one repeat smear showing non-dyskaryosis had cervical intraepithelial neoplasia grade III compared with only one of the 31 (3%) women with no dyskaryosis in four repeat cervical smears (P < 0.0001). None of the women had invasive cancer. Of 158 women whose index smear showed mild dyskaryosis and who were allocated to the group under surveillance for two years, only 40 had not defaulted or still had dyskaryotic smears by the end of the two years. CONCLUSION: Cytological surveillance, although safe, is not an efficient strategy for managing women with mildly abnormal smears. Women with any degree of dyskaryosis in a smear should be referred for colposcopy.
Adult↗
Cerebral metastases from epithelial ovarian carcinoma treated with carboplatin.
We describe three women with cerebral metastases who presented following treatment for ovarian cancer. In all three cases the primary tumor underwent complete remission following cytoreductive surgery and adjuvant platinum-based combination chemotherapy. Cerebral metastases occurred at 18, 19, and 25 months following initial diagnosis of ovarian carcinoma. These cerebral lesions were treated with carboplatin 400 mg/m2 as a single agent. In one case total resolution of a single cerebral metastasis was achieved. In the other two women a significant reduction in tumor mass occurred and one of these responded to repeat treatment on two occasions. Survival times from diagnosis of the cerebral lesions were 11, 16, and 25 months. The treatment afforded rapid subjective and objective relief, significantly improved survival times, and was associated with good quality of life. Carboplatin should be considered for the treatment of cerebral metastases for ovarian cancer.
Adenocarcinoma, Papillary↗
The role of human papillomavirus in the genesis of cervical cancer.
Explore the source record for details and available documents.
DNA, Viral↗
Cervical carcinoma in the Grampian region (1980-1991): a population-based study of survival and cervical cytology history.
OBJECTIVES: To study survival in women treated for cervical carcinoma in Grampian region, to identify clinical and pathological prognostic factors, and to correlate survival with cytology history. DESIGN: A retrospective study of all cases of cervical carcinoma using a prospectively gathered database. Data validated by 1 in 10 randomised retrospective case note sampling. SETTING: Aberdeen Royal Infirmary. SUBJECTS: Three hundred and sixty-three women resident within Grampian diagnosed as having cervical carcinoma between 1980 and 1991, with five-year survival data on the 206 diagnosed by the end of 1986. MAIN OUTCOME MEASURE: Five-year survival rates. RESULTS: The mean annual incidence of cervical carcinoma in our population was 11.2 per 100,000 women, with an overall five-year survival of 67% in those under 40 years of age and 60% in those aged 40 years and over. On univariate analysis, survival was significantly adversely affected by tumour stage, grade and absence of previous smears. On multivariate analysis, the effect of previous smear history was lost, but stage and grade remained strong independent risk factors for survival. There was no significant difference in five-year survival by age or tumour type. CONCLUSIONS: The prognosis of cervical carcinoma in Grampian region was independently affected only by stage of disease and tumour grading and cervical smear history.
Adult↗
Thermal tissue damage following laser and large loop conization of the cervix.
OBJECTIVE: To compare thermal injury zones produced with laser and diathermy loop conization. METHODS: Excisional cervical specimens (cones and cervices) were obtained from 40 consecutive women who underwent abdominal hysterectomy. The subjects were assigned to have either laser or diathermy loop conization (20 in each group). The duration of each procedure was recorded. Histopathologic measurements of thermal injury zones were performed in all specimens. RESULTS: The techniques produced cone specimens of similar depth. The mean depth of thermal injury produced with laser conization in cone specimens (mean +/- standard deviation 0.49 +/- 0.16 mm) and cervical craters (0.58 +/- 0.24 mm) was significantly greater (P < .001) than the corresponding depth in cone specimens (0.22 +/- 0.09 mm) and cervical craters (0.27 +/- 0.11 mm) obtained by diathermy loop excision. The mean time of the two procedures was also significantly different (P < .001); laser conization 11 +/- 4.5 minutes and loop conization 2 +/- 1.2 minutes. CONCLUSION: For routine conization, loop diathermy causes less thermal damage to the specimen and is a faster procedure than laser.
Adult↗