Treating CIN 2 in Young Women
Abstract & Commentary
By Frank W. Ling, MD, Clinical Professor, Departments of Obstetrics and Gynecology, Vanderbilt University School of Medicine, and Meharry Medical College, Nashville, is Associate Editor for OB/GYN Clinical Alert.
Dr. Ling reports no financial relationships relevant to this field of study.
Synopsis: Spontaneous regression does occur in women with CIN 2 in this age group.
Source: McAllum B, et al. Is the treatment of CIN 2 always necessary in women under 25 years old? Am J Obstet Gynecol 2011;205:478.e1-7.
In this retrospective study of young women performed in New Zealand between 2005 and 2009, 57% of 452 patients with biopsy-proven cervical intraepithelial neoplasia (CIN) 2 were treated immediately whereas 157 (35%) met the criteria for conservative management. Of these, 62% showed spontaneous regression based upon a median of 8 months follow-up. Persistent disease was identified in 38%. None of the patients had their dysplasia progress to cancer.
Commentary
My, my, how times have changed. In the remote past (i.e., during my residency in the late 1970s), we were collectively on a "seek and destroy" mission regarding dysplasia. After all, we wanted to prevent cervical cancer, and the best way to prevent dysplasia from progressing to invasive disease was to treat precursor lesions. We had the relatively new tool of colposcopy, allowing us to perform directed biopsies and, thereby, reducing the need for more invasive cold-knife conizations. Be it conization, cryosurgery, and even hysterectomy, ridding the woman of her dysplasia was on the top of our priority list. Admittedly, we didn't understand the role of human papillomavirus, so our world view was a bit skewed.
Fast forward a couple of decades, and our improved understanding of pathophysiology of the disease allows us to chill a bit. We were able to raise the age at which young women were counseled to be initially screened. We also became far more "hands off" in regard to treating dysplasia in adolescents, recognizing that the body's immune system would resolve cases of CIN 1 which, in the past, were treated with ablation, cryosurgery, and/or excision.
As science progresses, the potential need for us to intervene in many cases of CIN may be decreasing. I say "may" because, as these authors correctly point out, the safety of this approach needs to be validated with larger study. Within this small retrospective group of patients, even though no patients progressed to cancer, there were significant findings in the "immediately treated" group. One patient had microinvasive disease while two patients had adenocarcinoma in situ.
These data emphasize why patient care should not be driven by the outcomes of retrospective studies. The interpretation of data is fraught with a number of limitations. For instance, in this study, definitions were not controlled; conservative management was not outlined; treatment intervals varied; the rationale for immediate treatment or delayed management was not recorded; there was no long-term follow-up plan described; and there was no confirmation of histologic diagnoses, i.e., there was not a second pathologist's interpretation. Perhaps the most telling of the shortcomings, and maybe even a fatal flaw of the study, was the way in which regression of disease was defined. One-third (30.6%) of the patients were reported to show regression of CIN 2 — based only on normalizing of the pap smear and colposcopic appareance. Since both techniques have well-documented false-negative rates, the clinician would do well to cast a critical eye.
On a more positive note, since median follow-up was only 8 months, there are potentially more friendly factors to this management plan. For example, some cases of regression were seen at 18 to 24 months, suggesting that longer follow-up could bring even higher regression rates.
The prospective data collection hopefully will include data points that standardize time intervals, histologic definitions, human papillomavirus typing, and viral load as well as demographic information.
As always, our desire to "first do no harm" is a consideration. If we don't have to intervene on dysplasia and feel comfortable that even CIN 2 can be watched without jeopardizing a woman's health, that's a good thing. That willingness to keep our hands off must be based on sound scientific information, most of which still remains to be identified. For now, each young patient (under 25 years of age as defined in this article) presents a therapeutic challenge for both patient and physician to weigh the alternatives. Today, there appear to be more options for women in this age group to consider. We should be willing to partner with each one in deciding the path that makes the most sense for her. Even though this article is not "ideal," it will help me with how "I deal" with young patients with CIN 2.
In this retrospective study of young women performed in New Zealand between 2005 and 2009, 57% of 452 patients with biopsy-proven cervical intraepithelial neoplasia (CIN) 2 were treated immediately whereas 157 (35%) met the criteria for conservative management.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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