Failure to Diagnose Cervical Cancer: What Went Wrong?

Ms Helena, a 35-year-old secretary whose last smear three years ago was ‘normal’, presented for rescreening as scheduled. Her case record reveals a past history of recurrent vaginal discharge from trichomoniasis. She had one episode of post-coital spotting two months ago but did not take any action as it did not recur.

On speculum examination, the doctor noted the presence of a raised 1.5 cm irregular lesion on the anterior lip of a bulky cervix. The lesion had bled when the doctor was taking the smear. He had warned Helena that she might have spotting over the next few days. The smear was later reported as being unsatisfactory for evaluation due to the presence of blood and inflammatory cells.

At follow up a week later, the doctor reassured Helena that she has ‘only got inflammation’. He then scheduled an appointment for a repeat smear three months later.

However Helena continued to have irregular bleeding and spotting over the next one month. She was advised by friends to see a gynaecologist directly. A diagnosis of cervical cancer confirmed by biopsy was then made.

QUESTION:

1. Comment on the initial management. Would you have done a Pap smear?

2. What is the current cervical screening policy in Malaysia?

3. What should have been the appropriate cervical screening interval for Helena?

ANSWER:

1. The Pap smear should not have been done as there is already a history of post-coital spotting and a suspicious cervical lesion with irregular surface and contact bleeding.1,2,3 A provisional diagnosis of cervical cancer should have been made and Helena immediately referred to a gynaecologist for colposcopy.

   The Pap smear is a screening test to detect pre-cancerous lesions. It should not be used as a diagnostic tool for cervical cancer as this will further delay the due process of care and give a false sense of security to the patient as is so aptly exemplified in this case.

   This common misconception of doing a Pap smear in the presence of visible lesions should be corrected to prevent failure to diagnose cervical cancer and delay in treatment. Blood and cervical mucus can obscure visibility of the cells and cause misinterpretation as in this case.

2. The current policy in Malaysia recommends that all sexually exposed women should undergo cervical screening from the age of 20. After two negative consecutive smears done a year apart, the screening interval is three-yearly till age 65.1

3. Helena should be placed in the high risk group as she has a history of recurrent trichomona infection. Trichomona infection unlike candidiasis and bacterial vaginoses is almost always sexually transmitted.

   The appropriate cervical screening interval for Helena should be individualised to yearly. The three-yearly interval recommended by the Malaysian guidelines on Pap smear applies to low-risk women.1,2,3