“Oh my GOD I must have cancer"... a smear test letter threw me into a vortex of doom, and it turns out I’m not the only one – so I rewrote it

Last year, in the trough between Christmas and 2021, I got a letter saying that my cervix had severe cell abnormalities. 

I went into nuclear meltdown. I didn't sleep for a week. I had to delay a much-needed freelance gig. I only stopped weeping at hospital, when a gynaecological surgeon in glittery trainers (hey, it helps!) explained what exactly was going on.

Rewind to October. I’d been for my routine cervical screening appointment, as smear tests are now called, thanks to a genius rebranding exercise. It was my fourth in over a decade, following three all-clears. Armed with a speculum and a boatload of lube, the nurse scraped around inside me and sent the swab off to a lab. Bish bash bosh. The process barely registered in my consciousness. 

I guess I'd sort of forgotten the point of it all, which I know sounds silly in hindsight. But when the letter raised more questions than it answered, the only logical conclusion was that I am DEFINITELY DEFINITELY DYING.

And it turns out I'm not alone.

Since my cervical cancer scare, I've heard from three friends and a family member who had the same experience. Bear in mind I only mentioned the topic to seven women. To put it another way, you know people who have been through this too.

Here’s the thing. In the UK, all women aged 25-64 are invited to have cervical screening every few years. As the surgeon explained to me, most women will experience an "abnormal" result at some point in their lives, and most of the time, all that’s needed is minor treatment (if any). The terror that’s baked into the results letter is a false alarm.

Don’t get me wrong, there is value in this approach.  

Medical professionals don’t want to undersell the risk of cervical cancer. Rightly so. If they did, women may fail to act on the news that they need further investigation. It’s better for lots of women to freak out about the worst case scenario – only to discover that they’re actually tickety-boo – than the other way around. It’s a type 1 error, meaning we end up with fewer deaths overall but more doom overall (false positives), compared to a type 2 error, which would cause less doom but more deaths (false negatives).

The consequences of a type 2 error are obvious. But how do you square that with the consequences of a type 1 error?

My sample size of personal conversations is small, but I’ve also trawled through scores of threads on online forums such as Jo’s Trust and Cancer Research. Every year it seems thousands of women find themselves in a vortex of doom following an abnormal smear test result, struggling to cope with work and other commitments, convinced that they've got cervical cancer when they probably haven't. This degree of stress can also lead to the shortening of lives. It’s just not measured in the same way that cancer is measured.

What if you could communicate the results differently to reduce some of that suffering?

What if you could still persuade the same number of women (or more) to act on the information, but without causing so much associated stress? Is this asking for the moon on a stick? 

Maybe. Maybe I should wind my neck in. Maybe these results letters have already been analysed, tested and optimised to the n-th degree. But what if they haven’t?

I've spent a decade working as a copywriter, messaging strategist and writing coach in the world of tech and finance. I’ve written more thorny communications than I can count. You’ve defaulted on your loan… we screwed up… there’s been a data breach… our prices are doubling. I’ve seen for myself that it’s possible to reduce the negative impact of these comms, both for customers (less confusion, less fear, less frustration) and for the company (fewer complaints, less customer churn, more compliance).

So I’ve thought about two potential options for rewriting the cervical screening results letter to try to strike a better balance.

To be clear, I’m not saying my rewrites are *definitely* better. Medicine is complicated and multifactorial and I’m very aware that I’m not a gynaecologist. 

I should also note how grateful I am to even be able to access this sort of medical care in the first place. We all know that the NHS is overstretched and underfunded. Nobody expects harried medical experts to be experts in communication as well. As in any situation, when people don't know what they don't know, they roll with their personal default setting. They write a communication as it makes sense from their own perspective. 

Nevertheless, there’s always room for improvement, right?

So in the rest of this article, you’ll find:

  • The original letter (plus a link to my full teardown if you're interested).

  • Letter rewrite, option 1: including *and explaining* the results upfront.

  • Letter rewrite, option 2: removing all upfront attempts at explanation.

  • The 8 communication principles in operation behind both rewrites. 


Original letter

Here’s the link to the full teardown

Thank you for coming for cervical screening.

Your results show that you have HPV (human papillomavirus). This is called an “HPV positive” result. HPV is a common virus and most people will have it at some point in their life without knowing. Usually it goes away on its own. However sometimes it can be long-lasting, and this may cause abnormal cells in your cervix. The cells can, over time, turn into cancer if left untreated. 

We also tested our sample for abnormal cervical cells. We found changes to some of the cells in your cervix called “high-grade (severe) dyskaryosis”. In almost all cases these cell changes are not found to be cancer, but we would like you to come in for a further examination. 

The examination is called a colposcopy. It is similar to having cervical screening. We have requested a colposcopy appointment for you. This will take place in a hospital outpatient clinic. There is more information about colposcopy in the enclosed leaflet. 

If you have not received a colposcopy letter within 2 weeks of receipt of this letter please contact your GP or the person who took your test. 

You may want to discuss your results with your GP. If you do, please take this letter with you. 


Letter rewrite, option 1:
including *and explaining* the results upfront

Approach

I’ve restructured and expanded the information to match the level of awareness of the reader, giving context and reassurance where it’s needed.

New wording

Thank you for coming for cervical screening.

Your results show that we need to take a closer look at your cervix. We do this through a simple procedure called a colposcopy. You’ll get another letter soon about your colposcopy appointment.

We understand that this news might sound worrying, but it’s very common. Remember, the goal of cervical screening is to catch small problems before they turn into bigger problems. That’s why it’s important that you’re checked again by a specialist.

What we tested and why

First we tested you for HPV (human papillomavirus). This is done for every cervical screening.

HPV is a common virus, a bit like a wart. Most people have HPV at some point in their lives without ever knowing. Just like a wart, HPV often goes away by itself because your body manages to fight it off. It makes the cells (building blocks) of your cervix behave differently, which is called “dyskaryosis”.

If dyskaryosis is left untreated for many years, it may turn into cervical cancer. To be clear, this doesn’t happen quickly, and having dyskaryosis is not the same thing as having cancer (although they are related).

Dyskaryosis ranges from low grade to high grade. The higher the grade, the more likely you are to need treatment to get rid of both the HPV and the affected cells.

So if the first test shows that you have HPV, we do a second test for dyskaryosis.

Your results

The result of your cervical screening is that you have HPV and high-grade dyskaryosis. 

What happens next

We’ve requested a colposcopy appointment for you, so please look out for a letter about this.

It will take place in a hospital outpatient clinic (in other words, you come in and leave the same day). It’s a bit like having cervical screening, except that sometimes treatment is carried out at the same time. The enclosed leaflet gives you more information.

If you haven’t received your letter within 2 weeks, please contact the place where you attended your cervical screening appointment.

If you’d like to discuss your results with your GP, please feel free to make an appointment, and remember to take this letter with you. 

Possible downsides

As I’ve said before, this stuff is hard. There are no obvious solutions. We have to weigh up the pros and cons. 

You’re probably thinking “this version of the letter is WAY too long, people won’t read it!”. And you might be right. But – and this is really important – unless you are a woman who finds herself in the exact situation the letter relates to, you cannot trust your instincts. Irrelevant information always feels boring. The only way to find out if the letter is genuinely too long would be to test it with people who are in the target audience.

There’s also a chance that explaining things in more detail makes them more confusing, not less confusing. Again, this would have to be tested.

And yes, the reader might still scan the letter looking for the results. My theory here is that the rest of the info is within eyeshot, so at least they have a better chance of seeing it right away (rather than hyperventilating for an hour and then reading the leaflet about colposcopies that the letter came with. Which was actually very informative, but too little too late).


Letter rewrite, option 2:
removing all upfront attempts at explanation

Approach

I’ve stripped back most of the content, and the game here is twofold. Firstly I’m handing over all the technical stuff to the leaflet about colposcopies that came along with the letter. I’m also avoiding going into detail about the patient’s test results so all of that can be handled in person at the colposcopy appointment instead.

New wording

Thank you for coming for cervical screening.

Your results show that we need to take a closer look at your cervix. We do this through a simple procedure called a colposcopy. You’ll get another letter soon about your colposcopy appointment.

We understand that this news might sound worrying, but it’s very common. Remember, the goal of cervical screening is to catch small problems before they turn into bigger problems. That’s why it’s important that you’re checked again by a specialist.

What happens next

We’ve requested a colposcopy appointment for you, so please look out for a letter about this.

It will take place in a hospital outpatient clinic (in other words, you come in and leave the same day). It’s a bit like having cervical screening, except that sometimes treatment is carried out at the same time. The enclosed leaflet gives you more information.

If you haven’t received your letter within 2 weeks, please contact the place where you attended your cervical screening appointment.

If you’d like to discuss your results with your GP, please feel free to make an appointment, and remember to take this letter with you. 

Possible downsides

Maybe this letter is just too soft without the scary-sounding results there in black and white. Maybe there’s no way to maintain the current response rate without the shock factor. Maybe it’s just too risky to test. 

Also, I can guess there may be operational reasons why this option wouldn’t work. Maybe it’s a legal requirement to inform a patient about their test results before the colposcopy appointment. Maybe the knock-on impact (time, cost etc) of leaving the entire conversation for the surgeon to handle on the day is too big.

Or maybe it’s worth considering.


8 writing principles for “bad news” medical letters

These are the principles behind my two rewrites. For more background, check out the teardown with my notes on the original letter.

  1. Expect people to assume the worst when they encounter unfamiliar terminology (negativity bias).

  2. Expect people to not really understand the purpose of the medical process they’re going through, even if it was explained to them in the past.

  3. Expect *all* technical language to be confusing to laypeople. As a proxy, ask yourself, “would I ever come across this word or phrase in a children’s book?”

  4. Expect people to be unlikely to read any supplementary material, or if they do, expect it to be unlikely to change their mind about their initial conclusions. 

  5. When you’re sharing bad news asynchronously, the order of the information matters. Offer reassurance and context before anything else.

  6. In your opener, summarise the outcome of the previous step the patient went through (but without the gory details) and the next step they need to know about.

  7. Use everyday analogies as a sense-making tool. (OK, I haven’t done this brilliantly here, but the wart/HPV comparison is an example.)

  8. Connect the dots to demystify dependencies. 

OK... now what?

Of course it’s easy for someone like me to say all of this. Much harder to actually do something about it.

People who write medical letters are a) outrageously busy and b) not in the public arena. Not all comms are signed by name. Understandably, throughout the NHS, there are gatekeepers who protect the time and attention of internal teams. And the sheer number of stakeholders involved in making changes across the board makes my palms flood...

I’ll be sharing it as far as I can with the organisations that were involved, in case someone, somewhere, finds it helpful. If you know anyone who works in medicine or comms who might be interested in this article, please share it with them too.

Finally – I know I’ll have overlooked some critical pieces of the puzzle in my rewrites. My aim is just to find a starting point for discussion. Do you have strong opinions about this stuff yourself? Drop me a line at corissa@corissanunn.com, I’d love to have a conversation.

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