Initial observation of CIN2 does not appear to reduce quality of life in women under 25 years of age

"I feel reassured, but there is no guarantee." How do women with a future childbearing desire respond to active surveillance of cervical intraepithelial neoplasia grade 2? A qualitative study

INTRODUCTION

In Denmark, women with a future childbearing desire diagnosed with cervical intraepithelial neoplasia grade 2 (CIN2) are recommended active surveillance instead of excisional treatment. However, we have limited and contradictory knowledge about how active surveillance of CIN2 may affect women emotionally. The aim of this study was to explore thoughts and emotional responses in women undergoing active surveillance of CIN2 and to explore how active surveillance may affect women's future childbearing desire.

MATERIAL AND METHODS

This qualitative study was conducted in the gynecological outpatient clinic, the Department of Obstetrics and Gynecology, Gødstrup Hospital, Denmark. Women of childbearing age undergoing active surveillance with colposcopy, biopsy and smear every 6 months due to CIN2 were eligible for enrollment. In-depth semi-structured interviews were conducted. The interviews were audiotaped and transcribed verbatim. A thematic analysis was performed using a phenomenological approach.

RESULTS

A total of 20 women were included. All women experienced nervousness and anxiety when they were diagnosed with CIN2 initially. Their main concern was whether they had cancer. Most women carried on with their everyday lives with only minor occasional worries about CIN2, often prompted just before check-up. However, some women were particularly nervous and found the period between check-ups frustrating and challenging. Women did not want to postpone their plans for pregnancy because of CIN2, but experienced the worries and check-ups associated with active surveillance as disruptive elements in their family planning. Women preparing for fertility treatment had their startup unnecessarily delayed due to active surveillance of CIN2, as clinical guidelines were inconsistent across subspecialties. Various factors influenced women's emotional well-being: life circumstances, information needs, and mental and physical discomfort during colposcopic examination.

CONCLUSIONS

Women felt that worries and check-ups due to active surveillance of CIN2 were disrupting elements in their family planning, although they did not affect their every-day life. Some women, however, were particularly anxious, demonstrating the importance of including women's experiences and preferences in clinical counseling. The fact that fertility treatment was delayed due inconsistent guidelines across subspecialties, suggests a need for a revision of current guidelines.

Known Benefits and Unknown Risks of Active Surveillance of Cervical Intraepithelial Neoplasia Grade 2

Cervical intraepithelial neoplasia grade 2 (CIN 2) is an equivocal diagnosis with high interobserver variation. Owing to high regression rates of 50%, many countries recommend active surveillance of CIN 2, especially in women younger than age 25-30 years, where regression rates are even higher (ie, 60%). Additionally, excisional treatment is associated with increased risk of reproductive harm, particularly preterm birth. Active surveillance typically consists of semi-annual follow-up visits for up to 2 years, including colposcopy and either cytology, testing for human papillomavirus, or both. Excisional treatment is recommended for progression or persistent disease after 2 years. Because active surveillance in younger women is relatively new, knowledge on subsequent risk of cervical cancer is limited. Considering human papillomavirus latency, women undergoing active surveillance might be at higher risk of cervical cancer than women undergoing excisional treatment. Furthermore, there are limited data describing preferences of women for the management of CIN 2, and it is also unclear how active surveillance may affect planning for future pregnancy. In this context, biomarkers for risk stratification of CIN 2 into either high or low probability of progression would allow for targeted treatment. Currently, immunohistochemical staining for p16 is used to clarify the histologic diagnosis, but whether it or other biomarkers can be used for risk-stratification in clinical management of women with CIN 2 remains unknown. In conclusion, active surveillance of CIN 2 needs further investigation, including understanding the long-term cervical cancer risk and evaluation of markers that may enable risk stratification of CIN 2.

Conservative management of women with cervical intraepithelial neoplasia grade 2 in Denmark: a cohort study

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.

Justifying conservative management of CIN2 in women younger than 25 years - A population-based study

OBJECTIVE

In 2012, the joint clinical practice guideline from the Society of Obstetricians and Gynaecologists of Canada (SOGC) changed from immediate treatment to a more conservative management of Cervical Intraepithelial Neoplasia (CIN) grade 2 in young women. In this study, the outcomes before and after this management change were reviewed in Nova Scotia, Canada.

METHODS

A retrospective population-based cohort study was performed among women younger than 25 years with biopsy-proven CIN2, who were diagnosed in one of the colposcopy clinics in Nova Scotia between 2010 and 2014. Regression and progression rates were compared pre- and post-guideline changes.

RESULTS

Of the 636 women included in the study, 286 women were diagnosed with CIN2 before and 350 women after the management in Nova Scotia was changed. After implementation of the 2012 guidelines patients were more likely to receive conservative management (78.6% versus 44.1%; p < 0.001); which differs from the patients who underwent treatment during follow-up prior to the change in guidelines (73.4% versus 38.9%; p < 0.001). Regression occurred in 73.1% of all women, but women seen in the post-guideline change period had a higher regression rate and lower progression rate (p < 0.05). Histologic results from treatment specimen did not show a significant difference in low-grade or high-grade lesions before or after the guideline had been changed (p = 0.59).

CONCLUSION

Conservative management seems a safe and justified approach for women younger than 25 years with CIN2.