Thames Valley Cytology Society

The Implications of Cervical Cancer Audit

Report by Hilary Riches, Barnet General Hospital

TVCS scientific meeting at St Bartholomew's Hospital on 28th June 2001

Why audit?
What should be audited?
Who should audit?
How should one audit?
What should be recorded?

Dr. Peter Sasieni from the Imperial Cancer Research Fund spoke to the Thames Valley Cytology Society on 28 June 2001 at St. Barthomomew's Hospital, London, about the implications of cervical cancer audit, following the publication of Leicestershire Health Authority's audit.

The first question posed was 'Why Audit?'. Audit should be carried out for a variety of reasons. In Cervical Cytology it can be used to learn from mistakes of the past. Everyone involved in screening should look at smears to learn if a particular type of cell is missed. Problems can be spotted early. In this way audit can be used to evaluate the screening programme and if necessary be a lever to modify and improve the service.

All women who are diagnosed with cervical cancer should have their screening histories audited. As well as a cytology review, this should include dates and results of all correspondence to smear takers following abnormal smears (i.e. failsafe letters), colposcopy findings, biopsies and treatment.
The reason Leicester performed an audit was because the clinicians were keen to improve the service they provided for patients. Clinical records were looked at, the mode of presentation of the cancer, diagnosis, staging, treatment and outcome.

It was suggested by the speaker that auditors from the screening programme, individual gynaecologists and individual laboratories be responsible for the audit. In Leicester a slide review was carried out by expert cytopathologist.

The questions posed were: Should audit be carried out without consent, should it be performed anonymously or openly, blindly or openly, individually or in batches? Dr. Sasieni felt that audit must be performed routinely, without consent, as anonymously as possible and blindly.

Leicester performed their audit openly, and without consent. Their audit was performed in batches and in their case the reviewer was aware of a diagnosis of carcinoma of cervix..

What should be recorded? There should be a standard minimum data set based on routinely held information. On an individual level the results should be reported to the gynaecologist and a table of slide review results would be presented.

At Leicester there was a proportion of cases with false negative smears prior to diagnosis as well as undergraded smears.

There are three levels of audit

• Audit regularly routinely collected data - including sample of healthy women
• Selected slide review i.e review all smears within 6 years that were negative
• Occasionally (or possibly never) an in-depth clinical audit to include:
  - Hormonal status (HRT or OC),
  - Previous SI disease

Further research could perhaps be conducted in conjunction with a university, looking at more in depth data from GP notes, Gynaecology notes and Cytology.

Cases may be classified into the following

• Too old or too young
• Lack of coverage
• Failure to follow up abnormal cytology
• Failure to refer to colposcopy
• Colposcopy - false negative
• Histology - false negative
• Laboratory - false negative

In a similar way screening histories could be classified into

• No. of years since last smear
• No. of years since last negative smear
• No. of years since last treatment
• Unresolved abnormality
• Resolved abnormality

SUMMARY

In summary audit should be carried out on all new cases of cancer, and a sample of all women

Audit should be carried out routinely, without consent, openly and confidentially.

A slide review should be performed of possible informative cases.

There are ethical problems involved so Dr. Sasieni felt that audit should be done without consent although when the gynaecologists are informed of the review they must offer results of the audit to the women involved.