MULTIFACTORIAL AUDIT OF INVASIVE CERVICAL-CANCER - KEY LESSONS FOR THE NATIONAL SCREENING-PROGRAM

Aims-To audit factors associated with the development of invasive cerv ical cancer. Methods-Twenty cases of invasive cervical cancer in one h ealth district for 1991-93 were audited by multifactorial analysis. Re sults-The average age was 53 years with 20% (4/20) aged over 65 years. Of the patients, 45% (9/20) were identified by a cervical smear, with 40% (8/20) from the National Screening Programme (NSP) and 5% (1/20) opportunistically; 30% (6/20) had not received a smear, 10% (2/20) bei ng aged under 65 and 20% 65 or over. Those with no smear had all been hospital patients during the previous five years. No response to a sme ar invitation occurred in 5%. In 20%, there had been a true negative s mear two to five years previously. Inappropriate laboratory diagnosis or inappropriate clinical management occurred in 30% and 15% (3/20), r espectively. In 20%, two or more factors were present in the same pati ent. Conclusions-Why cervical cancer occurs after a true negative smea r requires research and women aged over 65 with no smear must be targe ted. Failsafe systems should incorporate inadequate smears and smear a dequacy should be given priority in quality assurance (QA) and trainin g. False negative reports must be minimised but accepted as an inheren t part of the NSP and not an automatic indicator of poor laboratory pe rformance. Comprehensive national QA standards are required, to which providers must conform. Postcoital bleeding is an absolute indication for a smear and, when appropriate, opportunistic smears offered at all hospital attendances. Cervical cancer audit must be guaranteed access to all clinical and laboratory information and be seen as a means to improve the effectiveness and quality of the NSP.