Education Archive

TOMBOLA results

Three separate papers in this week''s BMJ report the long awaited results from the TOMBOLA trial (Trial of the Management of Borderline and Other Low Grade Abnormalities). Collectively the papers reach three main conclusions:

1. Compared with cytological surveillance, a policy of immediate colposcopy for low grade cytological abnormalities detects more cervical intraepithelial neoplasia grade II or worse, and some more grade III or worse, but might lead to overtreatment. Such a policy is associated with a higher rate of reported after effects, which are more severe and of longer duration than those associated with cytological surveillance.
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2. 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. 
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3. A cost-effectiveness appraisal of three protocols for the management of low grade cytological abnormalities (cytological surveillance, referral to colposcopy for biopsy and recall or referral to colposcopy with immediate treatment based on colposcopic appearance) demonstrated no compelling economic reason to favour any one follow-up method over either of the others.
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