Cervical lesions – when to treat and when to watch and wait

By Jane Lewis
Most cervical intraepithelial neoplasia grade 2 (CIN2) lesions, particularly in women under 30 years of age, regress spontaneously or remain unchanged, new research published in the BMJ suggests.

‘Active surveillance of CIN2 rather than immediate intervention is justified, especially among younger women,’ the researchers concluded.

Commenting on the study and its implications, Professor Johnathan Carter, Head of Gynaecological Oncology at Chris O’Brien Lifehouse, Royal Prince Alfred Hospital, and Professor of Gynaecological Oncology at The University of Sydney, said cervical cancer rates had fallen dramatically in recent years, partly because of a national co-ordinated approach to screening.

‘HPV vaccination and the renewed cervical cancer screening program based on partial HPV genotyping is predicted to further dramatically reduce cervical cancer in this country. However, in young women, particularly those under 25 years, screening and treatment of precancer lesions known as CIN has not had an impact on the incidence of invasive cancer,’ he told Medicine Today.

The systematic review and meta-analysis included 36 studies involving 3160 non-pregnant women. It found that at 24months biopsy-proven CIN2 regressed in 50% of women kept under surveillance, persisted in 32% and progressed to CIN3 or worse in the remaining 18%. Subgroup analysis showed that outcomes were more favourable in women aged under 30years (n=1069), with corresponding rates of 60%, 23% and 11%, respectively. The rate of noncompliance during follow up in prospective studies was 8% at 24 months.

‘Knowledge of the rates of regression from CIN2 are reassuring but they must be presented in a meaningful way alongside clear information about the effects of both surveillance and treatment, so women can make fully informed choices,’ cautioned the author of an editorial published with the study.

According to Professor Carter, most clinicians involved in the colposcopic assessment of smear-detected abnormalities ‘have recognised that overtreatment may have occurred in the past for CIN1 and likely CIN2 lesions in younger patients.’ The current study ‘adds to the literature and our confidence in discussing with our patients, that in young women, a decision to adopt a conservative approach to CIN2, for most, is reasonable.’

‘Caution needs to be exercised that this approach is not right for all, as a significant progression rate exists, particularly in woman older than 30,’ Professor Carter added.
BMJ 2018; 360: k499; doi: 10.1136/bmj.k499.
BMJ 2018; 360: k771; doi: 10.1136/bmj.k771.