Management of low-grade cervical lesions in young women

Abstract

C ervical infection with high-risk (oncogenic) genotypes of human papillomavirus (HPV) is a necessary early event in cervical carcinogenesis; however, cervical cancer will not inevitably develop in women with such an infection. Therefore, high-risk HPV infection alone is not considered a sufficient cause of cervical cancer. Now that HPV testing is widely available, it is important for clinicians to understand the natural history of cervical intraepithelial neoplasia (CIN) and use this information to guide their recommendations to women regarding cervical cancer screening.CIN represents the spectrum of pre-invasive lesions that lie along the pathway from HPV infection to cervical cancer ( Fig. 1).1 The natural history of its cytologic counterpart, the squamous intraepithelial lesion (SIL), and of HPV infection has been shown to vary with the age of the affected woman (Fig. 2). [2][3][4][5][6][7] In particular, the development, persistence, regression and progression of low-grade SIL (LSIL) seem to demonstrate the greatest variability as a function of age. [8][9][10][11] Some investigators have stressed that adolescent females may be at increased risk of SIL because of differences in the biologic maturity of the immune system and cervix. In addition, the cervical ectopy and metaplastic changes in the transformation zone from puberty onward may increase the susceptibility of the cervix to HPV infection in the adolescent.12 These biologic changes in the cervix continue throughout a woman's lifetime, and thus it is difficult to speculate at what age these changes will alter the course of HPV infection or the behaviour of SIL. Most of the studies mentioned earlier have shown differences between "younger" and "older" women, 2-11 but the the marked heterogeneity across investigations does not permit a simple interpretation of a process that is more likely to be gradual rather than a blunt change in risk patterns.In the context of this commentary and our recommendations for HPV screening, we have defined "young" women as those aged 24 years or less. We chose this cut-off because the incidence of invasive cervical cancer is negligible among females 15-19 years old and very low (1.7 per 100 000 annually) among those 20-24 years old.13 In addition, studies involving females aged 13-22 years and those involving university students, described below, have shown relatively similar results in terms of the natural history of HPV cervical infection, LSIL behaviour and patterns of sexual activity.In developing guidelines for screening women aged 24 years or less and for following those with abnormal test results, we had to examine the natural history of HPV infection. The prevalence of cervicovaginal high-risk HPV in-

Docetaxel and irinotecan in recurrent or metastatic head and neck cancer

“…We demonstrate a strong association between patient age and number of HPV genotypes for all disease categories from <CIN2 to CIN3; however, disease category itself showed no association with number of genotypes. Prevalence and natural history studies on HPV infection have demonstrated that the peak age of HPV infections is between 20 and 25 years, related to the highest level of sexual activity and associated risk of exposure to HPV infections 25–30. In agreement with that, the average age of women with 2 or more HPV infections in our study was 30 or younger in the respective disease categories (except for women with cancer).…”

Not all guidelines are created equal

“…I have read with interest the recent editorial criticizing the Canadian Diabetes Association (CDA) Clinical Practice Guidelines (CPGs). 1 I am one of the few physicians who have served on both clinical practice guideline groups and drug review panels (in my case the CDA and Canadian Hypertension Education Program [CHEP] guideline groups and the Ontario Drug Programs Branch Pharmacoeconomic Review Committee respectively). The mandate of guideline groups and drug review panels differ so extensively that one should expect that their respective conclusions will often differ.…”

“…DOI:10.1503/cmaj.1050268 A recent CMAJ editorial drew attention to the potential for conflicts of interest to influence the development of clinical guidelines. 1 While we share your concerns, we wanted to register our disagreement with the CMAJ editorialist's conclusion that the only way to reduce potential conflicts of interest is to mandate that guideline panels consist only of non-experts. We believe strongly that clinical expertise in a particular area is necessary to properly interpret evidence related to that area.…”

Large loop excision of transformation zone procedures used in the management of cytological abnormalities of the cervix

“…Based on the 1994 National Health and Medical Research Council (NHMRC) guidelines, women with persistently abnormal Papanicolaou (PAP) smears have been treated surgically with removal of the abnormal area 1,2 . More recent knowledge of the natural history and causation of abnormal smears has changed the way these are managed in young women 3,4 . Human papilloma virus (HPV) causes infection in the cervix, which results in changes in the appearance of the cells and of the cervix.…”

“…Human papilloma virus (HPV) causes infection in the cervix, which results in changes in the appearance of the cells and of the cervix. Studies have shown that 40–70% of these changes are transient and will resolve in time, especially in younger women 4–6 . The 2005 NHMRC guidelines were developed to take into account that many low‐grade lesions will regress and do not require surgical treatment 3 .…”