BACKGROUND: Many family physicians perform colposcopy and provide treatment when biopsy reveals dysplasia. Before the adoption of loop electrical excision procedure (LEEP) gynecologic referral following colposcopy was required for a small percentage of women-most commonly for cold cone procedures. The use of LEEP and LEEP cones may obviate the need for cold conization, so we sought to assess the pattern of gynecologic referral in the practice of family physicians skilled in this procedure.
METHODS: We reviewed the referral practices of a family medicine residency practice that routinely provides LEEP for biopsy-proven cervical intraepithelial neoplasia requiring treatment. Colposcopy and, when indicated, LEEP were performed primarily by the senior author or by residents under close faculty supervision. The computerized clinic log was reviewed for all patients from its 1993 inception through November 1999, and all treatment decisions were evaluated.
RESULTS: During the study period, 283 women were seen in the clinic, and 26 individuals (9%) were referred by the family physician colposcopist to a consulting gynecologist.
CONCLUSIONS: Despite use of LEEP, a minority of patients continues to need gynecologic referral. Large acetowhite lesions extending onto the vaginal fornix accounted for the majority of referrals, and some patients were referred exclusively for cold cone biopsy. Although LEEP can allow family physicians to manage cases previously requiring referral, we urge that this procedure be employed only by those with the technical and decision-making skills required for safe and effective treatment.
Colposcopy is frequently performed by family physicians and is regarded as a core procedural technique in many family practice residencies. Although colposcopic skills are frequently taught to and employed by family physicians, the clinical situations prompting gynecologic referral by skilled family physician colposcopists have not been widely studied. Pfenninger1 reported that 28 of 200 patients (14%) requiring colposcopy in a family practice residency program received a referral to a gynecologist because of pregnancy, postmenopausal status, inadequate colposcopy, or the need for laser excision or conization. Conization accounted for approximately half of these referrals. Writing from the perspective of the practicing family physician offering colposcopy, Spoelhoeff2 found he needed to refer 10 of 45 women (22%) for specialist gynecologic management. Reasons for referra in-cluded incomplete visualization of the transformation zone, significant discrepancy between cytology and histology, and high-grade lesions requiring laser or conization. One patient was referred because she had multiple previous treatments by a gynecologist. Both Pfenninger and Spoelhoeff treated cervical lesions cryosurgically, referring for any required conization. With the advent of loop electrical excision procedures (LEEP), many cases that previously required referral for conization can be managed in the physician’s office. LEEP has been widely taught in family practice residencies and family physicians are increasingly adopting it for management of cervical dysplasia. In this paper we summarize the referral experience of a family practice cervical dysplasia clinic operating within a residency program during a 6-year period in which LEEP was used as primary management for cervical dysplasia.
Methods
In 1993 the family practice residency program at Via Christi Regional Medical Center in Witchita, Kansas, began the Cervical Dysplasia Clinic. The clinic serves as a major training resource for second-year and third-year family practice residents who gain skills in colposcopy and LEEP under the close supervision of 2 faculty members highly experienced in these procedures. Although educational experience was an important clinic objective, all clinical management decisions were made by one of the 2 faculty supervisors, most often the senior author of this paper. Referrals to the clinic are solicited and received from sources throughout the state of Kansas, primarily from public health clinics and those serving the indigent. The Cervical Dysplasia Clinic serves approximately 60 women each year and maintains a database of patient information including referring cytology, histology, disposition, treatment, and follow-up. We report a descriptive analysis of that database for all patients seen between April 1993 and November 1999.
Results
During the study period, 283 patients were seen in the Cervical Dysplasia Clinic with referring cervical cytology that ranged from atypical squamous cells of undetermined significance (ASCUS) to high-grade squamous intraepithelial lesions. A few patients had normal cytology but were sent to the Cervical Dysplasia Clinic because of visible cervical abnormalities or previous abnormal cytology. At the time of analysis, data was complete on 272 of these individuals, and the cytologic and histologic findings for those patients are summarized in the Table. For a small number of patients management decisions were made without biopsy, most commonly because of the combination of low-grade cytology and benign-appearing colposcopy.
In accordance with evolving practice patterns and cost-benefit analysis,3 the majority of patients with biopsy-confirmed low-grade lesions were scheduled for observation without treatment. High-grade lesions were either treated, almost exclusively with outpatient LEEP within the family practice center, or referred to a gynecologist. All patients with unsatisfactory colposcopy were treated with LEEP conization, provided the transformation zone was confined to the cervix and glandular atypia (adenocarcinoma in situ) had been ruled out. Overall, 26 patients (9%) were referred to a gynecologist for definitive management. The most common reason for referral was the presence of an atypical transformation zone extending onto the vaginal fornix. Although one of these patients was treated with LEEP by the gynecologist to whom she was referred, the remaining patients were treated with a laser or a combination of a laser and LEEP. Five patients were referred to a gynecologist because of the presence of glandular atypia. On the basis of local gynecologic opinion, these patients required cold cone biopsies to eliminate any possibility of histologic heat artifact from a LEEP excision. Two patients had lesions requiring more extensive therapy than could be offered in the dysplasia clinic (perianal warts in one and vaginal intraepithelial neoplasm-grade 2 in a second). One patient had carcinoma in situ with possible invasion, and one had a psychiatric condition that required sedation of the patient in a minor surgical facility for safe surgical management.