***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
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    Input: Background Large numbers of women who participate in cervical screening require follow-up for minor cytological abnormalities . Little is known about the psychological consequences of alternative management policies for these women . We compared , over 30-months , psychosocial outcomes of two policies : cytological surveillance ( repeat cervical cytology tests in primary care ) and a hospital-based colposcopy examination . Methods Women attending for a routine cytology test within the UK NHS Cervical Screening Programmes were eligible to participate . 3399 women , aged 20–59 years , with low- grade abnormal cytology , were r and omised to cytological surveillance  ( six-monthly tests ; n = 1703 ) or initial colposcopy with biopsies and /or subsequent treatment based on colposcopic and histological findings ( n = 1696 ) . At 12 , 18 , 24 and 30-months post-recruitment , women completed the Hospital Anxiety and Depression Scale ( HADS ) . A subgroup ( n = 2354 ) completed the Impact of Event Scale ( IES ) six weeks after the colposcopy episode or first surveillance cytology test . Primary outcomes were percentages over the entire follow-up period of significant depression ( ≥8 ) and significant anxiety ( ≥11 ; “ 30-month percentages ” ) . Secondary outcomes were point prevalences of significant depression , significant anxiety and procedure-related distress ( ≥9 ) . Outcomes were compared between arms by calculating fully-adjusted odds ratios ( ORs ) for initial colposcopy versus cytological surveillance . Results There was no significant difference in 30-month percentages of significant depression ( OR = 0.99 , 95 % CI 0.80–1.21 ) or anxiety ( OR = 0.97 , 95 % CI 0.81–1.16 ) between arms . At the six-week assessment , anxiety and distress , but not depression , were significantly less common in the initial colposcopy arm ( anxiety : 7.9 % vs 13.4 % ; OR = 0.55 , 95 % CI 0.38–0.81 ; distress : 30.6 % vs 39.3 % , OR = 0.67 95 % CI 0.54–0.84 ) . Neither anxiety nor depression differed between arms at subsequent time-points . Conclusions There was no difference in the longer-term psychosocial impact of management policies based on cytological surveillance or initial colposcopy . Policy-makers , clinicians , and women themselves can be reassured that neither management policy has a significantly greater psychosocial cost . Trial Registration Controlled-Trials.com IS RCT N OBJECTIVE The success of cervical screening relies on women with abnormal cervical cytology attending for follow-up by colposcopy and related procedures . Failure to attend for colposcopy , however , is a common problem in many countries . The objective of this study was to identify factors associated with non-attendance at an initial colposcopy examination among women with low- grade abnormal cervical cytology . STUDY DESIGN A cohort study was conducted within one arm of a multi-centre population -based r and omised controlled trial nested within the UK NHS Cervical Screening Programmes . The trial recruited women aged 20 - 59 years with recent low- grade cervical cytology ; women r and omised to immediate referral for colposcopy were included in the current analysis ( n=2213 ) . At trial recruitment , women completed a socio-demographic and lifestyle question naire ;  1693 women in the colposcopy arm were also invited to complete a psychosocial question naire , including the Hospital Anxiety and Depression Scale .  Women were sent up to two colposcopy appointments . A telephone number was provided to reschedule if necessary . Defaulters were defined as those who failed to attend after two appointments . Logistic regression methods were used to compute multivariate odds ratios ( OR ) to identify variables significantly associated with default . RESULTS 148 women  defaulted ( 6.7 % , 95%CI 5.7 - 7.8 % ) . In multivariate analysis , risk of default was significantly raised in those not in paid employment ( OR=2.70 , 95%CI 1.64 - 4.43 ) and current smokers ( OR=1.62 , 95%CI 1.12 - 2.34 ) . Default risk deceased with increasing age and level of post-school education/training and was lower in women with children ( OR=0.59 , 95%CI 0.35 - 0.98 ) . Among the sub-group invited to complete psychosocial question naires , women who were not worried about having cervical cancer were significantly more likely to default ( multivariate OR=1.56 , 95%CI 1.04 - 2.35 ) . Anxiety and depression were not significantly associated with default . CONCLUSIONS Women at highest risk of default from colposcopy are younger , not in paid employment , smoke , lack post-school education , have not had children and are not worried about having cervical cancer . Findings such as these could inform the development of tools to predict the likelihood that an individual woman will default from follow-up . Interventions to minimise default also deserve consideration , but a better underst and ing of reasons for default is needed to inform intervention development OBJECTIVE To investigate the potential value of tree classifiers for the triage of high- grade squamous intraepithelial lesions . STUDY DESIGN The data set comprised 808 histologically confirmed cases having a complete range of the cytologic sample assessment s -- liquid-based cytology , reflex human papillomavirus ( HPV ) DNA test , E6/E7 HPV mRNA test , and p16 immunocytochemical examinations .  Data include 488 histologically negative ( cervical intraepithelial neoplasia [ CIN ] 1 and below ) or clinical ly negative cases and 320 with histologic diagnosis of CIN 2 or worse . Cytologic diagnosis was made according to the criteria of the Bethesda System . Cases were classified in two groups according to histology : those with CIN 2 or worse and those with CIN 1 and below . Fifty percent were r and omly selected as a training set and the remaining were as a test set . RESULTS Application of tree classifier on the test set gave correct classification of 66.9 % for CIN 2 and above cases and 97.3 % for CIN 1 and below , producing overall accuracy of 91.5 % , outperforming cytologic diagnosis alone . CONCLUSION Application of tree classifiers , based on st and ard cytologic diagnosis and expression of studied biomarkers , produces improved classification results for cervical precancerous lesions and cancer diagnosis OBJECTIVE The detection of high- grade cervical intraepithelial neoplasia ( CIN ) amongst patients with low- grade cytology ( LSIL ) is challenging . This study evaluated the role of high-risk HPV ( HR-HPV ) DNA test and p16(INK4a ) immunostaining in identifying women with LSIL cytology at risk of harboring CIN2 or worse ( CIN2 + ) and the role of p16(INK4a ) in the triage of a population of HR-HPV positive LSIL . METHODS We conducted a prospect i ve study including women with LSIL cytology . Detection of HR-HPV was carried out by means of a polymerase chain reaction based assay . p16(INK4a ) immunostaining was performed using the Dako CINtec cytology kit .  All patients had colposcopically directed punch biopsies or large loop excision of the transformation zone of the cervix . The endpoint was detection of a biopsy-confirmed CIN2 + . RESULTS A series of 126 women with LSIL cytology were included . HR-HPV test had sensitivity 75 % and specificity 64 % for an endpoint of CIN2 + . p16(INK4a ) had significantly higher specificity of 89 % ( p=0.0000 ) but low sensitivity of 42 % . The role of p16(INK4a ) immunostaining  in the triage of LSIL positive for HR-HPV was also evaluated .  p16(INK4a ) triage had 70 % positive predictive value ( PPV ) ; however , this was not significantly higher than the PPV ( 56 % ) of HR-HPV test alone ( p=0.4 ) . CONCLUSIONS The results indicate that HR-HPV or p16(INK4a ) can not be used as solitary markers for the assessment of LSIL . The addition of p16(INK4a ) immunostaining led to an increase in HR-HPV specificity ; however , the biomarker needs to be assessed further to establish its role as an adjunct test in the triage of LSIL Objectives To compare the effectiveness of punch biopsy and selective recall for treatment versus a policy of immediate treatment by large loop excision in the management of women with low grade abnormal cervical cytology referred for colposcopy . Design Multicentre individually r and omised controlled trial , nested within the NHS cervical screening programmes . Setting Grampian , Tayside , and Nottingham . Participants 1983 women , aged 20 - 59 , with cytology showing borderline nuclear abnormalities or mild dyskaryosis , October 1999-October 2002 . Interventions Immediate large loop excision or up to four targeted punch biopsies taken immediately with recall for treatment ( by large loop excision ) if these showed cervical intraepithelial neoplasia grade II or III or worse . Participants were followed for three years , concluding with an exit colposcopy . Main outcome measures Clinical end points : cumulative incidence of cervical intraepithelial neoplasia grade II or worse and grade III or worse at three years . Clinical ly significant anxiety and depression and self reported after effects assessed six weeks after colposcopy , biopsies , or large loop excision . Results 879 women ( 44 % ) had a normal transformation zone at colposcopy and had no further procedures at that time . Colposcopists were less likely to classify the transformation zone as abnormal when the allocation was large loop excision ( 603 ( 60 % ) in the biopsy and selective recall group ; 501 ( 51 % ) in the immediate large loop excision group ) . Of women r and omised to biopsy and recall , 157 ( 16 % ) required a second clinic visit for treatment . Specimens from almost 60 % ( n=296 ) of women who underwent immediate large loop excision showed no cervical intraepithelial neoplasia ( 31 % ; n=156 ) or showed cervical intraepithelial neoplasia grade I ( 28 % ; n=140 ) . The percentages of women diagnosed with grade II or worse up to and including the exit examination were 22 % ( n=216 ) in the biopsy and recall arm and 23 % ( n=228 ) in the immediate large loop excision arm . There was no significant difference between the arms in cumulative incidence of cervical intraepithelial neoplasia grade II or worse ( adjusted relative for risk large loop excision v biopsy 1.04 , 95 % confidence interval 0.86 to 1.25 ) or grade III or worse ( 1.03 , 0.79 to 1.34 ) . A greater proportion of disease was detected at initial investigation and less during follow-up and at exit in the immediate large loop excision arm , but time of detection did not differ significantly between arms . Levels of anxiety and depression and reported pain did not differ between arms . Higher proportions of women r and omised to large loop excision reported moderate or more severe bleeding and discharge . Conclusion A policy of targeted punch biopsies with subsequent treatment for cervical intraepithelial neoplasia grade II or III and cytological surveillance for grade I or less provides the best balance between benefits and harms for the management of women with low grade abnormal cytology referred for colposcopy .  Immediate large loop excision results in overtreatment and more after effects and should not be recommended . Trial Registration IS RCT N 34841617 Objective It is well known that receipt of an initial abnormal cervical cytology test can trigger considerable anxiety among women . Less is known about the impact of follow-up by repeat cytology tests . We quantified prevalence , and identified predictors , of distress after repeat cytologic testing in women with a single low- grade test . Methods Within the framework of the TOMBOLA r and omized controlled trial of alternative managements , 844 women aged 20 to 59 years with a single routine cytology test showing borderline nuclear abnormalities ( BNA ; broadly equivalent to atypical squamous cells of undetermined significance ) were assigned to follow-up by repeat cytology in primary care ( the first test was due 6 months after the initial BNA result ) . Women completed sociodemographic and psychosocial question naires at recruitment and the Impact of Event Scale ( IES ) 6 weeks after their first follow-up cytology test . Factors associated with significant psychologic distress ( IES ≥ 9 ) were identified using logistic regression . Results The response rate was 74 % ( n = 621/844 ) . Of all the respondents , 39 % scored in the range for significant distress . Distress varied by follow-up cytology result : negative , 36 % ; BNA or mild dyskaryosis , 42 % ; other ( including high grade and inadequate ) , 55 % . After adjusting for the cytology result , risk of distress was significantly raised in women who had significant anxiety at recruitment , reported experiencing pain after the follow-up cyt 
    Output:
    
Based on low- or moderate- quality evidence using the GRADE approach and generally low risk of bias , the detection rate of CIN2 + or CIN3 + after two years does not appear to differ between immediate colposcopy and cytological surveillance in the absence of HPV testing , although women may default from follow-up .
Immediate colposcopy probably leads to earlier detection of high- grade lesions , but also detects more clinical ly insignificant low- grade lesions .