Diabetes and Cervical Dysplasia
By Bain, Stephen; Szarewski, Anne
CLINICAL Q&A
Our team of experts answer queries on the audit of diabetes and the Pill
Q In cases where a patient with type-2 diabetes is started on insulin because of poor control, should we change the diagnosis to type-1 for audit purposes?
Most of our insulin-dependent diabetic patients are followed up in hospital clinics, whereas our type-2 patients are seen in our own diabetic clinics.
A When a type-2 diabetes patient is started on insulin, their designation should not change. The distinction between type-1 and type-2 diabetes is based on the absolute requirement for insulin seen in type-1 diabetes, which is due to autoimmune destruction of beta-cells in the pancreatic islets.
Some patients who develop type-1 diabetes in later life may have a progressive condition and may initially be mislabelled as having type-2 diabetes (so-called latent-autoimmune diabetes in adults, shortened to LADA).
LADA patients tend to be less obese at diagnosis and have a swifter progression to insulin treatment. However, most type-2 diabetes patients are correctly diagnosed, and their subsequent need for insulin demonstrates the progressive nature of the disease.
Indeed,you could argue that, given the currently available therapies, all patients with type-2 diabetes would end up on insulin if they live for long enough.
This answer does not help the audit process if your aim is to assess whether insulin-treated patients are being managed in secondary care.
One way to address this issue could be to indicate the type of treatment that patients with type-2 diabetes are currently receiving.
Dr Stephen Bain, professor of medicine (diabetes), University of Wales, Swansea
Q Is there any association between the development of cervical dysplasia and the combined oral contraceptive pill (COCP)?
A There has long been a suggestion that the combined oral contraceptive pill (COCP) is associated with an increased risk of cervical cancer.
However, because the most important risk factor is sexually acquired persistent infection with high-risk human papillomavirus (HPV) types, it has always been difficult to separate the possible effects of the COCP from those of sexual behaviour.
In a paper in the Lancet (2002; 359: 1,085-92), the authors pooled the results of 10 studies which were mostly conducted in developing countries. The studies compared HPVpositive cases and HPV- positive controls for their use of hormonal contraceptives.
They found no increase in the risk of cervical cancer associated with using COCP for less than five years. Use for between five and nine years seemed to treble the risk, while use for more than 10 years seemed to increase it fourfold.
But the numbers of women in the trials using the Pill for more than five years were small. The increase in risk disappeared within six years of stopping the Pill.
Using the Pill was not associated with increased risk of being HPV positive.
In the UK, at least 80 per cent of women have used the Pill at some time, whereas only about a third of women in these studies had ever used the Pill.
They may therefore not be representative of the general population.
Although the analysis suggests that long-term users of the Pill who are HPV positive are at greater risk of cervical cancer, it does not prove that it causes it.
The greatest risk factor is having a persistent high-risk HPV infection, but the other risk factors seem to vary. For example, in developed countries, smoking doubles the risk of cervical cancer.
However, in developing countries where few women smoke, concurrent STIs seem to be more important. Recent studies in developed countries – not included in the Lancet analysis – have tended to suggest that smoking is an important risk factor, and have not found a significant association with use of the Pill (JAMA 2001; 285:2,995-3,002).
Most women do not know their HPV status, and in any case a single positive HPV test is not informative, as the infection is common and clears on its own in most women.
It is more important to have regular cervical smears and, in the UK, the incidence of cervical cancer has fallen in recent years as a result of the screening programme.
Also, the information in this study should be balanced against the known benefits of the Pill, including protection against both ovarian and endometrial cancers.
Dr Anne Szarewski, clinical consultant, Cancer Research UK
GPonline.com
Your favourite medical mugaziaes online
Clinical answers in 48 hours
www.GPonline.com
Persistent high-risk HPVinfection is the greatest risk factor for cervical dysplasia
Copyright Haymarket Business Publications Ltd. Oct 7, 2005