Cervical screening in under 25s: a high-risk young population

Does mode of delivery impact the course of cervical dysplasia in pregnancy? A review of 219 cases

OBJECTIVE

The prevalence of cervical intraepithelial neoplasia (CIN) in pregnancy is about 1%. The aim of this study was to analyze the regression, persistence and progression rates of cervical dysplasia in pregnancy and the impact of delivery mode.

STUDY DESIGN

In this retrospective study, data from pregnant patients with abnormal cytology findings, who presented to a colposcopic outpatient clinic of a university hospital within the last 10 years, were analyzed. Information on cytology, histology and Human Papillomavirus (HPV) status during pregnancy and postpartum and mode of delivery was collected.

RESULTS

219 women, who were assessed with cytology and /or biopsy antepartum and postpartum between January 2010 and July 2020, were included in the study. Antepartum patients presented with low grade squamous intraepithelial lesions (LSIL) in 37% and high grade squamous intraepithelial lesions (HSIL) in 53%. During pregnancy biopsy was performed in 78 patients (36%). Postpartum evaluation revealed an overall regression rate of 39%. Persistence rates were especially high in the HSIL group with 70 %. HSIL regressed in 28 %. Progression to invasive disease was rare and seen in two patients postpartum only. 141 women delivered vaginally (VD) and 51 received a cesarean section (CS). Regression rates were similar: 36 % and 47 %. There was no significant difference in progression or persistence rates.

CONCLUSION

Our study demonstrates that mode of delivery does not influence the course of SIL. SIL show high rates of regression and persistence, progression to invasive disease is rare.

Safety of Conservative Management of High-Grade Squamous Intraepithelial Lesion in Women Under 30 Years Old

Objectives:

To evaluate the outcomes of conservative management in young women with high-grade squamous intraepithelial lesion (HSIL).

Methods:

A retrospective cohort study included women younger than 30 years referred with HSIL (cytology or biopsy) managed conservatively from 2012 to 2019, in Campinas/Brazil. Regression was the outcome when no evidence of HSIL was observed in at least two consecutive follow-ups. Kaplan–Meyer method was used to determine regression probabilities. Other tests were chi-square or Fisher, Mann–Whitney and COX regression.

Results:

During the study period, 89 patients were included. No progression to microinvasive or invasive cancer was observed. Sixty-one (69%) patients were younger than 25 years, and 28 (31%) were aged 25–30 years. Spontaneous regression was seen in 64 (72%) and persistence in 25 (28%) of the overall sample. The average time to regression was 15.4 months (standard deviation [SD] = 7.7), and the follow-up time was 31.6 months (SD 19.0). Age, parity, first sexual intercourse, smoking, hormonal contraception, and colposcopy impression were not different among women with regression or persistence. Regression probabilities were, respectively, 28.9%, 60.2%, and 78.1% after 12, 18, and 24 months. Most of the events happened between 12 and 18 months of follow-up.

Conclusions:

Conservative management in women younger than 30 years was safe: spontaneous regression was observed in 72% of all women younger than 30 with HSIL managed conservatively. No clinical variable was relevant, influencing regression. In 2 years the regression probability was 78%.

Distribution of cervical lesions in young and older women

INTRODUCTION

Age range for cervical screening varies widely between countries. In addition, sexual behavior has changed, life expectancy is increasing, and new insights have been gained into the pathogenesis of HPV infection. Our aim is to evaluate the distribution of cervical lesions in young and older patients.

METHODS

Review of all cervical smears diagnosed in a public institution (2010-2017) and a private institution (2016-2017) in Madrid, Spain. We have included all women aged younger than 30 and older than 65 years with atypical smears (n = 1573).

RESULTS

Women younger than 30 years were diagnosed with ASCUS, ASC-H, LSIL, and HSIL in 47%, 5.3%, 45.17%, and 2.6% of atypical cases, respectively. Women older than 65 years were diagnosed with ASCUS, ASC-H, LSIL, HSIL, and SCC in 38%, 12.39%, 16.8%, 13.27%, and 19.5% of atypical cases, respectively. Medical records of patients from the public institution were reviewed. Of note, 76.3% of young women showed negative smears at follow-up and 14.1% showed high-grade dysplasia (HGD). Mean ages for low-grade and HGD were 24.7 and 25.7 years, respectively. HGD was found in 37.9% of women with histological examination (33.5%). As for older patients, 25% of them had no Pap smears performed before age 65, and in 60% of the previously screened women, the screening program had not been used adequately. Mean age of first smear was 69.5 years. Carcinoma was subsequently detected in 20.7% of patients.

CONCLUSIONS

Current guidelines seem to be adequately preventing carcinoma in young women. However, screening adherence should be encouraged to detect important lesions in both age groups, especially among older women.

Natural history of cervical intraepithelial neoplasia in pregnancy: postpartum histo-pathologic outcome and review of the literature

Background

To study the natural history of cervical intraepithelial neoplasia (CIN) during pregnancy and to compare the rates of persistence, progression and regression of CIN by colposcopically guided biopsy (CGB) during pregnancy with outcome in non-pregnant-women.

Methods

A retrospective analysis of all pregnant women diagnosed with CIN at our outpatient clinic between 2005 and 2010 was performed. A CGB for histo-pathological analysis was obtained in all participants and observational management was performed. The histo-pathologic findings of initial and postpartum visits were collected. Rates of persistence, progression and regression of CIN were assessed. Results were compared to a matched control group of non-pregnant women where observational management was performed for at least three months. In addition a review of the literature and pooled analysis of published data was performed.

Results

A total of 51 pregnant women with CIN were included into analysis. CIN 1, 2, and 3 was diagnosed by CGB in 33.3, 13.7 and 52.9 % of all pregnant women, respectively. The postpartum histo-pathologic evaluation of the pregnant cohort revealed a significantly higher tendency to spontaneous regression (56.9 versus 31.4 %, p = 0.010) and a considerably, but not significantly higher complete remission rate (41.2 versus 27.5 %, p = 0.144) when compared to the non-pregnant cohort. In addition, we observed a significantly lower CIN persistence rate than in the non-pregnant cohort (39.2 versus 58.8 %, p = 0.048). The progression rate was notably low in the pregnant cohort (3.9 %) and no progression to invasive cancer was observed.

Conclusions

CIN lesions show considerably high spontaneous regression rates postpartum. Once presence of invasive cancer is ruled out definitive treatment can be deferred to the postpartum period.

Cervical cancer screening in young and elderly women of the Xingu Indigenous Park: evaluation of the recommended screening age group in Brazil

Objective

To analyze the occurrence of atypia in the cytology/histology examinations of young women under the age of 25 years and of elderly women aged over 64 years, in the Xingu Indigenous Park and to evaluate, in a subjective manner, if the age range for screening established by the Ministry of Health and the Instituto Nacional de Câncer is appropriate for this population.

Methods

The Xingu/UNIFESP Project, in partnership with the Center for Gynecological Disease Prevention, develops programs to prevent cervical cancer. The exploratory, retrospective and descriptive study of cytological and histopathological examinations of young (12-24 years) and elderly (aged 64 and over) women of the Xingu Indigenous Park, between 2005 and 2011.

Results

There was low occurrence of cytological atypia in the elderly female population, but there were occasional high-grade lesions in the indigenous youth.

Conclusion

Interrupting screening at the limit age of 64 years, as established by the Ministry of Health and the Instituto Nacional de Câncer is justified. However, screening of young women should begin at an earlier age.

Prevention and early detection of cervical cancer in the UK

This literature review explores the prevention and early detection of cervical cancer in the UK. Current findings indicate that there is a risk for women under the age of 25 years, who may develop cervical cancer. There appears to be a gap in UK policy that may overlook these women, who are beneath the age for initial screening but exceed the age for vaccination. Despite the inextricable link between sexual activity and cervical cancer, cervical screening and sexual health promotion still appear to be disjointed, and the role of a sexually transmitted infection leading to the development of cervical cancer has not been emphasised enough in public health messages. Further training should be provided and its impact monitored, designed to address this anomaly in health promotion. There are many barriers to health promotion including, those of a societal, cultural and religious nature. Additional research is required to ascertain the types of educational and awareness interventions that would be most effective in promoting and encouraging positive sexual behaviours among young people, and to explore how these might be successfully implemented.

High-grade squamous intraepithelial lesions in pregnant and non-pregnant women

OBJECTIVES

To evaluate if the prevalence of cervical smear results varies between pregnant and non-pregnant women stratified by age group.

STUDY DESIGN

Observational analytical study with a total sample of 1,336,180 pregnant and non-pregnant women, aged between 20 and 34 years, who underwent cervical cancer screening in the Primary Health Care of the national health system in the area of Campinas in Brazil during the period of 2005-2009. The source is the information system for cervical cancer screening. Data collected on abnormal cervical smears were analyzed using the Chi-square test and Fisher's exact test and the magnitude of the association between pregnancy and high-grade squamous epithelial lesions was analyzed by odds ratio (OR) and estimated values with confidence intervals (CI) of 95%.

RESULTS

15,190 pregnant women and 395,961 non-pregnant women were analyzed and fulfilled the inclusion criteria. Regardless of age, no statistical differences were observed for high-grade squamous intraepithelial lesion prevalence (OR 0.90; CI 0.66-1.23). Taking into account the five-year age groups, however, low-grade squamous intraepithelial lesion was less prevalent in pregnant women aged 20-24 (OR 0.71; 0.54-0.95) and 25-29 years (OR 0.56; 0.35-0.89); also, atypical squamous cells of undetermined significance was more prevalent in non-pregnant women aged 25-29 years (OR 0.72; 0.54-0.97).

CONCLUSION

The study showed that the cytological prevalence of high-grade squamous intraepithelial lesion was similar in pregnant and non-pregnant women, regardless of age. The results indicate that there are no reasons for specific approaches to cervical cancer screening for pregnant women. The examination should be carried out only on pregnant women who have not been tested according to current recommendations.

Should cervical cancer screening begin at age 21 for everyone? A quantitative analysis in a high-risk, low-income, African American/Hispanic young-adult population

The American College of Obstetricians and Gynecologists has recommended modifying the baseline cervical cancer screening age from earlier of three years after first sexual intercourse or age 21 to age 21. In this study, we tracked abnormal cytologic diagnoses, with an emphasis on high-grade cervical lesions, in a high-risk, low-income, African American/Hispanic young-adult population. The intention was to assess if delaying cancer screening to 21 years of age would be effective in this subpopulation. A search of the cytopathology database between January 1, 2001 and December 31, 2009 was performed to identify all women with their first abnormal cytologic diagnosis prior to turning 21 years of age. All of the available follow-up cytologic and/or histologic diagnoses, made both prior to and after turning 21 years of age, were recorded and the results analyzed. Amongst the 8,011 total number of women under 21 years of age screened for cervical cancer at our institution from January 1, 2001 to December 31, 2009 the overall abnormal cytology rate was 25%, with a rate of 1% for HSIL, 3% for ASC-H/LG-H, and 22% for LSIL/ASC-US. The youngest subject diagnosed with HSIL was 14 years of age. Not a single study subject developed invasive cervical cancer prior to turning 21 years of age. In spite of the limitations of the study, we found that for patients served by our institution, delaying cervical cancer screening until 21 years of age is effective for the detection of early precancerous lesions.

The impact of policy and screening on cervical cancer in England

There has been a significant statistical decrease in the incidence of cervical cancer since screening programmes have been introduced. This article will explore and evaluate the impact of the Cancer Reform Strategy on cervical screening in England, which preceded the Government's policy for cancer care announced in January 2011. The Strategy raised the initial age of screening from 20 to 25 years of age. This left a group of the population who could not access screening while also not being eligible for vaccines against cervical cancer. Although this caused concern for many people, the media coverage and reaction to the human papilloma virus (HPV) vaccine and the death of Jade Goody, for example, encouraged women to consider cervical screening. The barriers to screening have been identified but overall the Cancer Reform Strategy was found have a positive impact both economically and socially. The Strategy has led the way for the Government's policy for cancer care, which needs to continue achieving the same positive outcomes.

Teenage cervical screening in a high risk American population

BACKGROUND

The new 2009 ACOG guideline for cervical cytology screening changed the starting age to 21 years regardless of the age of onset of sexual intercourse. However, many recent studies have shown a dramatic increase in the incidence of cervical epithelial abnormalities among adolescents within the past two decades.

MATERIALS AND METHODS

For this study, the reports of 156,342 cervical cytology were available of which 12,226 (7.8%) were from teenagers. A total of 192 teenagers with high grade intraepithelial lesion (HSIL) cervical cytology were identified. The ages ranged from 13 to 19 years with a mean of 17.7 years and a median of 18 years. Among them, 31.3% were pregnant, 12.0% were postpartum, and 13.5% were on oral contraceptive. Ninety-eight had prior cervical cytology.

RESULTS

The teenagers had statistically significant higher detection rates of overall abnormal cervical cytology (23.6% vs. 6.6%, P = 0), with 15.4% vs. 3.2% (P = 0) of low grade intraepithelial lesion (LSIL) and 1.8% vs. 1.0% (P = 2.56 × 10(-13) ) of HSIL compared to women ≥20 years. The teenage group had the highest abnormal cytology among all age groups. The LSIL/HSIL ratio was 8.5:1 for teenagers and 3.1:1 for women ≥20 years. A total of 131 teenagers had cervical biopsies within 12 months of the HSIL cytology, with diagnoses of 39 CIN 3, 1 VAIN 3, 15 CIN 2, 62 CIN 1, and 14 had a negative histology (CIN 0). Only in 19 of these 39 women, the CIN 2/3 lesion proved to be persistent.

CONCLUSION

We conclude that cytology screening of high risk teenagers is effective in detecting CIN 2/3 lesions. Moreover, treatment and careful follow-up can be realized.

Effectiveness of cervical screening with age: population based case-control study of prospectively recorded data

OBJECTIVE

To study the effect of cervical screening on incidence of cervical cancer as a function of age with particular focus on women screened under the age of 25.

DESIGN

Population based case-control study with prospectively recorded data on cervical screening.

SETTING

Selected centres in the United Kingdom.

PARTICIPANTS

4012 women aged 20-69 with invasive cancer diagnosed in participating centres and two controls per case individually matched on age and area of residence.

MAIN OUTCOME MEASURES

Odds ratios for strength of association between cervical cancer and screening at particular ages.

RESULTS

There is no evidence that screening women aged 22-24 reduced the incidence of cervical cancer at ages 25-29 (odds ratio 1.11, 95% confidence interval 0.83 to 1.50). Similar results were seen for cancers restricted to squamous carcinoma or FIGO (International Federation of Gynaecology and Obstetrics) stage IB or worse, but the numbers are insufficient to provide narrow confidence intervals. Screening was associated with a 60% reduction of cancers in women aged 40, increasing to 80% at age 64. Screening was particularly effective in preventing advanced stage cancers.

CONCLUSIONS

Cervical screening in women aged 20-24 has little or no impact on rates of invasive cervical cancer up to age 30. Some uncertainly still exists regarding its impact on advanced stage tumours in women under age 30. By contrast, screening older women leads to a substantial reduction in incidence of and mortality from cervical cancer. These data should help policy makers balance the impact of screening on cancer rates against its harms, such as overtreatment of lesions with little invasive potential.

Increasing the uptake of cervical screening programmes

Successful cervical screening programmes depend on the degree of coverage and the rate of attendance. There are many demographic reasons why some women fail to attend for cervical screening, including lack of knowledge and education and socioeconomic status. Moreover, a woman's ethnicity and her age also play a role in screening uptake. Community and practice nurses are ideally positioned to identify women's information needs and provide appropriate information to overcome barriers to screening attendance. This article discusses the main predictors of participation in cervical screening programmes and interventions that can be used to increase cervical screening uptake.