See-and-Treat for Cervical Intraepithelial Lesions
Abstract & Commentary
By Rebecca H. Allen, MD, MPH
Assistant Professor, Department of Obstetrics and Gynecology, Warren Alpert Medical School of Brown University, Women and Infants Hospital, Providence, RI
Dr. Allen reports no financial relationships relevant to this field of study.
Synopsis: In this retrospective, cohort study, a see-and-treat protocol resulted in only a 4.5% overtreatment rate, as long as the patient had both a high-grade referring pap smear and high-grade colposcopic impression.
Source: Bosgraaf RP, et al. Overtreatment in a see-and-treat approach to cervical intraepithelial lesions. Obstet Gynecol 2013;121:1209-1216.
This is a large, retrospective, cohort study of 3192 women who were referred for colposcopy at one medical center in the Netherlands and underwent a see-and-treat protocol. With all subjects entered into an internal database from 1981 to 2010, the authors were able to examine the referring Pap smear result, colposcopic impression, and final histopathologic interpretation on the large loop electrical excision of the transformation zone (LLETZ) specimen for this population. The Dutch cervical cancer screening program offers Pap smears every 5 years to women aged 30-60. This study also included women who had Pap smears for "cervical complaints" or outside of the population screening program. From the study description, women with high-grade cervical squamous intraepithelial lesion (HSIL) or worse and persistent low grade with positive high-risk HPV (HPV triage started in 2008) were referred for colposcopic examination. When the Pap smear result, colposcopic impression, or both were suggestive of high-grade cervical intraepithelial neoplasia (CIN 2 or worse), immediate treatment followed. Overtreatment was defined as treatment for no CIN or CIN 1 on final histopathology results.
The authors found that the referral Pap smear was low-grade in 20.2% (95% confidence interval [CI], 18.8-21.7) of cases and high-grade in 79.3% (CI, 77.8-80.7) of cases. Histologic examination of the 3192 specimens revealed 579 cases (18.1%; CI, 16.7-19.5) with no CIN or low-grade CIN, 2613 cases (81.9%; CI, 80.6-83.2) with CIN 2 or CIN 3, and 177 cases (5.5%; CI, 4.8-6.4) with cancer. Overall, the over-treatment rate was 18.1%. For women with a low-grade Pap smear and low-grade colposcopic impression, the rate was 73.4%. A low-grade Pap smear and high-grade colposcopic impression resulted in an overtreatment rate of 29.2%. Equally, a high-grade Pap smear with a low-grade impression resulted in an over-treatment rate of 28.6%. However, the overtreatment rate for women with both a high-grade Pap smear and high-grade colposcopic impression was only 4.5%. Older women had higher rates of overtreatment compared to women younger than 30 (odds ratio [OR], 1.77; 1.31-2.40 for age 40-49 years, and OR, 3.39: 2.31-4.99 for age 50 years and older).
This study took advantage of a single-institution database to report a large case series of the see-and-treat treatment protocol for CIN. Certain factors of this study are unique to the Netherlands. Namely, their cervical cancer screening program includes only women aged 30-60 years and only screens them every 5 years. This was and is different than other countries that typically screen a broader population at shorter intervals, which may result in higher over-treatment rates. In addition, the use of HPV testing for triage to colposcopy is not yet reflected in this study. The unique finding of this study was lower over-treatment rates for younger women. This likely reflects a more conservative approach by the colposcopist among women who may be at risk for preterm birth after LLETZ.
The see-and-treat approach to colposcopy has been studied before and rates vary in the literature depending on the population studied.1In the United States, it may be practiced less frequently due to the medico-legal climate. Indeed, in our colposcopy clinic, we usually only perform the see-and-treat approach for high-grade lesions in women who are unlikely to return for a follow-up visit. The advantage of see-and-treat protocols are patient convenience because diagnosis and treatment are combined. In addition, the diagnosis may be superior to punch biopsies that could miss a portion of the lesion or underestimate its severity. The disadvantage, of course, is the risk of overtreatment.1This is especially true depending on the skill of the colposcopist. However, as this study shows, overtreatment can be kept to a minimum as long as the patient has a high-grade referring pap smear and a high-grade colposcopic impression.
The American Society of Colposcopy and Cervical Pathology (ASCCP) 2012 guidelines do not recommend a see-and-treat protocol for women age 21-24 years with HSIL.2For women age 25 and older, immediate loop electrosurgical excision is acceptable for women with a high-grade pap smear (except in pregnancy) or colposcopy may be performed. Given that 60% of women with HSIL will have CIN 2 or worse, the ASCCP states that "this justifies immediate excision of the transformation zone for many women, especially those who are at risk for loss to follow-up or who have completed childbearing." On a humbling note, it is important to remember that studies show that the sensitivity of colposcopy for detecting CIN 2 or worse is lower than previously thought.3It is now recommended that multiple biopsies be performed at colposcopy rather than just taking one biopsy of the worst-appearing lesion.4Therefore, our motto in colposcopy clinic now is: "If it is white, take a bite."
- Cárdenas-Turanzas M, et al. See-and-treat strategy for diagnosis and management of cervical squamous intraepithelial lesions. Lancet Oncol 2005;6:43-50.
- Massad LS, et al. 2012 updated consensus guidelines for the management of abnormal cervical cancer screening tests and cancer precursors. J Low Genit Tract Dis 2013;17:S1-S27.
- Pretorius RG, et al. Colposcopically directed biopsy, random cervical biopsy, and endocervical curettage in the diagnosis of cervical intraepithelial neoplasia II or worse. Am J Obstet Gynecol 2004;191:430-434.
- Gage JC, et al. Number of cervical biopsies and sensitivity of colposcopy. Obstet Gynecol 2006;108:264-272.