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CME Released: 11/8/2004
Valid for credit through: 11/8/2005
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Nov. 8, 2004 -- Colposcopy is unjustified in screening young women for cervical cancer because most low-grade squamous intraepithelial lesions (LSILs) regress, according to the results of a longitudinal study published in the Nov. 6 issue of The Lancet.
"Our data suggest that most LSILs will regress spontaneously in immunocompetent young women, lending support to a practice of monitoring these cytological lesions," lead author Anna-Barbara Moscicki, MD, from the University of California in San Francisco, says in a news release.
Human papillomavirus (HPV) infections occur in up to 70% of adolescent and young women who are sexually active, and about one quarter of these patients develop LSILs after an HPV infection. About 20% to 40% of LSILs progress to high-grade squamous intraepithelial lesions (HSILs), and about 50% to 60% regress spontaneously.
"Most natural history studies of LSIL, however, have focused on women in their mid-20s to 40s who might represent a population with HPV infections that are already persistent," the authors write.
In this study, 899 female adolescents aged 13 to 22 years with HPV infections were examined every four months with cytology, colposcopy, and HPV DNA status. Of the 900 women, 187 developed LSILs and were eligible for study. Regression was defined as at least three consecutive normal Papanicolaou tests.
Median follow-up from the time of first LSIL diagnosis was 61 months (interquartile range [IQR], 34 to 80), and median time patients had been sexually active at diagnosis was 3.2 years (IQR, 2.6 to 6.5). For the entire cohort, the probability of regression was 61% (95% confidence interval [CI], 53 to 70) at 12 months and 91% (95% CI, 84 to 99) at 36 months of follow-up.
There were no associations between LSIL regression and HPV status at baseline, sexual behavior, contraceptive use, substance or cigarette use, incident sexually transmitted infection, or biopsy. Based on multivariate analysis, only HPV status at the current visit was associated with rate of regression, whether infection was caused by one or more viral types (relative hazard, 0.3 [95% CI, 0.21 to 0.42] and 0.14 [95% CI, 0.08 to 0.25], respectively).
"Follow-up HPV status was a strong predictor of regression, but HPV status at time of LSIL diagnosis was not," Dr. Moscicki says. "The finding that persistence of multiple HPV types slows rates of regression should be examined more closely."
Study limitations were the exclusion of women who were shown to have HSILs on histology at their baseline LSIL visit, difficulty in generalizing these findings to women attending inner-city clinics with high rates of sexually transmitted infections and low rates of compliance, use of three cytology results per year restricting comparison to current clinical practice, and limited examination of factors predictive of regression because few women had persistent LSILs.
The authors report no conflict of interest. The National Cancer Institute, National Institutes of Health, Maternal, and Child Health Bureau Training Grant, the Cigarette and Tobacco Surtax Fund of the State of California, and the AIDS Clinical Research Center of the University of California, San Francisco, supported this study.
In an accompanying commentary, Anne Szarewski, MD, and Peter Sasieni, PhD, from Cancer Research U.K., suggest that LSILs are not only common, but also "essentially meaningless" in young women. The authors point out that there is considerable anxiety and psychosexual morbidity associated with cervical screening and colposcopy.
"If this is the case in general, how much more so in young women? How might this affect their future emotional and sexual development?" the authors write. "Since there is no point in treating LSIL in young women, we should reflect on the basic tenet of medicine: at least do no harm. We see absolutely no role for colposcopy in adolescents as part of routine management."
The department using these editorialists has received a research grant from Digene. Dr. Sasieni receives a research grant from the National Health Service Cervical Screening Programme in England, and Dr. Szarewski is starting an HPV-vaccine trial of women aged 15 to 25 years sponsored by GlaxoSmithKline.
Lancet. 2004;364:1678-1683
