EVIDENCE-BASED ANSWER
Excision or ablation of the transformation zone are equally effective for treating an initial diagnosis of cervical intraepithelial neoplasia (CIN) grades 2 or 3 in women with a satisfactory colposcopy and no suggestion of microinvasive or invasive disease (strength of recommendation [SOR]: A, based on randomized controlled trials [RCTs]).
Laser or loop electrosurgical excision procedure (LEEP) are the preferred treatment methods for recurrent CIN 2 and CIN 3 (SOR: B, based on clinical trials without randomization).
For women with an unsatisfactory colposcopy or suspicion of invasive disease, a diagnostic excisional procedure is recommended (SOR: C, based on consensus guidelines).
Observation or deferred treatment may be acceptable for CIN 2 in adolescents with satisfactory colposcopy and negative endocervical sampling (SOR: C, based on consensus guidelines).
Limit diagnostic excisional procedures in pregnancy to cases where suspicion of invasive cancer is high (SOR: C, based on consensus guidelines).
Clinical commentary
LEEP provides tissue for examination and a short recovery time
Timothy Huber, MD
Oroville, Calif
Close follow-up of observable disease and aggressive intervention continue to drive down the number of cervical cancer deaths each year.
It remains to be seen what the true effect of the HPV vaccine will be, although the presumed result will be a dramatic decline in high-grade lesions (CIN 2 and 3), carcinoma in situ, and invasive disease.
When intervention is necessary, my preferred method is LEEP because it provides tissue for examination and the recovery time is short.
Cryotherapy is an acceptable alternative, but the 4 to 8 weeks of leukorrhea and the lack of a tissue diagnosis often make it a less desirable option for patient and physician.
Evidence summary
Morbidity profile makes LEEP appear best
Similar efficacy. All 7 available surgical techniques were found to have similar efficacy, in a 2005 Cochrane review of 28 randomized trials.1 Resolution of CIN 2 or 3 lesions was 77% to 98%, using knife cone biopsy, laser conization, loop excision, laser ablation, cryotherapy, or 2 techniques not used commonly in the US, cold coagulation and radical diathermy. Surgical techniques were tested in various combinations, but no trial compared all of the techniques with one another. Most studies were underpowered, limiting the results.
Pap test: Good, but underused We’ve made great progress. What was the 2nd leading cancer in US women in incidence and mortality is now 11th in incidence and 13th in mortality. Yet, even with perfect attendance at annual screenings, women still get cervical cancer. And many still do not have screenings—they account for about half of all cervical cancers. The Pap, as good as it is, has flaws. The test is subjective, and sensitivity varies from lab to lab. 9
Dr. J. Thomas cox, university of California. Member, American Cancer society Cervical guidelines Committee, the 2002 Bethesda Workshop; ACS HPV vaccine Advisory Committee; author, ASCCP guidelines Committee
Each year in the united states approximately 500,000 women are diagnosed with high-grade cervical cancer precursor lesions, CIN 2 and CIN III.4 If left untreated, 22% of CIN 2 lesions progress to carcinoma in situ or invasive cervical cancer, 43% regress, and 35% persist at the same level. Fourteen percent of untreated CIN 3 lesions progress, 32% regress, and 56% persist at the same level.
HPV vaccine: Won’t replace prevention or protection Although an effective vaccine is a major advance in the prevention of genital HPV and cervical cancer, it will not replace other prevention strategies, such as cervical cancer screening for women or protective sexual behaviors. Women should continue to get Pap tests as a safeguard against cervical cancer.
Dr. Anne Schuchat, Director, CDC National Center for Immunization and respiratory Diseases, June 29, 2006 press release (www.cdc.gov/od/oc/media/pressrel/r060629.htm)
The HPV vaccine (Gardasil) that prevents the development of lesions caused by HPV types 6, 11, 16, and 18, was approved by the us Food and Drug Administration in June 2006 for use in females 9 to 26 years oof age. Shortly after, the Advisory Committee on Immunization Practices issued guidelines, stating that vaccination is recommended for all women <26 years of age. (www.cdc.gov/vaccines/recs/schedules/adult-schedule.htm).
HPV testing: Adjunct to cytology The United States is falling behind other countries in assessing how best to utilize HPV testing for screening. Ongoing trials in The Netherlands, Italy, United Kingdom, Canada, and Finland are evaluating whether cytology can be replaced by HPV DNA testing for screening. Currently, HPV testing is only approved as an adjunct to cytology for cervical cancer screening in the United States, and no similar trials are underway. 10
Dr. Thomas C. Wright, Columbia university. Author, 2001 Consensus guidelines on Managing Women with Cytological and Histological Abnormalities, the 2004 Interim guidance for use of HPV DNA testing for Primary screening, and the 2001 Bethesda system