Rare Event: Iatrogenic Injury During Cervical Cancer Screening

Roxanne Nelson, RN, BSN

November 10, 2020

Cervical cancer screening is a routine procedure, but in rare instances, there can be medical complications. A new study finds that, compared to women who have normal results, women who are diagnosed with an invasive malignancy have an increased risk for iatrogenic injuries.

Researchers in Sweden analyzed data regarding more than 3 million women who had undergone cervical cancer screening. They found that 42 iatrogenic injuries that required at least 2 days of hospitalization occurred during the diagnostic workup of women who had an abnormal screening test. "Although cervical cancer screening is one of the most successful cancer prevention programs...our research indicates that women with invasive cervical cancer experienced medical complications and psychological stress during their diagnostic workup, although at a very low level," commented corresponding author Qing Shen, PhD, from the Department of Medical Epidemiology and Biostatistics at the Karolinska Institute in Stockholm, Sweden.

The study was published in Cancer Epidemiology, Biomarkers and Prevention.

"Injuries can occur with diagnostic evaluation for cervical cancer," commented Kecia Gaither, MD, MPH, FACOG, director of perinatal services at Lincoln Medical and Mental Health Center, New York City Health and Hospitals System, who was not involved in the study.

"Given the fact that neovascularization occurs with cancers, a large biopsy in such a circumstance could lead to a hematoma or excessive blood loss. It rarely occurs, but most certainly is possible," said Gaither.

Also weighing in with comments, Cathy Popadiuk, MD, FRCS, an associate professor of medicine in the Department of Obstetrics and Gynecology at Memorial University, Newfoundland, St. John's, Canada, said the findings are reflective of the real world and North American experience.

"There are indeed rare bad things that can happen during diagnostic workup of abnormal pap smears, and usually this is with associated other disease, such as actual cancer or fibroids that can also bleed and may be in the cervix, etc," she told Medscape Medical News. "And definitely, when there is undetected cancer, this can bleed, requiring transfusion and hospital admission."

Popadiuk pointed out that Sweden may be more liberal in admitting patients to hospital, whereas in North America, "we are trying to move away from inpatient care." She added, "When you are getting these relatively minor procedures, you don't expect something bad to happen in the clinic."

Women may become anxious, and admission is the easiest way to arrange for care such as transfusions or observation for more bleeding, she noted. In addition, vaginal packing may be needed to control hemorrhage, and "with vaginal packing, women are unable to void and need a Foley catheter, and that, again, cannot be managed at home easily," she explained. "After bleeding settles, the vaginal pack is removed, often the next day." This may be why some women are admitted to hospital.

Increased Risk of Injury

In a previous study, Shen and colleagues found that there was an increased risk for injuries during the period before and after a diagnosis of any cancer (BMJ. 2016;354:i4218). Those findings suggested that the interval between first suspicion of cancer and diagnosis or initiation of treatment might be a high-risk time for injuries in cancer care.

In this latest study, they assessed whether there was a similar increase in injury risk among patients screened for cervical cancer. Using the Swedish Total Population Register, they identified 3,016,307 women who had undergone cervical screening during the period 2001 to 2012.

The final analysis included 1,853,510 women whose pap smear results were normal; 22,435 women who were diagnosed with cervical intraepithelial neoplasia (CIN); 20,692 women with CIN2; 36,542 women with CIN3 or adenocarcinoma in situ (AIS); and 5189 women with invasive cervical cancer.

The team found that among women who had an abnormal screening test, 42 iatrogenic injuries occurred that required at least 2 days of hospital admission. The highest risk was among women diagnosed with invasive cancer. The risk was also increased among women diagnosed with CIN3/AIS, but not among women with lower grades of CIN.

The most common types of iatrogenic injuries were hemorrhage or hematoma and infections. Among all groups of women, the incidence rate of injuries that were caused by medical procedures and care was greater than that of injuries caused by drugs or biological substances.

A total of 91 noniatrogenic injuries that required at least 1 day of hospitalization were identified. The risk was increased among women with invasive cervical cancer but not for women with other cervical abnormalities. The most common type of noniatrogenic injury was unintentional injuries.

The study was sponsored by the Swedish Cancer Society and the Swedish Research Council for Health, Working Life and Welfare. One author received a Karolinska Institute Senior Researcher Award and a Strategic Research Area in Epidemiology Award, and one author received a grant from the China Scholarship Council. Shen has disclosed no relevant financial relationships. Popadiuk has received personal fees and nonfinancial support as a member of the OncoSim Initiative from the Canadian Partnership Against Cancer.

Cancer Epidemiol Biomarkers Prev. 2020 Nov;29:2230–2234. Abstract

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