Objectives Current practice monitors women with low-grade cervical abnormalities at 12 months later, but women with high-grade cervical abnormalities (cervical intraepithelial neoplasia (CIN) 2 and 3) routinely receive immediate treatment to remove abnormal cells. There is evidence of increased risk of obstetric complications following invasive treatment of the cervix. Between 50–60% of high-grade abnormalities may regress to normal within two years, with higher rates of regression in younger women (under 30 years of age). An alternative management option is active surveillance, with a proposed protocol to monitor women every six months with HPV, cytology and histology biopsies (from colposcopy), and to only treat women if CIN2 persists after two years from when it was first detected, or if it progresses to CIN3 (or worse) at a repeat screening visit.
This study aimed to investigate framing of communication about active surveillance as a management option for CIN2 in women of childbearing age.
Method Participants were women aged 25–40 who had attended for cervical screening in Australia since December 2017. Participants were all presented with the same hypothetical diagnosis of HPV and CIN2 through an online survey and randomised to one of four groups using a between-subjects factorial (2 × 2) design to evaluate the effects of (i) method of explanation of regression of abnormal cells (natural clearance versus regression of abnormal cells) and (ii) inclusion of an overtreatment statement (overtreatment statement versus no overtreatment information). Participants were told to keep the diagnosis given in the scenario in mind whilst completing the survey. Primary outcome was management preference, measured as a direct dichotomous choice following the scenario: active surveillance or immediate treatment. Secondary outcomes included diagnosis anxiety, management choice anxiety, perceived seriousness of the condition, cancer worry, and perceived risk of cervical cancer.
Results 1638 women were randomised. Overall, preference for active surveillance was high (78.9%; n=1293/1638). There was no effect of framing (χ2(1) = 0.88, p = 0.35) or providing overtreatment information (χ2(1) = 2.14, p = 0.14), or their interaction (χ2(1) < 0.01, p = 0.99) on management choice. Participants were less likely to choose active surveillance over surgery if they already had children (aRR=0.87, 95%CI 0.83 to 0.92), had no plans for children in future (aRR=0.88, 95%CI 0.83 to 0.94), had a family history of cancer (aRR=0.93, 95%CI 0.87 to 0.99), a history of endometriosis (aRR=0.89, 95%CI 0.80 to 0.99), were predisposed to seek health care even for minor problems (aRR=0.93, 95%CI 0.91 to 0.96), or had lower health literacy (aRR=0.88, 95%CI 0.83 to 0.94). Older age (aRR=1.04, 95%CI 1.01 to 1.07), and more trust in GP (aRR=1.03, 95%CI 1.01 to 1.07), increased the likelihood of choosing active surveillance.
Conclusions Although there was no effect of framing across the four conditions, we found a high level of interest in active surveillance with predictors of increased interest that accord with the desire to minimise potential risks of CIN2 treatment on obstetric outcomes. This is valuable data for future clinical trials of active surveillance for management of CIN2 in younger women.
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