THE VALUE OF REPEAT PAP SMEAR AT THE TIME OF INITIAL COLPOSCOPY

Objective. The objective was to determine if repeating a Pap smear at the time of an initial colposcopy has sufficient clinical benefit to j ustify its clinical and financial costs. Methods. The records were rev iewed of all patients who had an initial colposcopy at Queens Hospital Center between 1984 and 1995. Data were gathered regarding the referr al cytology, the cytology done at the time of colposcopy, and the resu lts of any biopsies which were taken. The terminology for cytology and histology done prior to 1989 was adjusted to the Bethesda classificat ion system. A repeat Pap smear was defined as clinically valuable if i t would have changed the patient's management, i.e., if it suggested m ore advanced disease than the referral Pap and that the disease was no t identified on the colposcopically directed biopsy. Results. Two thou sand nine hundred sixty-nine records were reviewed. In 139 cases, no P ap smear was repeated at the time of colposcopy. Of the remaining 2830 women, only 1347 (47.6%) showed exact correlation between their refer ral Pap smear and the Pap done at the time of colposcopy. In another 1 016 (35.9%), the Pap at colposcopy was within one grade of the referra l Pap. In 312 women, the Pap at the time of colposcopy was a higher gr ade than the referral Pap. However, in 236, the higher grade of diseas e was detected by the colposcopically directed biopsy. Of the remainin g 76 women, 58 had a normal biopsy, but their Pap at the time of colpo scopy showed low-grade squamous intraepithelial lesions (44) or high-g rade squamous intraepithelial lesions (HGSIL) (14). Seventeen others h ad a biopsy showing low-grade dysplasia while the Pap at the time of c olposcopy 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 tim e 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 lev el, skipping the repeat smear would save more than $24,000,000 annuall y. Conclusion. Using current triage protocols at our institution, repe ating the Pap smear at the time of an initial colposcopy would have ch anged 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 an d the potential detrimental effects on the colposcopic examination. (C ) 1997 Academic Press.