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Lycke KD, Kahlert J, Damgaard RK, Eriksen DO, Bennetsen MH, Gravitt PE, Petersen LK, Hammer A. Clinical course of cervical intraepithelial neoplasia grade 2: a population-based cohort study. Am J Obstet Gynecol 2023; 229:656.e1-656.e15. [PMID: 37595822 DOI: 10.1016/j.ajog.2023.08.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 08/01/2023] [Accepted: 08/09/2023] [Indexed: 08/20/2023]
Abstract
BACKGROUND Cervical intraepithelial neoplasia grade 2 has historically been the threshold for surgical excision, but because of high regression rates, many countries are transitioning to active surveillance. However, estimates for regression rates are based on small studies with heterogeneous definitions of regression and progression. OBJECTIVE This study aimed to describe regression and progression rates of cervical intraepithelial neoplasia grade 2 using nationwide healthcare registry data. STUDY DESIGN This was a nationwide population-based cohort study on women aged 18 to 40 years who had undergone active surveillance for cervical intraepithelial neoplasia grade 2 in Denmark from 1998 to 2020. This study excluded women with a previous record of cervical intraepithelial neoplasia grade 2 or worse or surgical excision. Cumulative incidence functions were used to estimate the rates of regression and progression at 6, 12, 18, and 24 months after diagnosis. In addition, a modified Poisson regression was used to estimate the crude and adjusted relative risks of progression within 24 months stratified by index cytology and age. RESULTS During the study period, 11,056 women underwent active surveillance, 6767 of whom regressed and 3580 of whom progressed within 24 months. This corresponded to regression rates of 62.9% (95% confidence interval, 61.9-63.8) and progression rates of 33.3% (95% confidence interval, 32.4-34.2) at 24 months of follow-up. Most women regressed (90%) or progressed (90%) within the first 12 months. Women with high-grade index cytology had a higher risk of progression than women with normal index cytology (adjusted relative, 1.58; 95% confidence interval, 1.43-1.76), whereas there was no difference in the risk of progression between women aged 30 and 40 years and women aged 23 to 29 years (adjusted relative risk, 0.98; 95% confidence interval, 0.88-1.10). CONCLUSION The observed high regression rates of cervical intraepithelial neoplasia grade 2 supported the transition in clinical management from surgical excision to active surveillance, particularly among women with low-grade or normal index cytology.
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Affiliation(s)
- Kathrine D Lycke
- Department of Gynecology and Obstetrics, Gødstrup Hospital, Herning, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.
| | - Johnny Kahlert
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Rikke K Damgaard
- Department of Gynecology and Obstetrics, Gødstrup Hospital, Herning, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Dina O Eriksen
- Department of Gynecology and Obstetrics, Gødstrup Hospital, Herning, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Mary H Bennetsen
- Department of Pathology, Randers Regional Hospital, Randers, Denmark
| | - Patti E Gravitt
- Center for Global Health, National Cancer Institute, Rockville, MD
| | - Lone K Petersen
- Department of Gynecology and Obstetrics, Odense University Hospital, Odense, Denmark; Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Anne Hammer
- Department of Gynecology and Obstetrics, Gødstrup Hospital, Herning, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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Reijntjes B, Eising M, Kleppe M, Geuken E, Woolderink JM. The clinical relevance of excisional margins after large loop excision of the transformation zone for the persistence of cervical dysplasia. Int J Gynaecol Obstet 2023; 163:140-147. [PMID: 37243333 DOI: 10.1002/ijgo.14888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 04/12/2023] [Accepted: 05/09/2023] [Indexed: 05/28/2023]
Abstract
OBJECTIVE A new guideline on population-screening cervical cytology was introduced to improve diagnosis and management of (pre-)malignant cervical lesions. Subsequently, more colposcopies and more large loop excision of the transformation zone (LLETZ) were performed. There is little information about the relevance of positive margins for cervical intraepithelial neoplasia (CIN) after LLETZ. This study assesses the clinical relevance of margins on the presence of CIN. METHODS In this retrospective study, 567 women who had undergone LLETZ due to cervical dysplasia between January 2017 and December 2019 in Martini Hospital Groningen were included. The primary outcome was the persistence of cervical dysplasia (Pap ≥2) in relation to excisional margins. A χ2 test was performed and hazard ratios with 95% confident intervals (CIs) were reported. RESULTS After median follow-up of 14 months, 9% (N = 28) with affected margins and 4% (N = 9) with clear margins had persistent cervical dysplasia (P = 0.044). Positive human papillomavirus (HPV) status was an independent risk factor (hazard ratio [HR] 8.97, 95% confidence interval [CI] 4.19-19.22). Women with affected margins and of older age were less prone to clear HPV (P < 0.001). CONCLUSION Women treated with LLETZ for cervical dysplasia show favorable long-term outcomes, with low residual rate. High-risk HPV combined with excisional margin status and age appears to be an adequate risk stratification and individualized management might be based on these factors.
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Affiliation(s)
- Bianca Reijntjes
- Department of Obstetrics and Gynecology, Martini Hospital Groningen, Groningen, the Netherlands
| | - Manon Eising
- Department of Obstetrics and Gynecology, Martini Hospital Groningen, Groningen, the Netherlands
| | - Marjolein Kleppe
- Department of Obstetrics and Gynecology, Martini Hospital Groningen, Groningen, the Netherlands
| | - Erwin Geuken
- Department of Pathology, Martini Hospital Groningen, Groningen, the Netherlands
| | - Jorien M Woolderink
- Department of Obstetrics and Gynecology, Martini Hospital Groningen, Groningen, the Netherlands
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Ferreira AL, Dibe ND, de Paiva BR, Portari EA, Dock DCDA, Ferreira NVC, Gomes SC, Russomano FB, de Andrade CV. Cervical Intraepithelial Neoplasia grade 2 biopsy: Do p16INK4a and Ki-67 biomarkers contribute to the decision to treat? A cross-sectional study. SAO PAULO MED J 2023; 142:e2022527. [PMID: 37646766 PMCID: PMC10452003 DOI: 10.1590/1516-3180.2022.0527.r2.280423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 04/08/2023] [Accepted: 04/28/2023] [Indexed: 09/01/2023] Open
Abstract
BACKGROUND Managing cervical intraepithelial neoplasia grade 2 (CIN2) is challenging, considering the CIN2 regression rate, perinatal risks associated with excisional procedures, and insufficient well-established risk factors to predict progression. OBJECTIVES To determine the ability of p16INK4a and Ki-67 staining in biopsies diagnosed with CIN2 to identify patients with higher-grade lesions (CIN3 or carcinoma). DESIGN AND SETTING Cross-sectional study conducted at a referral center for treating uterine cervical lesions. METHODS In 79 women, we analyzed the correlation of p16INK4a and Ki-67 expression in CIN2 biopsies with the presence of a higher-grade lesions, as determined via histopathology in surgical specimens from treated women or via two colposcopies and two cytological tests during follow-up for untreated women with at least a 6-month interval. The expression of these two biomarkers was verified by at least two independent pathologists and quantified using digital algorithms. RESULTS Thirteen (16.8%) women with CIN2 biopsy exhibited higher-grade lesions on the surgical excision specimen or during follow-up. p16INK4a expression positively and negatively predicted the presence of higher-grade lesions in 17.19% and 86.67% patients, respectively. Ki-67 expression positively and negatively predicted the presence of higher-grade lesions in 40% and 88.24% patients, respectively. CONCLUSIONS Negative p16INK4a and Ki67 immunohistochemical staining can assure absence of a higher-grade lesion in more than 85% of patients with CIN2 biopsies and can be used to prevent overtreatment of these patients. Positive IHC staining for p16INK4a and Ki-67 did not predict CIN3 in patients with CIN2 biopsies.
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Affiliation(s)
- Amanda Leal Ferreira
- MSc. Biomedical and PhD Student, Laboratory of Diagnosis Pathology and Cytopathology, Instituto Nacional de Saúde da Mulher, da Criança e do Adolescente Fernandes Figueira (IFF), Fundação Oswaldo Cruz (FIOCRUZ), Rio de Janeiro (RJ), Brazil
| | - Nasle Domingues Dibe
- MD. Gynecologist, Laboratory of Diagnosis Pathology and Cytopathology, Instituto Nacional de Saúde da Mulher, da Criança e do Adolescente Fernandes Figueira (IFF), Fundação Oswaldo Cruz (FIOCRUZ), Rio de Janeiro (RJ), Brazil
| | - Bruna Rodrigues de Paiva
- MD. Postgraduate Student in Nutrology, Laboratory of Diagnosis Pathology and Cytopathology, Instituto Nacional de Saúde da Mulher, da Criança e do Adolescente Fernandes Figueira (IFF), Fundação Oswaldo Cruz (FIOCRUZ), Rio de Janeiro (RJ), Brazil
| | - Elyzabeth Avvad Portari
- MD, MSc, PhD. Pathologist, Researcher in Laboratory of Diagnosis Pathology and Cytopathology, Instituto Nacional de Saúde da Mulher, da Criança e do Adolescente Fernandes Figueira (IFF), Fundação Oswaldo Cruz (FIOCRUZ), Rio de Janeiro (RJ), Brazil
| | - Dione Corrêa de Araújo Dock
- MD. Physician and Pathologist, Laboratory of Diagnosis Pathology and Cytopathology, Instituto Nacional de Saúde da Mulher, da Criança e do Adolescente Fernandes Figueira (IFF), Fundação Oswaldo Cruz (FIOCRUZ), Rio de Janeiro (RJ), Brazil
| | - Nilma Valéria Caldeira Ferreira
- BSc. Immunohistochemistry Technician, Laboratory of Diagnosis Pathology and Cytopathology, Instituto Nacional de Saúde da Mulher, da Criança e do Adolescente Fernandes Figueira (IFF), Fundação Oswaldo Cruz (FIOCRUZ), Rio de Janeiro (RJ), Brazil
| | - Saint Clair Gomes
- BSc, PhD. Researcher in Clinical Research Unit, Instituto Nacional de Saúde da Mulher, da Criança e do Adolescente Fernandes Figueira (IFF), Fundação Oswaldo Cruz (FIOCRUZ), Rio de Janeiro (RJ), Brazil
| | - Fábio Bastos Russomano
- MD, MSc, PhD. Gynecologist, Center for the Clinical and Surgical Care of Women, Instituto Nacional de Saúde da Mulher, da Criança e do Adolescente Fernandes Figueira (IFF), Fundação Oswaldo Cruz (FIOCRUZ), Rio de Janeiro (RJ), Brazil
| | - Cecília Vianna de Andrade
- MD, MSc, PhD. Pathologist, Laboratory of Diagnosis Pathology and Cytopathology, Instituto Nacional de Saúde da Mulher, da Criança e do Adolescente Fernandes Figueira (IFF), Fundação Oswaldo Cruz (FIOCRUZ), Rio de Janeiro (RJ), Brazil
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Willows K, Selk A, Auclair MH, Jim B, Jumah N, Nation J, Proctor L, Iazzi M, Bentley J. 2023 Canadian Colposcopy Guideline: A Risk-Based Approach to Management and Surveillance of Cervical Dysplasia. Curr Oncol 2023; 30:5738-5768. [PMID: 37366914 DOI: 10.3390/curroncol30060431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 06/05/2023] [Accepted: 06/07/2023] [Indexed: 06/28/2023] Open
Abstract
This guideline provides evidence-based guidance on the risk-based management of cervical dysplasia in the colposcopy setting in the context of primary HPV-based screening and HPV testing in colposcopy. Colposcopy management of special populations is also discussed. The guideline was developed by a working group in collaboration with the Gynecologic Oncology Society of Canada (GOC), Society of Colposcopists of Canada (SCC) and the Canadian Partnership Against Cancer (CPAC). The literature informing these guidelines was obtained through a systematic review of the relevant literature via a multi-step search process led by information specialists. The literature was reviewed up to June 2021 with manual searches of relevant national guidelines and more recent publications. Quality of the evidence and strength of recommendations was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework. The intended users of this guideline include gynecologists, colposcopists, screening programs and healthcare facilities. Implementation of the recommendations is intended to promote equitable and standardized care for all people undergoing colposcopy in Canada. The risk-based approach aims to improve personalized care and reduce over-/under-treatment in colposcopy.
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Affiliation(s)
- Karla Willows
- Nova Scotia Cancer Centre, Division of Gynecologic Oncology, Dalhousie University, Halifax, NS B3H 4R2, Canada
| | - Amanda Selk
- Women's College Hospital, Toronto, ON M5S 1B2, Canada
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, ON M5S, Canada
| | - Marie-Hélène Auclair
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Hôpital Maisonneuve-Rosemont, CIUSSS de l'Est de l'Île de Montréal, Montréal, QC H1T 2M4, Canada
| | - Brent Jim
- Division of Gynecologic Oncology, Allan Blair Cancer Centre, University of Saskatchewan, Regina, SK S7N 5A2, Canada
| | - Naana Jumah
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, ON M5S, Canada
- Department of Obstetrics and Gynecology, Northern Ontario School of Medicine, Thunder Bay, ON P7B 5E1, Canada
| | - Jill Nation
- Division of Gynecologic Oncology, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 1N4, Canada
| | - Lily Proctor
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University of British Columbia, Vancouver, BC V6T 1Z4, Canada
| | - Melissa Iazzi
- The Society of Gynecologic Oncology of Canada (GOC), Ottawa, ON K1H 8K3, Canada
| | - James Bentley
- Nova Scotia Cancer Centre, Division of Gynecologic Oncology, Dalhousie University, Halifax, NS B3H 4R2, Canada
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Dovnik A, Poljak M. The Role of Methylation of Host and/or Human Papillomavirus (HPV) DNA in Management of Cervical Intraepithelial Neoplasia Grade 2 (CIN2) Lesions. Int J Mol Sci 2023; 24:ijms24076479. [PMID: 37047452 PMCID: PMC10095339 DOI: 10.3390/ijms24076479] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 03/28/2023] [Indexed: 03/31/2023] Open
Abstract
Cervical intraepithelial neoplasia grade 2 (CIN2) is an intermediate stage between CIN 1, which is a low-grade lesion, and CIN3, which is the immediate precursor of cervical cancer (CC). Traditionally, CIN2 was regarded as a high-grade lesion and was treated with conization or ablative methods. In recent years, there has been a shift in the management of younger patients, who are now more often being managed conservatively due to frequent spontaneous CIN2 regression and possible adverse effects of treatment on future pregnancies. Because the risk of progression to CC still exists with conservative management, a personalized approach is needed to identify patients with a higher probability of progression. In this regard, research has focused on the role of host and human papillomavirus (HPV) gene methylation. This systematic review summarizes the current knowledge regarding conservative CIN2 management focusing on the main methylation markers and its implementation in conservative CIN2 management, and it describes major ongoing longitudinal studies on the subject. The review showed that DNA methylation is an accurate predictor of disease progression and a valid triage tool for HPV-positive women, with CIN2 performing better than triage cytology. Because virtually all CCs are methylation-positive, methylation-negative women at baseline have an extremely low risk of CC.
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Affiliation(s)
- Andraž Dovnik
- University Clinic for Gynecology and Obstetrics, Maribor University Medical Center, Ljubljanska 5, 2000 Maribor, Slovenia
- Correspondence: ; Tel.: +386-2-321-2178
| | - Mario Poljak
- Institute of Microbiology and Immunology, Faculty of Medicine, University of Ljubljana, Zaloška 4, 1000 Ljubljana, Slovenia;
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Blimp-1 is a prognostic indicator for progression of cervical intraepithelial neoplasia grade 2. J Cancer Res Clin Oncol 2022; 148:1991-2002. [PMID: 35386001 PMCID: PMC9294030 DOI: 10.1007/s00432-022-03993-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 03/22/2022] [Indexed: 11/10/2022]
Abstract
Background Progression of cervical intraepithelial neoplasia (CIN) to higher grade disease is associated with persistent human papillomavirus (HPV) infection and an absence of immune-mediated regression. However, the immune microenvironment that distinguishes progression from persistent or regressing lesions has not been well defined. Methods A total of 69 patients under the age of 25 with high-risk HPV-positive cytology and biopsy-confirmed p16-positive CIN2 were included in the study. Biopsies were stained using 20 antibodies to a range of immune markers. Based on a 2-year follow-up, samples were analysed in “progressor” (CIN3 +) or “persister/regressor” (CIN1, 2 or normal) groups. Results Progression was most strongly associated with Blimp-1 positive cell staining in the lesion (P = 0.0019) and with low numbers of infiltrating CD4 cells in the dermal region beneath the lesion (P = 0.0022). The presence of CD4, CD8 and T bet-positive cells in the dermal region most strongly correlated with CD11c cells in the persister/regressor but not the progressor group. Conclusion High numbers of Blimp-1 + cells in CIN2 lesions may predict progression to more severe disease. Measurement of Blimp-1 may have diagnostic utility for the determination of the need to treat women with cervical pre-cancer. Highlights CIN2 progression is associated with high numbers of Blimp-1 positive cells in the lesion. Detection of Blimp-1 in the lesion may have utility as a prognostic test to inform the need to treat CIN2. Supplementary Information The online version contains supplementary material available at 10.1007/s00432-022-03993-4.
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Comparison of Expectant and Excisional/Ablative Management of Cervical Intraepithelial Neoplasia Grade 2 (CIN2) in the Era of HPV Testing. Obstet Gynecol Int 2022; 2022:7955290. [PMID: 35371262 PMCID: PMC8970964 DOI: 10.1155/2022/7955290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Revised: 01/25/2022] [Accepted: 02/16/2022] [Indexed: 11/23/2022] Open
Abstract
Objective To investigate conservative and excisional/ablative treatment outcomes for cervical intraepithelial neoplasia grade 2 (CIN2) following introduction of virological test of cure. Methods This was a retrospective study of prospectively collected data at a teaching hospital colposcopy unit. 331 sequential biopsy-proved CIN2 cases were involved. CIN2 cases diagnosed between 01/07/2014 and 31/12/2017 were either conservatively managed or treated with excision/ablation and then were followed up until discharge from colposcopy clinic and then using the national cervical cytology database. Outcomes were defined: cytological/histological regression was absence of high-grade CIN on biopsy and/or high-grade dysplasia; virological regression was cytological/histological regression and negative human papillomavirus testing; persistence was biopsy-proven CIN2 and/or moderate dyskaryosis; progression was biopsy-proven CIN3+ and/or severe dyskaryosis. Results Median follow-up was 22.6 months (range: 1.9–65.1 months). Among 175 (52.9%) patients initially managed conservatively, 77.3% (133/172) regressed, 13.4% (23/172) persisted, 9.3% (16/172) progressed to CIN3+, and 97 (56.4%) patients achieved virological regression. 156 (47.1%) patients underwent initial excision/ablation, with an 89.4% (110/123) virological cure rate. After discharge, 7 (4.0%) and 3 (1.9%) patients redeveloped CIN in the conservative and treatment groups, respectively, during a median period of 17.2 months. Conclusion Conservative management is a reasonable and effective management strategy in appropriately selected women with CIN2. High rates of histological and virological regression should be expected. The previously mentioned data provide useful information for deciding management options.
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Sykes PH, Simcock BJ, Innes CR, Harker D, Williman JA, Whitehead M, van der Griend RA, Lawton BA, Hibma M, Fitzgerald P, Dudley NM, Petrich S, Eva L, Bergzoll C, Kathuria J, McPherson G, Tristram A, Faherty J, Hardie D, Robertson A, Robertson V, Pather S, Wrede CD, Gastrell F, Fentiman G, John M, White E, Parker C, Sadler L. Predicting regression of cervical intraepithelial neoplasia grade 2 in women under 25 years. Am J Obstet Gynecol 2022; 226:222.e1-222.e13. [PMID: 34534506 DOI: 10.1016/j.ajog.2021.09.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 08/17/2021] [Accepted: 09/08/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND A number of retrospective and prospective studies have documented substantial rates of regression in cervical intraepithelial neoplasia grade 2 lesions in young women. Initial observational management of cervical intraepithelial neoplasia grade 2 is increasingly accepted as appropriate for women under 25 years of age with screen-detected abnormalities and is included in a number of clinical guidelines. However, there has been a paucity of large prospective studies on observational management with strict inclusion criteria. A number of important questions remain, specifically regarding the clinical variables that are associated with the risk of progression or persistence of disease. To investigate these factors and to ensure that young women with cervical intraepithelial neoplasia grade 2 undergoing observational management were being managed in a well-monitored and an appropriately informed fashion, we conducted a large, multicenter prospective study on observational management of cervical intraepithelial neoplasia grade 2 in women under 25 years. OBJECTIVE This study aimed to determine the regression rates and clinical, cytologic, and pathologic predictors of regression of cervical intraepithelial neoplasia grade 2 in women under 25 years undergoing observational management over 24 months. STUDY DESIGN This study was a multicenter prospective study on observational management of cervical intraepithelial neoplasia grade 2 (ie, repeat colposcopy, cytology, and cervical biopsy every 6 months) for up to 24 months. A total of 615 consenting women under 25 years with newly-diagnosed, biopsy-proven cervical intraepithelial neoplasia grade 2 were recruited (from 2010 to 2016) through 16 hospital-based colposcopy units in New Zealand and Australia. RESULTS At completion, 326 women had confirmed regression, 156 had persistent high-grade cervical intraepithelial neoplasia grade 2 or 3 or adenocarcinoma in situ, and 24 had unconfirmed regression (ie, first regression at the 24-month follow-up). A total of 109 women did not complete the protocol (41 because of delayed follow-up, 41 lost to follow-up, 22 elected treatment, 4 refused a biopsy, and 1 died of an unrelated cause). Confirmed regression was observed in 53% (326 of 615) of all women enrolled in the study and, when missing data were imputed, it was estimated that 64% of women (95% confidence interval, 60%-68%) would have experienced regression. Similarly, lesions regressed in 64% (326 of 506) of women who completed the observational protocol. Based on a multivariable analysis, detection of human papillomavirus 16 in a liquid-based cytology sample at the time of initial colposcopy decreased the chance of regression by 31% (risk ratio, 0.69; 95% confidence interval, 0.56-0.86; P<.001). In addition, at initial colposcopy, low-grade or normal colposcopic impression, later year of diagnosis, low-grade or normal cytology, and being a nonsmoker were all independently associated with an increased chance of regression. CONCLUSION More than half of women under 25 years with cervical intraepithelial neoplasia grade 2 will regress to cervical intraepithelial neoplasia grade 1 or normal within 24 months without destructive treatment. The absence of human papillomavirus 16 is the most important predictor of regression.
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Affiliation(s)
- Peter H Sykes
- Department of Obstetrics and Gynaecology, University of Otago, Christchurch, New Zealand; Christchurch Women's Hospital, Canterbury District Health Board, Christchurch, New Zealand.
| | - Bryony J Simcock
- Department of Obstetrics and Gynaecology, University of Otago, Christchurch, New Zealand; Christchurch Women's Hospital, Canterbury District Health Board, Christchurch, New Zealand
| | - Carrie R Innes
- Department of Obstetrics and Gynaecology, University of Otago, Christchurch, New Zealand
| | - Dianne Harker
- Department of Obstetrics and Gynaecology, University of Otago, Christchurch, New Zealand
| | - Jonathan A Williman
- Biostatistics and Computational Biology Unit, University of Otago, Christchurch, New Zealand
| | - Martin Whitehead
- Department of Pathology, University of Otago, Christchurch, New Zealand; Canterbury Health Laboratories, Christchurch Hospital, Christchurch, New Zealand
| | | | - Beverley A Lawton
- Centre for Women's Health Research, Victoria University of Wellington, Wellington, New Zealand
| | - Merilyn Hibma
- Department of Pathology, University of Otago, Dunedin, New Zealand
| | | | - Narena M Dudley
- Women's Health Service, Waikato District Health Board, Hamilton, New Zealand
| | - Simone Petrich
- Gynaecology Services, Southern District Health Board, Dunedin, New Zealand
| | - Lois Eva
- National Women's Health, Auckland District Health Board, Auckland, New Zealand
| | - Cecile Bergzoll
- National Women's Health, Auckland District Health Board, Auckland, New Zealand
| | - Jyoti Kathuria
- Counties Manukau District Health Board, Auckland, New Zealand
| | | | - Amanda Tristram
- Capital and Coast District Health Board, Wellington, New Zealand
| | - Jim Faherty
- Obstetrics and Gynaecology Services, Southland Hospital, Invercargill, New Zealand
| | - Donna Hardie
- Northland District Health Board, Whangarei, New Zealand
| | - Anne Robertson
- MidCentral District Health Board, Palmerston North, New Zealand
| | | | - Selvan Pather
- Chris O'Brien Lifehouse, Camperdown, Sydney, Australia; Central Clinical School, University of Sydney, Sydney, Australia
| | - C David Wrede
- The Royal Women's Hospital, Melbourne, Australia; Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Australia
| | - Flora Gastrell
- Nelson Marlborough District Health Board, Nelson, New Zealand
| | - Gary Fentiman
- Nelson Marlborough District Health Board, Nelson, New Zealand
| | - Michael John
- Bay of Plenty District Health Board, Tauranga, New Zealand
| | - Elaine White
- Hawke's Bay District Health Board, Hastings, New Zealand
| | | | - Lynn Sadler
- National Women's Health, Auckland District Health Board, Auckland, New Zealand; Department of Obstetrics and Gynaecology, University of Auckland, Auckland, New Zealand
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Vash-Margita A, Kobernik EK, Flagler EN, Quint EH, Dalton VK. National Trends in Cervical Cancer Screening in Adolescents. J Pediatr Adolesc Gynecol 2021; 34:717-724. [PMID: 33601068 DOI: 10.1016/j.jpag.2021.02.097] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 01/07/2021] [Accepted: 02/07/2021] [Indexed: 12/26/2022]
Abstract
STUDY OBJECTIVE To characterize patterns of cervical cancer screening among adolescents ages 14-20 years before and after the 2009 American College of Obstetrics and Gynecology recommendations. DESIGN Retrospective cohort study. SETTING National Ambulatory Medical Care Survey 2005-2016 data. PARTICIPANTS Female adolescents and young women ages 14-26 years. INTERVENTIONS Multivariable logistic regression models identified independent predictors of unindicated cervical cancer screening at office-based visits among adolescents ages 14-20 years. MAIN OUTCOME MEASURES Cervical cancer screening in women ages 14-20 and 21-26 years in 2 time periods: 2005-2008 and 2009-2016. RESULTS Between 2005 and 2016, 11,768 office visits were among adolescents ages 14-20 years. Overall, the cervical cancer screening rate for young women ages 14-20 years was 4.0%, which decreased from 4.5% to 0.4% (P = .008) during the study period. Adolescents who received cervical cancer screening during an office visit were older (18-20 years: 24.1% vs 14-17 years: 8.2%; P < .001), had a preventive care visit (preventive care: 79.7% vs other visit types: 20.3%; P < .001), and saw an obstetrician/gynecologist (obstetrician/gynecologist: 74.81% vs other specialties: 25.1%; P < .001). After adjusting for age, year, period, insurance status, region, and provider type, screening for cervical cancer was associated with living in the Southern region of the United States (adjusted odds ratio, 1.88; 95% confidence interval, 1.09-3.25; P = .02) and public insurance (adjusted odds ratio, 0.47, 95% confidence interval, 0.34-0.64; P < .001). CONCLUSION Despite recommendations, cervical cancer screening continued to occur in the adolescent population-especially older adolescents-creating unnecessary costs and potential harms. These findings show a slow uptake of guidelines nationally and the need for initiatives that encourage implementation of performance measures for providers, including ongoing provider and patient education.
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Affiliation(s)
- Alla Vash-Margita
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University School of Medicine, New Haven, Connecticut.
| | - Emily K Kobernik
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan
| | - Emily N Flagler
- The Ohio State University, Wexner Medical Center, Columbus, Ohio
| | - Elisabeth H Quint
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan
| | - Vanessa K Dalton
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan
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The Natural History of Cervical Intraepithelial Neoplasia Grades 1, 2, and 3: A Systematic Review and Meta-analysis. J Low Genit Tract Dis 2021; 25:221-231. [PMID: 34176914 DOI: 10.1097/lgt.0000000000000604] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The aim of the study was to obtain an updated overview of regression, persistence, and progression rates of conservatively managed cervical intraepithelial neoplasia grade 1 (CIN 1)/CIN 2/CIN 3. METHODS Data sources were MEDLINE, Embase, and Cochrane (January 1, 1973-April 14, 2020). Two reviewers extracted data and assessed risk of bias. To estimate outcome rates, we pooled proportions of the individual study results using random-effects meta-analysis, resulting in point estimates and corresponding 95% CIs. Heterogeneity was quantified by the I2 and τ2 measures. RESULTS Eighty-nine studies were included, 63 studies on CIN 1 (n = 6,080-8,767), 42 on CIN 2 (n = 2,909-3,830), and 7 on CIN 3 (n = 245-351). The overall regression, persistence, and progression to CIN 2 or worse and CIN 3 or worse rates for women with conservatively managed CIN 1 were 60% (95% CI = 55-65, I2 = 92%), 25% (95% CI = 20-30, I2 = 94%), 11% (95% CI = 8-13, I2 = 89%), and 2% (95% CI = 1-3, I2 = 82%), respectively. The overall regression, persistence, and progression rates for CIN 2 were 55% (95% CI = 50-60, I2 = 85%), 23% (95% CI = 19-28, I2 = 83%), and 19% (95% CI = 15-23, I2 = 88%), respectively. Finally, for CIN 3, these were 28% (95% CI = 17-41, I2 = 68%), 67% (95% CI = 36-91, I2 = 84%), and 2% (95% CI = 0-25, I2 = 95%), respectively. Cervical intraepithelial neoplasia grade 2 regression was significantly higher in women 30 years or younger and high-risk human papillomavirus-negative women (66%, 95% CI = 62-70, I2 = 76%; 94%, 95% CI = 84-99, I2 = 60%). Only 2/7,180 (0.03%) and 10/3,037 (0.3%) of the CIN 1 and CIN 2 cases progressed to cervical cancer. CONCLUSIONS Most CIN 1/CIN 2 will regress spontaneously in less than 24 months, with the highest rates in high-risk human papillomavirus-negative and young women, whereas progression to cancer is less than 0.5%. Conservative management should be considered, especially in fertile women and with expected high compliance. Given the heterogeneity in regression rates of high-grade histology, this should be classified as CIN 2 or CIN 3 to guide management.
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Dwivedi R, Kar A, Melson L, Eedarapalli P. Conservative Management of CIN2. INDIAN JOURNAL OF GYNECOLOGIC ONCOLOGY 2021. [DOI: 10.1007/s40944-021-00527-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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12
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Zarochentseva NV, Belaiya JM, Malinovskaya VV. Combined Use of Interferon Alpha-2b Drugs with Tetravalent Vaccine against Reinfection in HPV Female Patients. ELECTRONIC JOURNAL OF GENERAL MEDICINE 2020. [DOI: 10.29333/ejgm/8369] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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13
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Skorstengaard M, Lynge E, Suhr J, Napolitano G. Conservative management of women with cervical intraepithelial neoplasia grade 2 in Denmark: a cohort study. BJOG 2020; 127:729-736. [PMID: 31880054 PMCID: PMC7383715 DOI: 10.1111/1471-0528.16081] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/18/2019] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Assess the progression, persistence, and regression of cervical intraepithelial neoplasia grade 2 (CIN2) after new guidelines on conservative treatment, compared with previous practice. DESIGN Nationwide register-based cohort study. SETTING Denmark. POPULATION Women aged 18-44 years diagnosed with CIN2 on biopsy: 6721 in 2008-2011 and 6399 in 2014-2017. METHODS Register data were retrieved from before (2008-2011) and after (2014-2017) the introduction of new guidelines. Histology diagnoses at second visit were used to assess progression (CIN3+), persistence (CIN2), or regression (CIN1/normal). MAIN OUTCOME MEASURES Proportion of CIN2 by type of management. Relative risk (RR) and corresponding 95% confidence intervals (95% CIs) for progression, persistence, and regression at second visit in 2014-2017, versus 2008-2011. RESULTS The proportion of CIN2 managed conservatively increased from 29.6% in 2008-2011 to 53.3% in 2014-2017 (RR 1.81, 95% CI 1.73-1.89). Time to second visit increased by 2 months. Regression increased from 23.5 to 30.2% (RR 1.29, 95% CI 1.22-1.36), whereas persistence and progression decreased, from 42.6 to 34.9% (RR 0.82, 95% CI 0.78-0.86) and from 28.0 to 22.8% (RR 0.81, 95% CI 0.77-0.86), respectively. In 2008-2011, women managed conservatively had a regression rate of 41.8%, persistence rate of 40.9%, and progression rate of 16.6%. In 2014-2017, these rates were 46.7, 35.5, and 17.1%, respectively. CONCLUSION After implementation of the new guidelines, conservative management became more frequent, and is now used for more than half of women with CIN2. Lesion regression became more frequent, now experienced by 47% of women managed conservatively. Similar regression rates were seen in women younger and older than 30 years, suggesting that conservative management is justifiable for women of childbearing age. TWEETABLE ABSTRACT In Denmark, more than half of women with CIN2 are managed conservatively, and half of these women experience lesion regression.
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Affiliation(s)
- M Skorstengaard
- Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - E Lynge
- Nykøbing Falster Hospital, University of Copenhagen, Copenhagen, Denmark
| | - J Suhr
- Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - G Napolitano
- Department of Public Health, University of Copenhagen, Copenhagen, Denmark
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Dovnik A, Repše-Fokter A. p16/Ki-67 immunostaining in the triage of young women with LSIL, ASC-US, and ASC-H cytology. Diagn Cytopathol 2019; 48:96-97. [PMID: 31714671 DOI: 10.1002/dc.24339] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2019] [Revised: 10/02/2019] [Accepted: 10/23/2019] [Indexed: 11/08/2022]
Affiliation(s)
- Andraž Dovnik
- University Clinic for Gynaecology and Perinatology, University Medical Centre Maribor, Maribor, Slovenia
| | - Alenka Repše-Fokter
- Department for Pathology and Cytology, General Hospital Celje, Celje, Slovenia
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Klügel S, Lücke C, Mehren A, Malik E, Philipsen A, Schild-Suhren M, Müller HH. Patients with cervical intraepithelial neoplasms show different states of health-related quality of life and different coping styles depending on the choice of therapy: findings from the CIN study. Int J Womens Health 2019; 11:511-517. [PMID: 31572019 PMCID: PMC6750162 DOI: 10.2147/ijwh.s208257] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Accepted: 07/23/2019] [Indexed: 11/23/2022] Open
Abstract
Purpose To examine the effects of type of therapy (conservative therapy vs conization) on the psychosocial well-being of patients with cervical intraepithelial neoplasia grade II (CIN II) in a prospective cross-sectional study designed to simplify future choice of therapy. Patients and methods In a cross-sectional study comparing 24 CIN II patients who were treated via conservative therapy with 17 CIN II patients who were treated via conization (not randomized), we examined the association between therapy type and psychosocial well-being after the treatment. Scores on the Hospital Anxiety and Depression Scale (HADS) (prevalence of depression/anxiety), SF-12 (health-related quality of life (HRQoL)) and Brief COPE (coping mechanisms) questionnaires were compared between the two subgroups via nonparametric Mann-Whitney U-tests. Results The prevalence of depression/anxiety and mental HRQoL did not differ between patients undergoing conservative therapy and those undergoing conization but differed significantly from those of the healthy population. Regarding physical HRQoL and coping strategies, the conservative therapy subgroup achieved higher scores and better performance. Conclusion Patients with CIN II are at risk of developing depressive or anxiety symptoms. The choice of therapy seems to have an influence on physical HRQoL and coping strategies but not on depression/anxiety and mental HRQoL.
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Affiliation(s)
- Stephanie Klügel
- Department of Psychiatry and Psychotherapy, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - Caroline Lücke
- Department of Psychiatry and Psychotherapy, University of Bonn, Bonn, Germany
| | - Aylin Mehren
- Department of Psychiatry and Psychotherapy, Carl von Ossietzky University Oldenburg, Oldenburg, Germany.,Biological Psychology Lab, Department of Psychology, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - Eduard Malik
- Department of Gynecology and Obstetrics, Carl Von Ossietzky University Oldenburg, Oldenburg, Germany
| | - Alexandra Philipsen
- Department of Psychiatry and Psychotherapy, University of Bonn, Bonn, Germany
| | - Meike Schild-Suhren
- Department of Gynecology and Obstetrics, Carl Von Ossietzky University Oldenburg, Oldenburg, Germany
| | - Helge Ho Müller
- Department of Psychiatry and Psychotherapy, Carl von Ossietzky University Oldenburg, Oldenburg, Germany.,Department of Psychiatry and Psychotherapy, University of Bonn, Bonn, Germany
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