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A Systematic Review of Postcoital Bleeding and Risk of Cervical Cancer

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A Systematic Review of Postcoital Bleeding and Risk of Cervical Cancer Systematic Review A systematic review of postcoital bleeding and risk of cervical cancer Mark Shapley, Joanne Jordan and Peter R Croft INTRODUCTION ABSTRACT GPs have been criticised for both too few and too many urgent referrals of patients with symptoms of Background Postcoital bleeding may be a symptom of cervical possible cancer. This has given rise to debate cancer. Guidance to aid a GP in determining whom to concerning the reasons for the referral rates, and investigate or refer exists but recommendations vary. how the prognosis in patients with malignancy may Women need to be involved in decisions about their be improved.1–7 There is agreement that research on care and this involves communicating risk and an 8 exploration of the implications of the risk. Risk common symptoms in primary care is lacking, that estimates of postcoital bleeding for cervical cancer are primary care clinicians have difficulty identifying not available. people most at risk of cancer,7 and that the research Aim base for published guidelines lies within secondary To provide an estimate of the positive predictive values care.1 Cancer research is difficult within primary of postcoital bleeding for cervical cancer to aid decision making in primary care about whom to care due to the rarity with which the disease investigate for cervical cancer. presents. In contrast the symptoms of possible Design of study cancer are often common.9 This produces a difficult A systematic review. decision for the primary care clinician about whom Setting to investigate. Community, primary and secondary care. For the symptom of postcoital bleeding, guidance Method has been produced to identify those women whom Six electronic databases were searched from the beginning of each of their time frames. Inclusion GPs should refer for investigation. The content of criteria were that the study was published in English this guidance varies, and includes recommending and reported or contained enough data to calculate the referral for all women,10,11 or women with non- prevalence or incidence of postcoital bleeding within defined ‘persistent’12,13 or ‘repeated’ postcoital the study population. No studies were excluded on 14 issues of methodological quality. bleeding, or postcoital bleeding that ‘persists for Results more than 4 weeks in women over 35 years of The search strategy identified 910 unique articles. The age’.14 Some recommendations have also point prevalence of postcoital bleeding in the combined the symptom of postcoital bleeding with community ranged from 0.7 to 9% among women. One specific abnormal cervical cytology.12,13 study reported an annual cumulative incidence of 6% of menstruating women. The prevalence of postcoital Patients have the right to accept or refuse bleeding in women with cervical cancer ranged from whatever is proposed and in taking a decision as to 0.7 to 39%. Calculation of risk that a woman in the whether or not to investigate for underlying community developing postcoital bleeding has cervical malignancy, informed consent is required.15 The cancer ranges from 1 in 44 000 at age 20–24 years to 1 in 2 400 aged 45–54 years. There was no information General Medical Council states that two of the allowing the direct calculation of risk in women presenting to primary care. M Shapley, DM, FRCGP, GP and research fellow; J Jordan, Conclusion MSc, MA, research assistant: systematic reviews; PR Croft, The evidence base for management strategies of MD, MRCGP, professor of epidemiology, Primary Care postcoital bleeding and calculations of risk for cervical Sciences Research Centre, Keele University, Staffordshire. cancer in women with postcoital bleeding are poor. Recommendations for clinical practice are made on the Address for correspondence current evidence. Dr Mark Shapley, Primary Care Sciences Research Centre Keywords Keele University, Staffordshire, ST5 5BG. cervical cancer; postcoital bleeding; uterine E-mail: [email protected] neoplasms. Submitted: 9 February 2005; Editor’s response: 1 July 2005; final acceptance: 9 November 2005. ©British Journal of General Practice 2006; 56: 453–460. British Journal of General Practice, June 2006 453 M Shapley, J Jordan and PR Croft risk, should allow the patient to make an informed Potentially relevant papers identified decision. For cardiovascular disease it is known and screened for retrieval (n = 910) that the risks patients and doctors are prepared to take differ.18,19 Effective risk communication and shared decision making are dependent on several Papers excluded (n = 842) due to: factors and include the style of the consultation, Treatment or treatment complications (n = 311) which may vary from doctor-centred to patient- Diagnostic or screening techniques (n = 55) 20 21 Unusual tumours or disease and case series of <15 (n = 176) centred, and the constraints of time. A number of Cancer in pregnancy (n = 19) aids and strategies are available which may No original data (n = 94) promote shared decision making.22 Non-English language (n = 145) Non-gynaecological (n = 42) The purpose of this study is to gain an estimate of positive predictive values of postcoital bleeding for cervical cancer to aid decision making in primary Papers retrieved for more detailed care about whom to investigate for cervical cancer. evaluation (n = 68) The method used was a systematic review of the literature on postcoital bleeding in women in the community, in primary and secondary care and in Papers excluded (n = 37) due to: Insufficient data to circulate prevalence or incidence of women with cervical cancer. By combining incidence postcoital bleeding (n = 32) rates of the symptom with the incidence of cervical Duplicate or report using data published in an earlier cancer derived from national data, predictive values study (n =5) can be calculated.23 Papers providing data on prevalence METHOD or incidence rate of postcoital Searching strategy bleeding (n = 31) Six databases were searched from the start of each of their time frames to 11 August 2005. The Further 15 papers retrieved for more databases, search strategy and terms used are given detailed evaluation from reference lists in Box 1. of those initially retrieved (n = 46) Inclusion and exclusion criteria Papers exluded (n = 8) due to: Studies of any design were included in the Insufficient data to calculate prevalence or incidence of systematic review if they had been published in postcoital bleeding English in peer-reviewed journals. The article had to report or contain enough data to calculate the Papers providing data on prevalence prevalence or incidence of postcoital bleeding within or incidence rate of postcoital bleeding (n = 38) the study population. The purpose of the review was to provide predictive values for use in community populations or in general practice consultation, and Figure 1. Flow diagram of duties of a doctor are to ‘give patients information so studies on treatment or treatment complications, inclusion process. in a way they can understand’ and ‘respect the diagnostic and screening techniques, unusual types rights of patients to be fully involved in decisions of cervical cancer (that is, not squamous or about their care’.16 Predictive values, expressed as adenocarcinoma) and cancer in pregnancy were natural frequencies, are the foundation for excluded. Studies were also excluded if they were of communicating risk17 and, used in conjunction with less than 15 cases or non-gynaecological studies an adequate exploration of the implications of the (such as cervical spine). Box 1. Search terms and strategy. How this fits in Ǡ Databases Postcoital bleeding may be a symptom of cervical Medline, EMBASE, CINAHL, British Nursing Index, AMED and PsycINFO cancer. We do not know how useful this symptom Ǡ Postcoital bleeding search terms is for predicting the presence of the disease. Text words: ((postcoital OR coital) NEXT bleeding) OR (bleeding NEXT intercourse) Systematic review evidence is gathered to calculate Ǡ Cervical cancer and postcoital bleeding search terms predictive values of postcoital bleeding in the Subject heading: (Cervical cancer OR cervix neoplasms OR uterine neoplasms) community for cervical cancer. Recommendations AND Text word: bleed$ OR Text word: ((Cancer AND (cervix OR cervical)) AND for clinical practice are made on the current bleed$) OR ((carcinoma AND (cervix OR cervical)) AND bleed$) evidence. 454 British Journal of General Practice, June 2006 Systematic Review The results of the electronic searches were population studies on the Finnish mass cervical reviewed by reading the titles and abstracts. Papers cytology screening programme27,33 and a study in were retrieved if they contained information on Belgium concerning screening for chlamydia35 symptoms of postcoital or coital bleeding or found a prevalence of coital bleeding of around symptoms prior to diagnosis in patients with 1%. In contrast the two studies performed in squamous cell or adenocarcinoma of the cervix. England28,31 on smaller populations and a Nigerian Reference lists of all articles retrieved were searched study in a hospital cytology clinic34 found a for additional articles. prevalence of around 5%. The disparities may be due to differences in definition of postcoital Assessment of methodological quality bleeding relating to time period covered (bleeding No studies were excluded on the basis of an in the past month,36 2 months,27,33 3 months35 or assessment of methodological quality. Some early 6 months31), frequency (ever in the time frame27,31,33 studies failed to report response or recruitment or frequently35), study populations (such as age, rates24,25 or only reported proportions26,27 but had the sexual activity, use of hormones, infection) and the advantage of involving large populations. Later effects of temporal trends.27 One study reported an studies, which also failed to give this information, annual cumulative incidence in menstruating were included in the review as they were more likely women which was 6%.31 to reflect current clinical activity.28–30 Only one study31 There were no studies of women consulting determined the prevalence or incidence of postcoital primary care.
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