Management of the low-grade abnormal Pap smear: What are women’s preferences?
- OBJECTIVE: To evaluate preferences among ethnically diverse women for the management of a low-grade abnormal Pap smear result: early colposcopy or observation with repeat Pap smears.
- STUDY DESIGN: Structured interviews were conducted with 170 women of diverse ethnic backgrounds to assess their preferences. Trained personnel conducted standardized interviews. A standard description of all tests and procedures was read to participants. The participants were presented with scenarios of contrasting management approaches for a hypothetical low-grade abnormal Pap smear result—observation with repeat Pap smear vs. immediate colposcopy.
- POPULATION: Study participants were recruited from the waiting rooms of 5 family planning clinics in Northern California’s Central Valley.
- OUTCOMES MEASURED: The primary outcome measures for each scenario were utilities (quantified preferences for specific health states) measured by the Standard Gamble.
- RESULTS: The range in utilities was large for all scenarios. Mean utilities (SD) for observation: 0.96 (± 0.13) followed by resolution; 0.93 (± 0.17) followed by cryotherapy; 0.91 (± 0.21) followed by cone biopsy. Mean utilities for early colposcopy: 0.93 (± 0.20) followed by resolution; 0.95 (± 0.14) followed by cryotherapy; and 0.92 (± 0.16) followed by cone biopsy. Subject characteristics explained less than 20% of the variance in utilities. Decision analysis gave a slightly higher overall utility for early colposcopy (0.940 vs 0.932 for observation), but was sensitive to small changes in branch utilities.
- CONCLUSIONS: Women’s preferences for management of a low-grade abnormal Pap result vary widely. Clinicians should adopt a flexible approach to the management of low-grade abnormal Pap smears to incorporate individual preferences.
Strengths of our study include the diversity of the subjects, the formal process for preference assessment, and the paired scenarios, which allow assessment of preferences for a single management decision, in which 2 separate paths lead to an equivalent ultimate outcome. Our findings are consistent with previous work showing that the sequence of events leading to an outcome will influence utilities for the outcome.18
Application to clinical practice
How might our findings be translated into clinical practice? In clinical situations where different approaches to management are unlikely to result in substantial outcome differences (a “toss-up”), patient preferences are a key aspect of the decision-making process.19 For women with lowgrade Pap abnormalities, several diagnostic options are available and no single option is strongly supported by evidence to offer better outcomes. Our study indicates that no single option is preferred by most women. Under these conditions, engaging the patient in the decision-making process may produce better health outcomes.20 Clinicians should anticipate highly varied preferences, and will need to adopt a flexible approach. Not all patients will want to be actively involved in the decision process, but the desire for information is nearly universal. Flexible use of the questions in Table 4 may help patients to define their preferences and will likely improve their satisfaction and adherence to the treatment plan.
TABLE 4
Questions for patients with an abnormal Pap smear
| What is your understanding of what it means for you to have an abnormal Pap smear showing _____________? |
| There are different options for the next step. Would you like to be involved in deciding which option is preferred for your case? |
| What questions do you have about these options? |
| How important is it to you to have a definite answer as soon as possible? |
| How do you feel about undergoing colposcopy? |
| Would you prefer to have a follow-up Pap smear in ____ months, which might avoid a colposcopy, or would you prefer to have a colposcopy sooner? |
· Acknowledgments ·
The authors thank the staff of Planned Parenthood Mar Monte East for their assistance with subject recruitment and interviews.
