Unsatisfactory colposcopy: clinical decision-making in conditions of uncertainty

BACKGROUND Unsatisfactory colposcopy, where the cells of interest are not visible in women with a positive cervical screening test, is a common area of clinical uncertainty due to the lack of clear evidence and guidance. Colposcopists' opinions and experiences are likely to have a significant influence on service provision and the development of national policy. The aim of this study was to analyse decision-making when applied to women with unsatisfactory colposcopy. METHODS A multi-centre qualitative study utilizing a series of focus groups in an English healthcare region. Sampling aimed to ensure heterogeneity of experience and healthcare provider demographics. A topic guide covered a range of clinical and cytological variables and was compiled by the researchers and three expert Colposcopists. Using an iterative approach, thematic analysis was selected as the most appropriate method to identify factors affecting decision-making. RESULTS Twenty-three Colposcopists from four units participated. The decision to treat was easier in women with high-grade cytology and high risk women with low-grade cytology such as heavy smokers, poor attenders, older women, those who had completed their families and women opting for treatment. Where decision-making was more complex, intuition and a multi-disciplinary approach were used to guide management. Areas of dissonance, which are affected by paucity of evidence and emotive factors, included cytological collection device, clinical setting and length of conservative follow-up and depth of excision in women at high risk of treatment-related morbidity. CONCLUSIONS Anxiety of missing a cancer deters long-term cytological follow-up, resulting in heterogeneity of care and higher than anticipated excisional treatments in women with low-grade screening and unsatisfactory colposcopy. In areas of clinical uncertainty when decisions are dominated by affect, clinical guidance can reduce the difficulty and anxiety of decision-making.