Women With Cervical Cancer At Increased Risk Of Injury During Diagnostic Workup

Among the women who were screened for cervical cancer in Sweden, those with invasive cancer and carcinoma in situ were at increased risk of injury associated with diagnostic workup, a new study finds.

In an analysis of medical records from more than three million women who participated in cervical cancer screening between 2001 and 2012 in Sweden, researchers found an increased risk of injuries, including hemorrhage and hematoma, that required hospitalization among those with invasive cervical cancer (ICC) and grade 3 neoplasias, according to the report published in Cancer Epidemiology, Biomarkers & Prevention.

"In our study, although extremely rare, we observed increased risk of iatrogenic injuries that required at least two days of hospital admission during the diagnostic workup of women with ICC, and to a smaller extent, also women with CIN3/AIS," write the researchers led by Qing Shen, of the department of medical epidemiology and biostatistics at the Karolinska Institute in Stockholm.

"This result pattern was expected because women with CIN3/AIS and invasive cancer were more likely to receive invasive procedures for evaluation and possible treatment than women with a normal smear," they add. "Furthermore, women with invasive cancer have commonly greater vascularity in tumor growth, whereas hemorrhage and hematoma were indeed the most common types of iatrogenic injuries during the diagnostic workup of women with ICC."

The researchers did not respond to a request for comment.

Previous work by Shen and colleagues had shown an increased risk of injuries during the time period before and after a diagnosis of any cancer.

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To look at whether there was a similar risk among women screened for cervical cancer, Shen and her colleagues combined data from the Swedish National Cervical Screening Registry and the Swedish Total Population Registry. The Swedish National Cervical Screening Registry (NKCx) comprises complete nationwide information on cytology results of Pap smears, histology results of punch biopsies, and surgical treatments for cervical cancer and its precursors from 1969 onward, including both the organized and opportunistic screening.

In Sweden, until 2017, women at ages 23 to 60 were invited to participate in cytology screening for cervical cancer every three years (those aged 23-50) or five years (those aged 51-60), and the coverage of cervical screening was around 80% nationally, the researchers note.

Shen and her colleagues identified 1,853,510 women with normal smears, 22,435 women with cervical intraepithelial neoplasia grade 1 (CIN1), 20,692 women with CIN2, 36,542 women with CIN3/adenocarcinoma in situ (AIS), and 5,189 women with invasive cervical cancer (ICC). They also identified 42 iatrogenic injuries that required at least two days of hospital admission during the diagnostic workup of women with a cervical diagnosis.

Compared with the reference group, no statistically significant increased rate of iatrogenic injuries was noted during the diagnostic workup of women with CIN1-2. There was, however, an increased rate during the diagnostic workup of women with CIN3/AIS (Incidence Rate Ratio: 3.04) and ICC (IRR: 8.55). The common types of iatrogenic injuries were hemorrhage or hematoma, and infections.

In the U.S. these types of injuries are more often seen in women who are uninsured or underinsured and who receive a more invasive procedure to either diagnose or treat cancer, said Dr. Robert Edwards, a professor of obstetrics and gynecology and chair the department of obstetrics and gynecology at the UPMC Magee Womens Hospital in Pittsburgh.

"These cancers by their nature are highly vascular and women usually present with bleeding which is not cyclic," Dr. Edwards said. "What tends to happen is either the initial diagnosis or a more invasive procedure is done in either an outpatient or office setting because of a lack of patient resources. And what can happen is when doctors are doing a biopsy or excisional procedure, they can get into a situation that is more than they bargained for and usually the result is the patient is admitted for some sort of bleeding mitigation strategy."

The solution is better access to health care, Dr. Edwards said. "Many of these patients are underserved and have very limited resources themselves," he added. "They are often younger women of poorer socioeconomic status. Appalachia is really a hotbed of this problem."

Dr. Konstantin Zakashansky was surprised to see cases, albeit rare, cropping up in Sweden where there is universal health coverage.

"It's not necessarily always about coverage," said Dr. Zakashansky, an associate professor of gynecologic oncology at the Icahn School of Medicine at Mount Sinai and director of minimally invasive surgery for the Mount Sinai Health System in New York City. "Some people don't get preventive care because of their religion, because they're too busy or because they just ignore it - even the early signs."

In some cases, it can be because of geographic issues, Dr. Zakashansky said. The doctor might be four hours away, he explained.

—Linda Carroll

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