Management of women with mild and moderate cervical dyskaryosis

Flannelly, Grainne; Anderson, David J.; Kitchener, Henry C; Mann, EvelynM.F.; Campbell, Marion K; Fisher, Peter; Walker, F.; Templeton, Allan

doi:10.1136/bmj.308.6941.1399

Cited by 127 publications

(99 citation statements)

References 18 publications

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“…The biology of the various CIN grades vary, however, with the majority of CIN 1 lesions regressing without treatment (Nasiell et al, 1986;Montz et al, 1992;Flannelly et al, 1994), while CIN 2 and 3 lesions have a higher risk of persisting or progressing to invasive cancer. (Luthra et al, 1987;Murthy et al, 1996) Typically, most patients with CIN 2 or 3 lesions are promptly treated with ablation of the lesion or conisation of the cervix to prevent invasive disease.…”

Section: Discussionmentioning

confidence: 99%

HPV infection and number of lifetime sexual partners are strong predictors for ‘natural’ regression of CIN 2 and 3

et al. 2003

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The aim of this paper was to evaluate the factors that predict regression of untreated CIN 2 and 3. A total of 93 patients with colposcopic persistent CIN 2 and 3 lesions after biopsy were followed for 6 months. Human papillomavirus (HPV) types were determined by polymerase chain reaction at enrolment. We analysed the biologic and demographic predictors of natural regression using univariate and multivariate methods. The overall regression rate was 52% (48 out of 93), including 58% (22 out of 38) of CIN 2 and 47% (26 out of 55) of CIN 3 lesions (P ¼ 0.31 for difference). Human papillomavirus was detected in 84% (78 out of 93) of patients. In univariate analysis, 80% (12 out of 15) of lesions without HPV regressed compared to 46% (36 out of 78) of lesions with HPV infection (P ¼ 0.016). Women without HPV and those who had a resolution of HPV had a four-fold higher chance of regression than those with persistent HPV (relative odds ¼ 3.5, 95% CI ¼ 1. 4 -8.6). Women with five or fewer lifetime sexual partners had higher rates of regression than women with more than five partners (P ¼ 0.003). In multivariate analysis, HPV status and number of sexual partners remained as significant independent predictors of regression. In conclusion, HPV status and number of lifetime sexual partners were strongly predictive of regression of untreated CIN 2 and 3. Cervical cancer continues to be the most deadly female cancer in developing countries. (Ponten et al, 1995) The dramatic decrease in mortality rates in Western countries is attributed to cervical cancer screening. (Harlan et al, 1991) The successful implementation of these screening programmes is based on the underlying model that cervical intraepithelial lesions (CIN) behave as progressive stages of a biologic continuum towards the development of invasive cervical cancer (Richart and Barron, 1969;Campion et al, 1986).Genital human papillomavirus (HPV) infection has been established as the critical step in the development of most cervical cancers (IARC, 1995). The cervical carcinogenesis model involves HPV infection, intraepithelial neoplasia, and invasion. Human papillomavirus infection is found in over 40% of young, sexually active, college students (Ho et al, 1998). However, the incidence of cervical cancer is uncommon compared to the lifetime cumulative incidence of viral infection. Thus, there must be essential biological mechanisms and associated risk factors other than HPV infection that are responsible for the progression of precursor lesions to invasive cervical cancer (Schiffman & Brinton, 1995).The aetiology and risk factors involved with cervical carcinogenesis are amenable to study as invasive cervical cancer typically arises after many years from a morphologically defined precancerous lesion. However, since untreated high-grade lesions can progress to invasive cancer, most women with CIN 2 or 3 are treated promptly. Accordingly, there are few reports on the natural history of high-grade dysplasia. On the other hand, not all CIN lesions progress to invasive canc...

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Section: Discussionmentioning

confidence: 99%

HPV infection and number of lifetime sexual partners are strong predictors for ‘natural’ regression of CIN 2 and 3

et al. 2003

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“…Also, in ALTS it's concluded that follow-up with pap smear tests would be the best choice for ASCUS patients (17) . Flannelly et al randomized patients with low grade abnormal cytology to follow-up with smear test and immediate colposcopy arms (18) . The frequency of CIN II or worse was somewhat higher in the group offered immediate colposcopy than in the follow-up patients.…”

Section: Discussionmentioning

confidence: 99%

The value of colposcopy, high risk HPV-DNA and histopathologic examination in the management of abnormal Pap smear results

Bayramov¹,

Şükür²,

Tezcan³

2011

J Turk Soc Obstet Gynecol

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“…Over 200,000 smears with borderline change or mild dyskaryosis are identified in England each year, comprising 4.1% and 2.4% of all smears, respectively. 1 Two prospective randomised clinical trials of women with mild dyskaryosis 2,3 have demonstrated that cytological regression only occurred in 25% and concluded that colposcopy would be a more effective strategy than cytological surveillance. Colposcopy detected more cases of CIN and the cost per case detected was cheaper than cytological regression.…”

Section: Introductionmentioning

confidence: 99%

A randomised controlled trial of cytological surveillance versus patient choice between surveillance and colposcopy in managing mildly abnormal cervical smears

Kitchener

Burns

Nelson

et al. 2003

BJOG

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Objective To determine whether choice of colposcopy or six month cytological surveillance would be beneficial to women with mildly abnormal smears when compared with the national policy of six months surveillance in terms of psychological morbidity. Design A randomised trial based on the Zelen design. Setting A hospital‐based research clinic. Population Four hundred and seventy‐six women who had had a recurrent borderline or mildly dyskaryotic smear on routine cervical screening in primary care. Methods Women were randomised either to six months cytological surveillance or to make a choice between that or colposcopy and were followed up for 1 year. Main outcome measures The primary outcome measure was caseness (score ≥4) on the General Health Questionnaire at 12 months follow up. Other measures were the Spielberger State and Trait scores, default rates and cytology/colposcopy outcomes. Results There was no significant difference between the arms for General Health Questionnaire (GHQ) scores and Spielberger State and Trait at 12 months. There was a significant reduction in psychometric morbidity between baseline and 12 months in both arms. Overall rates of default from the protocol were the same in both arms, but default that led to uncertain ascertainment of cervical pathology was greater in the no‐choice arm. Conclusions This trial indicates that having choice did not impact favourably or harmfully on anxiety or feelings of wellbeing. If a patient is anxious, allowing the patient to choose immediate colposcopy may be preferable because it will improve ascertainment of underlying disease in a group who are more likely to default.

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Management of women with mild and moderate cervical dyskaryosis

Cited by 127 publications

References 18 publications

HPV infection and number of lifetime sexual partners are strong predictors for ‘natural’ regression of CIN 2 and 3

HPV infection and number of lifetime sexual partners are strong predictors for ‘natural’ regression of CIN 2 and 3

The value of colposcopy, high risk HPV-DNA and histopathologic examination in the management of abnormal Pap smear results

A randomised controlled trial of cytological surveillance versus patient choice between surveillance and colposcopy in managing mildly abnormal cervical smears

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