Neal M. Lonky

External cephalic version after previous cesarean section.

Approximately 100,000 cesarean sections are performed each year in the United States because of breech presentation. Numerous studies have shown that external cephalic version can eliminate the need for many of these operations. However, because of the fear of uterine rupture, these studies have generally excluded patients who have undergone previous cesarean section. To evaluate the validity of this exclusion policy, we studied patients with one or more previous cesarean sections and breach presentations near term. Version attempts were successful in 82% of 56 patients who had undergone a previous cesarean section. Sixty-five percent of the successful version patients went on to have vaginal birth after cesarean section. There were no serious maternal or fetal complications associated with the version attempts. We conclude that external cephalic version is a reasonable option in patients with prior low transverse cesarean section.

The clinical significance of the poor correlation of cervical dysplasia and cervical malignancy with referral cytologic results.

OBJECTIVEnWe prospectively studied the diagnostic utility of our Bethesda system-based cervical cytology screening program with colposcopy and biopsy as the criterion standard.nnnSTUDY DESIGNnWe prospectively collected and studied the correlation of cytologic, colposcopic, and histologic data in women referred for colposcopic examination because of nonnormal cytologic results or other risk factors.nnnRESULTSnWe found that 771 of 5585 initial colposcopic visits yielded high-grade (cervical intraepithelial neoplasia II or worse) biopsies (13.8% prevalence); 13 showed invasive cancer (0.23% prevalence). Only 132 of 771 cases of high-grade dysplasia (17%) and 5 of 13 cases of invasive cancer (38%) followed Papanicolaou smears suggesting high-grade intraepithelial lesions or cancer, with 77% being discovered after minor Papanicolaou smear abnormalities. High-grade disease or cancer was confirmed in 1 of 2 high-grade or cancer Papanicolaou referrals and in 1 of 11 referrals with atypical squamous cells of undetermined significance.nnnCONCLUSIONnPapanicolaou smears, especially those that are low grade, should not be equated with histologic sampling in association with poor cytohistopathologic correlation. Most high-grade dysplasias and cancers occur in women with either minor Papanicolaou smear abnormalities or visible lower genital tract lesions or both. Colposcopy for women with any nonnormal screening result is feasible.

Triage of atypical squamous cells of undetermined significance with hybrid capture II: colposcopy and histologic human papillomavirus correlation.

OBJECTIVE To estimate the effectiveness of Hybrid Capture II to predict high-grade cervical intraepithelial neoplasia (CIN) from a cytological cervical sample. Evidence of high-risk human papillomavirus (HPV) was also determined from biopsy samples using the polymerase chain reaction (PCR) for women referred with atypical squamous cells of undetermined significance (ASCUS) Papanicolaou smears. METHODS: We screened 8170 women with Papanicolaou smears, of whom 278 (3.4%) returned ASCUS. All ASCUS cases underwent colposcopy and Hybrid Capture II testing. High-grade CIN biopsy specimens were tested for high-risk HPV by PCR. RESULTS Nearly 30% of ASCUS cases had CIN biopsy results (11.9% showing CIN II or CIN III and 17.6% showing CIN I). Hybrid Capture II positive rates were 93.3% for cases with CIN III, 72.2% for CIN II, and 51.0% for CIN I (P< .001). ASCUS-Premalignant Process Favored cases showed a 28.1% high-grade biopsy rate and a 100% Hybrid Capture II positive rate. For ASCUS-Undefined and ASCUS-Reactive Process Favored cases, Hybrid Capture II returned positive in 90.9% of CIN III and 61.5% of CIN II cases (P < .001). Sixty-nine of 178 (38.8%) patients with no evidence of CIN tested positive for Hybrid Capture II. Human papillomavirus deoxyribonucleic acid (DNA) high-risk subtypes were detected by PCR in the tissue of all high-grade CIN cases with negative Hybrid Capture II results. CONCLUSION Hybrid Capture II returned negative in 25% of cases with biopsy-proven high-grade CIN with associated high-risk HPV DNA by PCR (non-Premalignant ASCUS subset), and positive in 39.3% of cases with normal results; this limits its clinical utility.

Low-grade papanicolaou smears and the Bethesda system: A prospective cytohistopathologic analysis

Objective To examine the clinical usefulness of the Bethesda classification system of low-grade cervicovaginal cytology as it relates to predicting underlying histology and aiding in triage to colposcopy. Methods We evaluated 1454 women with abnormal cytologic screening results: 782 with atypical squamous cells of uncertain significance (atypia), 355 with low-grade squamous intraepithelial lesions (SIL) determined by the presence of human papillomavirus (HPV) alone, and 317 with low-grade SIL determined by the presence of cytologic evidence of mild dysplasia (cervical intraepithelial neoplasia [CIN] I) devoid of HPV cytopathologic features. All women underwent colposcopy, directed-punch biopsy or loop electrosurgical excision, and/or endocervical curettage (ECC), as indicated. Results Women from the low-grade SIL-CIN I referral cytology group were significantly more likely to harbor all grades of biopsy-proven dysplasia than were those from the atypical squamous cells of uncertain significance and lowgrade SIL-HPV groups, which showed no statistical differences. Conclusion Contrary to the Bethesda system, which combines CIN I and HPV changes because of cytomorphologic similarities, this study suggests that patients with HPV cytologic smears are similar to patients with atypical smears and are less likely to harbor any biopsy-proven CIN lesions than are patients with CIN I cervicovaginal smears. If excluded from colposcopic triage, approximately 5% of patients with atypical cytologic smears from a well-screened population similar to ours will harbor high-grade lesions that may progress during any waiting period. Triage of low-grade cervicovaginal smears based on histopathologic correlation is encouraged.

Reducing death from cervical cancer: Examining the prevention paradigms

The prevention of morbidity and mortality from cervical cancer will hinge upon our understanding of the epidemiology, the molecular basis, and natural history of the disease and its associated precursors. This article serves as an introduction and presents our current challenge to prevent or find all women at risk, and alter the course of disease to effect a regression or a cure.

Poor correlation of high-grade cervical dysplasia with referral cytology: clinical implications.

Objective: We questioned the diagnostic utility of cervical cytology by studying whether women with colposcopically guided biopsy proven high-grade cervical dysplasia or cancer had referral cytology results that correlated highly with their disease.Methods: All women with any cytologic abnormality or visible lower tract lesion(s) are referred for colposcopic examination. Ten thousand visits to our colposcopy clinic were prospectively collected, tracked, and reviewed, which revealed 566 cases of high-grade dysplasia and 8 cancers on biopsy. The proportion of high grade disease that was discovered by high grade cytology was measured.Results: The diagnosis of high grade cervical disease was not preceded by high-grade cytology (HGSIL) or rule out cancer cytology result (n = 95, 16.8%) in the majority of cases (P <.0001, chi(2)). High-grade disease was more often preceded by low-grade cytology (LGSIL) (n = 224, 39.5%), followed by atypical Papanicolaou smears (ASCUS) (n = 220, 38.9%) and visible cervical or vaginal lesion(s) (n = 27, 4.8%). A very high percentage of cancer cases had preceding HGSIL cytology (6 of 8 cases at least HGSIL, 75%).Conclusion: High-grade cervical neoplasia was more likely to be discovered following colposcopic triage of minor Papanicolaou smear abnormalities (ASCUS or LGSIL). The false negative rate of a single Papanicolaou smear to detect dysplasia may be as high as 65% (with specificity at the 90% range) (Fahey MT, Irwig L, Macaskill P. Meta analysis of Pap test accuracy. Am J Epidemiol 1995;141:7:680-9), making cytology an inaccurate diagnostic replacement for colposcopy. We should rethink the significance of minimally abnormal Papanicolaou smears when designing triage protocols that delay or eliminate colposcopy based on the Bethesda Grading System alone.

Risk factors related to the development and mortality from invasive cervical cancer: Clinical utility and impact on prevention

The focus of this article is to explore the various risk factors related to cervical cancer and the practical context in which they can be applied. The ability to link dinical outcomes (disease presence, persistence, progression, and recurrence) with antecedent risk factors is strengthened by a new understanding of the molecular mechanisms that are responsible for malignant transformation.

Hysterectomy for benign conditions: Complications relative to surgical approach and other variables that lead to post-operative readmission within 90 days of surgery:

Objective: To examine variables associated with hysterectomy-related complications, relative to surgical approach and other variables, that lead to readmission within 90u2009days of surgery. Methods: We conducted an observational cohort study for which data were extracted from electronic health records. Data were extracted of all patients (nu2009=u20093106) who underwent hysterectomies at 10 Kaiser Permanente Southern California medical centers between June 2010 and September 2011. Patients who were pregnant or had a cancer diagnosis were excluded from the study. To identify univariate associations between examined variables and procedure type, chi-square tests for categorical variables and t-tests or analysis of variance for continuous variables were used. Generalized estimating equations methods were used to test associations between independent variables and primary outcomes of interest. Statistical significance was determined using a p-valueu2009<.05. Results: Of 3106 patients, 109 experienced 168 post-operative complications. The most common post-operative complications were related to pelvic abscesses, bowel obstruction, or severe ileus, and the vaginal cuff. Pelvic abscesses were most frequent among total laparoscopic hysterectomy and total abdominal hysterectomy cases (pu2009=u2009.002), and vaginal cuff complications were most frequent among total laparoscopic hysterectomy cases (pu2009=u2009.015). Patients who underwent total vaginal hysterectomy (odds ratiou2009=u20092.13, confidence intervalu2009=u20091.15–3.92), laparoscopic supracervical hysterectomy (odds ratiou2009=u20093.11, confidence intervalu2009=u20091.13–8.57), and total laparoscopic hysterectomy (odds ratiou2009=u20095.60, confidence intervalu2009=u20092.90–10.79) experienced increased occurrence of post-operative complications resulting in readmission. Other variables associated with an increased risk for readmission included high estimated blood loss (201–300u2009mL and 301+u2009mL, relative to 0–50u2009mL; odds ratiou2009=u20092.28, confidence intervalu2009=u20091.24–4.18 and odds ratiou2009=u20092.63, confidence intervalu2009=u20091.67–4.14) and long length of stay of 3u2009days or more (relative to 0u2009days; odds ratiou2009=u20092.93, confidence intervalu2009=u20091.28–6.69). Pelvic specimen weight in the 151–300u2009g and 501+ g ranges appeared protective (odds ratiou2009=u20090.40, confidence intervalu2009=u20090.25–0.64 and odds ratiou2009=u20090.54, confidence intervalu2009=u20090.33–0.90). In a sub-analysis of 1294 patients, 74 hospital operative complications directly related to hysterectomy were identified among 59 patients. The most common hospital operative complications were excessive bleeding associated with surgery or injury to nearby structures. Among the sub-sample of 1294 patients, those with hospital operative complications were more likely to experience post-operative complications that lead to readmission (odds ratiou2009=u20093.82, confidence intervalu2009=u20091.55–9.43, pu2009=u2009.004). Conclusion: The observed increased risk of complications among patients of Black race, who underwent laparoscopic supracervical hysterectomy or total laparoscopic hysterectomy, who experienced more than 300u2009mL surgical blood loss, who suffered hospital operative complications, and those whose hospitalization was 3u2009days or greater, offers an opportunity for higher scrutiny and preventive measures during usual hysterectomy care to prevent later readmission.

Patterns and correlates of cervical cancer screening initiation in a large integrated health care system

BACKGROUND: The latest 2012 US Preventive Services Task Force cervical cancer screening guidelines recommended screening initiation at age 21 years. Little is known about the cervical cancer screening initiation practices in the community and whether there are critical gaps with respect to adherence to current clinical guidelines. Despite an overall decline in cervical cancer incidence across women of all ages, the incidence rate has not declined among 24–25 year olds between 2000 (2.79 per 100,000) and 2013 (2.93 per 100,000). Thus, it is important to understand cervical cancer screening initiation in young women and how woman‐ and provider‐level factors affect the timing of screening initiation to identify areas for improving cervical cancer prevention. OBJECTIVE: We examined patterns and correlates of cervical cancer screening initiation among women turning age 21 years in a large community‐based practice. STUDY DESIGN: Female members of Kaiser Permanente Southern California who turned age 21 years (baseline) during 2013–2015 and had not previously received a Papanicolaou test were included. Cervical cancer screening initiation through October 2016 was captured using electronic health records. Incidence rate and cumulative incidence of screening initiation was calculated. Associations between patient and provider characteristics and screening initiation were evaluated using multivariable Cox models. RESULTS: A total of 38,257 women were included and the Papanicolaou screening initiation rate was 44 per 100 person‐years during the study period. Approximately 40% initiated screening within 1 year after turning age 21 years. In multivariable analyses, Asian/Pacific Islanders (hazard ratio, 0.91; confidence interval, 0.86–0.96 compared with non‐Hispanic whites); Medicaid enrollees (hazard ratio, 0.90; confidence interval, 0.83, 0.97); those whose primary language is not English (hazard ratio, 0.71; confidence interval, 0.67, 0.75); those who have a historical inpatient visit, primary care physician in pediatrics, internal medicine, or another specialty compared with family practice; and have a male rather than female primary care physician (hazard ratio, 0.46; confidence interval, 0.36, 0.57) less often initiated screening. On the other hand, those who used other preventive services such as getting a human papilloma virus and influenza vaccination and those with a history of pregnancy, contraception use, and sexually transmitted infections more often had timely screening initiation. CONCLUSION: Less than half of the women insured for preventative services initiated screening at age 21 years. Strategies to improve adherence to screening initiation guidelines should consider a tailored approach for at‐risk subgroups and addressing initiation challenges associated with male physicians.

Preventing mortality and morbidity from cervical cancer

Over 50 years ago, Papanicolaou and Traut’s discovery changed the way we view cancer screening. The link between cytological sampling and histopathology was made, and the natural history of cervical carcinoma was explored. We now face a multi-billion dollar ‘‘cervical cancer prevention’’ practice model and industry which has traditionally advocated screening with the conventional Papanicolaou smear, followed by diagnostic colposcopy, biopsy, and potential treatment of precursors for the ‘‘at-risk’’ patient. Despite all of our efforts, the initial significant reduction in cervical cancer incidence and mortality has reached a plateau in the last decade. The prevalence of high grade precursors and high risk behavior is on the rise. This issue refocuses on the desired endpoint, as our goal all along has been to the end the suffering and mortality associated with cervical carcinoma. To achieve that goal we must re-examine the etiology, natural history, the existing, and new strategies used in caring for women prone to develop cervical neoplasia and carcinoma. We must measure the value of interventions on several levels which include the impact on the quality of care (outcomes), the quality of services rendered (accessible, culturally sensitive care), and cost effectiveness or benefit. The intent of the authors of this issue is to provide a guide for women’s health care givers that is hinged upon finding effective interventions in the context of three levels of prevention. Our introductory articles set the context with background information, and provides a financial ‘‘primer’’ on standardizing and measuring the value of health care interventions. We then ‘‘begin with the end in