Dr L London
M B C h B , B S c ( H o n s ) , D O H l)cpartment of Con.rnrunit,v Hcalth M e d i c a l S c h o o l
Universiq'of Capc Toun OBSERVATORY 7 9 2 5
Curriculum vitae
Lcslie Lonc-lor-r graduatecl fiom UCT in 1983.
Aficr his internship at Groote Schuur, he rxrrkcd as the medical otlicer fbr thc F'ood Workers Meclical Bcr.refit Funcl in Paarrl fi-or.n 1987 until 1991, rur.rr.ring ;r priman' hcirlth car-c ficilitv fbr n'orkers in the fbotl grrocessir.rg i n d u s t n , in t h c B o l l n c l . H e i s c u r r e n t l v a registrar in the Dcplrtr.r-rent of Conrnruniti' H c a l t h : r t U C T s i t h i u r r c l i v e i l t e r c s t ir r Occr,rpationiil Hc;rlth resc;rrch.
An Evaluation of a Pup Smear Service in a Rural General Practice - L London
Suntmary
It is recogttised th;tt cenical cvtologl' (PAP) screening ciut play ;tn
intportant role in the pret,cntion <>l' ntorbiditt, and ntortalitt,due kt cen,icttl ctTncer. The PAP sntertr servicc orovided tlt a rLtrtl] Meclicttl Benetii Func! practice in tl'te Western Cape was evalttatec{ basecl on reviev' of 205 stnears taken over thc oeriod Junc 1987 to Decenber 199b. High inciclences of cvtol ogical
abnonnalities w'erc Ibund itnongst a pre c! onti n a n tl ), "' C o I ottre cl "
popu lation. l)espite covcri n g less than l0% ol'lintale patients, the efiiciencv <tt'the sen'ice in tcrnts of follow-ttp itnc! intcrvention was high.
Reasons arc advancecl tir tlte ncccl to direct screening at v'onen w'ho clo not receitc PAP sntears li'ont Statc clinics. This studt' rcintbrccs the xrguntent flttt rhcre i.s ;ttt iDtport:tnl role Ibr opportLutistic PAP scrcening b1, general pr"actitioncrs lbr patients w h o wo tt lcl ot h c n'ise /?cr 11' rrL'el c adecTuate ct,tological scrccning. A call is tttrtcle tbr State l;tboraton' tacilities to bc trttrle ;tr ailtl'tlc for tlii., pLttT',osc as parl ttf-,t cortc'crtc'<l p.tr'c'utivc c J I 11 p J i g r t :t g ;t i t t s t ccn ri';t/ c.l/1('('1-.
S Ati' Fant Pract 1993: l1: 196-202
I(EYWORDS:
Cervix Dysplasia; C),tology;
Women, $.orking; Phvsiciar-rs, Family.
196 SA Farlilv Pr;rctice Mav 1993 SA Hr.rislrtsprrktvk Mci 1993
Introduction
Cancer of the Uterinc Cen'ix represcnts onc of the important preventable ptrblic health problems in the u'<>rld tocla\',i o pirrticularlv ilrlrollgst wonlen in the third r'r.orld' t and amor-rgst n,orking class u,omen.2 3'6 Studies in Soutl-r Af ica have
confirrned that cancer of the cen'ix is common anoltgst Afircan
rvonle n" I" artd is irrcrcasirrg alnongst
"Coloured" $,olrren.r I Desoite the potcutial tbr Paparricolorr snrears (PAP srnears) to prevent the development of cancer of the gg6,ixr':'o'; rr-rs nnd to drasticallv reduce health crre costs duc to the discase,s 13. r7. re it appears that many South Aliicin \vomen u'ho are rnost at risk do not have access to PA-P screeniug.o. r: 16 17.20 Horvevcr, PAP smear sen'iccs r.nav be fi'ausl"lt u,ith ( ) p c r i t i ( ) l r a l d i f l i c u l t i c s " r r r i - 1nd should be constantlt, monitorcd and evalrr;rted to cnsrrre thcir
efFectivencss. r. r:. r+
PAP snrears in Sor-rth Afi'ica irre providcd b), both put'rlic scctor healt1r ficilitics ancl privtrtc scctor general and spcciirlist practitioners, yet little qLlantitativc clirtrr is avirilablc on the distribr.rtior-r of PAP slrears.rr There is cridcucc th.rt ti'c tbr-scnicc
reimburser.r.rcut iu thc orivatc health scctor d()cs l'lot encollragc
prevcntati\.e health mcasr.lres'.lmongst those ;latients u'ho cirnnot 'rf-fbrd it.15 20 T h c r < l l c o t - g c u e r . r l p l ' i l c t i t i ( ) u c r s i l r the orevention of ccrvical crucer hirs llot1)ccn exrrlorcci in South Afi-ica to rllte. H,r'iderrcc li'onr thc Unitcd IGngclor-r-r su ggests thirt fan-ri I v practitioners crrn Pllv lrr irDpol.tarrt lolc in prorit'ling l prcvcrrt;.rtile sen,ice fbr ccn'ical carcinolt'trt.t' 2r' l. r7 re Tire Iood Workers Medical Benefit Funcl (FWMBF) runs a full-time
general practice in Paarl for workers in the food processing and packing industry, of whom the majoriry are
"Coloured" women employed seasonally. Starting in 1987, the clinic has provided a PAP smear service for women who are unable to obtain their smears from the local
municipality clinics or who prefer to attend the FWMBF clinic for their
Early detection drastically reduces costs.
PAPs. This service was not intended to replace existing services providing PAP smears but to supplement in situations where access to State services proved to be difficult for the patient. Since 1988, the clinic has made use of a register to ensure thorough recall of women when a follow-up smear is indicated.t* For smears of normal cytology requiring routine follow-up, the FWMBF clinic followed a policy of repeating the smear within a year on women who were receiving their first ever smear) and within three years fbr all others.
For smears of abnormal cytology, laboratory guidelines for follow-up were followed. Cytological analysis of smears was performed free of charge at the Department of National Health and Population Development laboratory until its closure in
February 1989 and at Groote Schuur Hospital Cytology laboratory
thereafter. This study was undertaken to review the service ofiered to women eligible to use the clinic during 1987-1990.
The objectives of the study were to:
l. Describe the pattern of PAP smear
z .
3 .
utlllsatlon amongst women attending the FWMBF clinic.
Describe the incidence of
abnormal cytology and associated abnormalities.
Evaluate the efficiency of the service offered in terms of follow- up and intervention.
The study concentrated on measures of process and not on outcome , since morbidity and mortality would have been bevond the scooe ofthe evaluation. The study therefore sought to evaluate efficiency rather than effectiveness of the PAP smear service provided.
Material and Methods
Evaluation ol PAP smear service efficiency was performed by record review of all PAP smears taken at the FWMBF clinic from June 1987 to D e c e m b e r 1 9 9 0 . In f o r m a t i o n o n a g e , date of smear, cytologv result and follow-up outcome was recorded for all smeari. Follow-up was defined in
terms of (a) whether the patient received fu rther colposcopic
examination or definitive treatment at Provincial gynaecology services for an abnormal smear, or (b) whether they returned within the time period recommended by the cytology laboratory services for a follow-up smear. Smears were taken according to standard technique.t'27 For a random sample of 30 smears taken at the FWMBF practice during the study period, assessment was made of the indication for taking the smear.
Classification of cytology results was done according to World Health Organisation (WHO) guidelines and is reported in terms of the Cervical Intra-epithelial Neoplasia (CIN) system.t
Analysis
Interquartile ranges were estimated according to methods outlined in Sclove and Anderson for grouped data.30 As measures of association, Odds Ratios were calculated with
Table l. Age distribution of PAP smear users 1987-L990, women patients in 1990 and female workforce in L987
Median Age
r"iiiq"uilir*
,-g.ange
PAP Smear Users 1987-90 ( n = 2 0 5 )
3 B 2 9 - 4 5 1 9 - 6 4
Worr.ren Patients 1990 ( n = 1032)
3 1
Female Workforce 1987 ( n = 1635)
, :,,:::,:::
2 9 ,
, t.:,,:'tt.
i4',- gB t 6 - 6 9
197 SA Family Practice May 1993 SA Huisartspraktyk Mei 1993
Table 2. PAP smears and and patient population.
Pap Smear Service
Proportion of coverage of workforce
95% confldence intervals according to Fleiss.3' Statistical significance of differences in proportions werc c a l c u l a t c d u s i r r g a X ' ] s t a t i s t i c o r , r,vhere cells were too small, by means of Fisher's exact probability.
Results
There wcrc 205 smcars taken at thc FWMBF clinic during the period undcr investigation, of r'vhich 10 results were still or-rtstar.rding at tl.re time of record revier,r'. Table I gir.es the age distribution of u,omen receiving PAP smears at the FWMBF clinic and lists the distribution of fbmale patients attending the clinic in 1990 and the distribution of the age of the female rvorkfbrce in l9B7 (latest accurate figr,rres available).'tt Table 2 lists the numbers of smears tal<en each Ic:rr rrrd tlrc proporriorr these constitutcd of tire lbmale rvorkfbrce and of the fbmale patient population, respectively.
Denominators fbr
"vorkforce size liom l98B are estimates based on
I 9 8 7 d a t a .
Table 3 lists the indications for PAP
smears amongst a random sample of 30 women and Table 4 describes cytological abnormalities found amongst 195 srnears for r.vhich results rvere available at the time of revier,v.
An abnormality rate (ir-rch-rdir-rg severe dvsplasia or u'orse) of l% of all smears and I,2% of all first smears was found.
Evidence of Human Paoilloma Virus Inlection wxs n()ted in 4 smcars (2.4T") . Other abnormalities
(including lesser degrees of dysplasia or atypia) amounted to 18,9% of first smears and20,5% of all smears.
All 9 smears with evidence of intra- epithelial neoplasia (CIN t or worse) were reported after February 1989 by the Groote Schuur laboratory. Of the 101 smears processed by the State laboratory prior to its closure, none were reported as having evidence of CIN or invasive carcinoma. (Fisher's e x a c t t e s t : p < 0 , 0 5 )
Of the 4 women requiring follow-up for abnormal cytology on their first srnear (fbr CIN 1,2 or 3), all were successfully recalled and follow up established. Three patients underwent colposcopv at a local State
Gynaecology senice and twcr subsequently underwent
hysterectomy. The fourth patient reccived a follow up smear according to laboratory recommendations and is still being follorved-up. Three patients rvhose initial smear cytology was reported as normal had CIN I on their second smear and are due to receive follow-up smears. The patient
Table 3. Indication fbr PAP smear amonsst a random samDle of PAP smear users
Time Period PA? Smears
Rate per Female lVorkforce
Rate per Femal(
Patients'
Iune 87 - Dec 87
l 1 0,6%
l , i %Ian B8 - Dec BB
/ 54 , 3 %
8,8%n]an 89 - Dec 89 / 4
3 9 %
9,64/oJan 90 - Dec 90
+ /2.3Yo 4,6%:
Indication for PAI Number of PAP's
Presence of a Gynaecological Prob-lem
tr (37v")
Attendance for an unr,elated Medical Probler:r
t2 (40v0)
Specifically requested a PA-P smear2 (7v")
Reason Unstated
s ( r 7 % )
TOTAL 30 {100%)
198 SA Family Practice May 1993 SA Hr"risartspraktvk Mei 1993
Table 4. Cen,ical Cytology amongst PA? results (n : 195)
Cytology
First Smears
Second Smears
Third
Smears , All Smears
Normal
r 3 5 ( 8 0 % ) r s ( 6 0 % ) r (roo%) r51 (77v")
Mild or Moderate arypia
29 \15%) 6 (24%) 3 5 ( 1 6 % )
Mild dyspl (CIN 1) 2 ( 1 , 5 7 0 ) 4 (l6e/a)6 {3%)
Moderate dysp (CIN2)
I ( 0 , 6 % ) I (0;5%)
Severe
dyspl (CIN
5 )r (0,6%) r {0;5%}
Invasive Carcinoma
r (0,6%) I ( 0 , 5 % )
with invasive carcinoma r,vas refbrred to hospital but rcfuscd follon.-up.
O f t h e 2 9 u o m e r r w i t h a r y p i a o n cvtology on their initiai smcar, l6 received a follor,r, up smear b,v the end of 1990 and only 9 rl'omen had missecl appointments fbr tl-reir fbllor,v up smears. lIo$,cvcr, the follow-up pattern of n omen r,vith normal smears rvas sigr-rificar-rtly poorer. Of- the l0 womcn rvho rvere due fbr a fbllorv-up smear by the cnd of 1990, onl1, 3 had received a follow-up smear by the end of 1990. This diflerence r'vas statistically signilicant (Fisher's exact test I tailed: p < 0,05).
Discussion
There can be little doubt tl-rat cen'ical cytology can pla1, an indispensable role in the early detection of pre- malignant dysplastic lcsions of the uterine cervixr.e.12. 1: and contriblrte to a reduction in the mortalitv due tcr
c e r v i c a l c a n c e r . r . 3 . 6 . 7 , e r 1 ' r s . r 7 Flowever)
many studies have pointed to the fhct that many \,\.omen in Souti-r Africa do
not have access to cervical smear servicesrs.16' 17,20 as a result of which, Black South Aliican women tend to prcscllt r,r ith latc stage invasive carcinoma of tl-re cen'ix.s Because of this, many authors have argued for opportunistic PAP screening of female patients attending health sen'ices fbr visits unrelated to cytological scrccning,s' r6. 27' :3 including routine PA? testing of all worlen over the age of 20 ),ears admitted to State and Provir-rcial Hospitals."'
Little data is available on the role of primary carc physicians in PAP smear provisior-r. In the United I(ngdom, general practitioncrs are routinelv involved in the taking of PA?
smears.22.2a'27 to In South fuiica, it a p p e . l r s t h a t g e n e r a l p r J c t i t i o n e r s in the privatc sector tcnd to provide PAP sr-r-rear services to women of higher sc-rciocconomic class who need it least.'o It has been argued that the task of taking cervical smears should not be the responsibilitv of doctors lvho are freqr-rentlv too busv.s
199 SA Familv Practicc Mav 1993 SA Huisartspraktyk Mei 1993
However, WTIO recommendations regard all health care workers with s u i t a b l e t r a i n i n g a s a p p r o p r i a t e personnel to carry out cervical screening.' This would include both primary health care doctors and nurses.
In order to Drevent rhe massive individual and social burden of invasive carcinoma of the cervix, there seems every reason for general practitioners, or their trained staff, to take PAP smears on Datients at risk for cervical carcinoml and its precursors.s'21,2e,34 A pilot study of
100 patients presenting with cervical cancer in Soweto showed that 32 of these oatients had first attended g.t-r..il practitioners for their initial symptoms. Of these, there was a delay in the diagnosis in l3 cases as a result of failure by the GP to provide PAP smears.o
Table 3 reinforces the argument that opportunistic screening for cervical d y s p l a s i a i n r g e n e r a l p r a c t i c e i s a feasible prospect. The FWMBF clinic was doing PA? smears on roughly one in 11 female Datients in t9B8 and 1989 with a slight decline in 1990 due to stafling changes. The reasons for uotake of smears at the
Register to ensure recall when follow-up is indicated.
FWMBF clinic in oreference to other s ( ) L l r c c s m a y in c l u d c e a s i e r a c c e s s . greater explanation, more familiar surroundings and more suitable times ofservice. These asoects need further documentation.u,' On the other hand. data in Table 2 shows that there were still manv women who were
cytology to non-medical aid patients.
l{owever, the experience ofthe FWMBF Clinic has been that, with State or Hospital facilities providing free laboratory examination at little or no extra cost to their own overheads, the costs to patient and practitioner are minimal. Given the fact that a general practice already provides an appropriate
infrastructure , the costs of providing PAP smears are limited to the actual materials, time taken for performance of the smear and the administrative costs required for processing of the smear. In comparison, the financial burden placed on our tertiary health services by patients presenting with cervical carcinoma has been shown to be extraordinarily highs'16 and a huge potential exists for PAP smears to save costs in terms of health care expenditure.t6
Conclusion
The value of routine cytological screening of all female patients at risl(
to cervical cancer should not be underestimated. There is ample evidence that the failings of cer-rain cervical cytology programmes are not attributable to intrinsic problems in the notion of screening for cervical dysplasia, but are due to inadequacies in the organisation of the
programmes ,2t,2a and could be addressed by strengthening logistical aspects, rather than cutting back on such programmes.
Ideally, the provision of preventive and oromotive services should be a coordinated national programme in which general practitioners'
contribution to preventive health care is supplementary to services provided at State clinics and hospitals. This, in turn, implies a serious commitment to the establishment of a National
Pap Smear Service
Health Service.'s Until such a National Health Service is a realiw- the value of opportunistic screening by GPs remains one of the most important ways of reaching many women who would otherwise miss the opportunity of having a PAP smear.3a Many General Practitioners are in an ideal position to provide such screening to black working class female Datients who either cannot afford private laboratory costs, or do not have access to State clinics.2o'2e There is also evidence that General Practitioners' attitudes are crucial to encouraging take-up of cervical qtology screening'''?e and can play an
Crucial role of general practitioners in promoting uptake and follow-up of PAP smears.
important role in follow-upts,z2 and in educating and counselling patients to allay fears concerning the test and treatment for abnormalities.6' e, 22, 2e There seems an urgent need for the State to upgrade the capacity ofits laboratory facilities as part of a national preventive programme to combat cer-vical cancer.r3, 16. 33 Services offered free to women at high risk for cervical neoplasia through general practitioners should therefore be integrated with existing state services.T''z3 Public education on the value of PAP screening is crucial to the success of PAP smear programmes" and there is growing evidence that communities and organised labour would be receptive to the idea of such a campaign for women's health.3e'ao
201 SA Family Practice May 1993 SA Huisartspraktyk Mei 1993
Acknowledgements
I wish to tltank the workers of the Food and Allied Workers Union titr thcir co-opc'rarion and Mpunti Mthupha and Mpho Maraisane lbr their assistance in this study. I also wish to thank Dr Mohamed Jeebhay, Dr Debbie Bradshaw and the stalf of the Departmcnt of' Community Health at rhe University of Cape Town for their valuablc contmcnrs.
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