Spitzer M, Ryskin M, Chernys A E, Shifrin A
Department of Obstetrics & Gynecology, Queens Hospital Center, Jamaica, New York, USA.
Gynecol Oncol. 1997 Oct;67(1):3-7. doi: 10.1006/gyno.1997.4829.
The objective was to determine if repeating a Pap smear at the time of an initial colposcopy has sufficient clinical benefit to justify its clinical and financial costs.
The records were reviewed of all patients who had an initial colposcopy at Queens Hospital Center between 1984 and 1995. Data were gathered regarding the referral cytology, the cytology done at the time of colposcopy, and the results of any biopsies which were taken. The terminology for cytology and histology done prior to 1989 was adjusted to the Bethesda classification system. A repeat Pap smear was defined as clinically valuable if it would have changed the patient's management, i.e., if it suggested more advanced disease than the referral Pap and that the disease was not identified on the colposcopically directed biopsy.
Two thousand nine hundred sixty-nine records were reviewed. In 139 cases, no Pap smear was repeated at the time of colposcopy. Of the remaining 2830 women, only 1347 (47.6%) showed exact correlation between their referral Pap smear and the Pap done at the time of colposcopy. In another 1016 (35.9%), the Pap at colposcopy was within one grade of the referral Pap. In 312 women, the Pap at the time of colposcopy was a higher grade than the referral Pap. However, in 236, the higher grade of disease was detected by the colposcopically directed biopsy. Of the remaining 76 women, 58 had a normal biopsy, but their Pap at the time of colposcopy showed low-grade squamous intraepithelial lesions (44) or high-grade squamous intraepithelial lesions (HGSIL) (14). Seventeen others had a biopsy showing low-grade dysplasia while the Pap at the time of colposcopy showed HGSIL. In 1 patient, the repeat Pap showed malignant cells while the biopsy showed a high-grade lesion. Based on the triage protocols at our institution, this means that a repeat Pap at the time of colposcopy would have indicated a cone biopsy in 31 patients (1.1%) and more careful follow-up of another 44 patients (1.6%). Skipping the repeat Pap smear would not have resulted in any missed cancers. In our series of 2830 patients, the cost savings of skipping the repeat smear would have been $68,580 or $24.23 per patient. On a national level, skipping the repeat smear would save more than $24,000,000 annually.
Using current triage protocols at our institution, repeating the Pap smear at the time of an initial colposcopy would have changed the management in 2.7% of patients and indicated a conization in only 1.1% of patients. It is doubtful that this justifies its cost and the potential detrimental effects on the colposcopic examination.
确定在初次阴道镜检查时重复进行巴氏涂片检查是否具有足够的临床益处，以证明其临床和经济成本是合理的。
回顾了1984年至1995年间在皇后医院中心接受初次阴道镜检查的所有患者的记录。收集了有关转诊细胞学检查、阴道镜检查时进行的细胞学检查以及所取任何活检结果的数据。将1989年之前进行的细胞学和组织学检查术语调整为贝塞斯达分类系统。如果重复进行的巴氏涂片检查会改变患者的治疗方案，即如果它提示的疾病比转诊巴氏涂片检查所提示的更严重，且该疾病在阴道镜引导下活检中未被发现，则定义为具有临床价值。
共审查了2969份记录。在139例病例中，阴道镜检查时未重复进行巴氏涂片检查。在其余2830名女性中，只有1347名（47.6%）的转诊巴氏涂片检查结果与阴道镜检查时进行的巴氏涂片检查结果完全一致。在另外1016名（35.9%）女性中，阴道镜检查时的巴氏涂片检查结果与转诊巴氏涂片检查结果相差一个级别。在312名女性中，阴道镜检查时的巴氏涂片检查结果级别高于转诊巴氏涂片检查结果。然而，在236名女性中，通过阴道镜引导下活检发现了更高级别的疾病。在其余76名女性中，58名活检结果正常，但她们阴道镜检查时的巴氏涂片检查显示为低级别鳞状上皮内病变（44例）或高级别鳞状上皮内病变（HGSIL）（14例）。另外17名女性活检显示为低级别发育异常，而阴道镜检查时的巴氏涂片检查显示为HGSIL。在1名患者中，重复进行的巴氏涂片检查显示有恶性细胞，而活检显示为高级别病变。根据我们机构的分流方案，这意味着在阴道镜检查时重复进行巴氏涂片检查会提示31名患者（1.1%）进行锥形活检，另外44名患者（1.6%）需要更密切的随访。跳过重复进行的巴氏涂片检查不会导致任何癌症漏诊。在我们这组2830名患者中，跳过重复涂片检查节省下来的费用为68580美元，即每位患者节省24.23美元。在全国范围内，跳过重复涂片检查每年可节省超过2400万美元。
根据我们机构目前的分流方案，在初次阴道镜检查时重复进行巴氏涂片检查会改变2.7%患者
