Active Monitoring vs. Surgery for Moderate Cervical Lesions

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Active Monitoring vs. Surgery for Moderate Cervical Lesions: Long-term Cancer Risk Revealed

Active Monitoring vs. Surgery for Moderate Cervical Lesions: Long-term Cancer Risk Revealed

Moderate cervical lesions and the possibility of avoiding surgery?

Cervical intraepithelial neoplasia (CIN) is categorized into CIN1, CIN2, and CIN3. CIN2 is considered a high-grade intraepithelial neoplasia or a precursor to cervical cancer. If left untreated, CIN2 may progress to cancer. The commonly employed clinical method for treating CIN2 is Large Loop Excision of the Transformation Zone (LLETZ).

However, numerous studies have suggested a high probability of spontaneous regression for CIN2 (50% to 60% within two years). This indicates a significant risk of overtreatment if all CIN2 patients undergo LLETZ treatment.

Of particular concern is the association between LLETZ and an increased risk of premature birth. Consequently, many countries have adopted active monitoring as a disease management option for young CIN2 patients.

Nevertheless, the impact of this conservative management strategy on the risk of cervical cancer remains insufficiently studied until now.

A recent population-based cohort study published in “The BMJ” confirms that while the absolute risk of cervical cancer is low for women with CIN2, those opting for active monitoring face an almost fourfold increase in the cumulative risk of cervical cancer over 20 years compared to those receiving LLETZ treatment.

The study emphasizes that active monitoring of CIN2 is associated with a long-term increase in cervical cancer risk compared to immediate LLETZ treatment. These findings suggest that women choosing active monitoring for CIN2 should continue to undergo prolonged follow-up.

Active Monitoring vs. Surgery for Moderate Cervical Lesions: Long-term Cancer Risk Revealed

Active monitoring primarily involves follow-up through vaginal colposcopy and cervical biopsies. Women opting for active monitoring may face a certain risk of cervical cancer. Even if histopathological results show regression of CIN2, the risk of persistent human papillomavirus (HPV) infection may endure. The study, based on patient data from the Danish registry study, evaluated whether active monitoring of CIN2 (including semi-annual colposcopy follow-ups, cervical cytology examinations, and multiple biopsies) is associated with an increased risk of cervical cancer.

The analysis included 27,524 women diagnosed with CIN2 between 1998 and 2020 (aged 18-40 at diagnosis). These patients chose either active monitoring (12,483 cases, 45%) or LLETZ treatment (15,041 cases, 55%) after diagnosis.

In the period from 1998 to 2012, the majority of women chose immediate LLETZ treatment (66%), while after 2013, the majority opted for active monitoring (68%). Overall, women undergoing active monitoring (median age 26) were younger than those immediately receiving LLETZ treatment (median age 30).

During follow-up, 56 patients (54%) in the active monitoring group and 48 patients (46%) in the LLETZ treatment group were diagnosed with cervical cancer.

The results showed that in the second year after the diagnosis of CIN2, the cumulative risk of cervical cancer for women in the active monitoring group was 0.56%, while it was 0.37% for the LLETZ treatment group. Beyond 2 years of follow-up, the cumulative risk for women in the active monitoring group increased, while the risk for women receiving LLETZ treatment remained relatively stable. Analysis of 20 years of follow-up data showed that the cumulative risk of cervical cancer for women in the active monitoring group was nearly four times higher than that for women in the LLETZ treatment group, at 2.65% and 0.76%, respectively. Overall, there was no significant difference in the International Federation of Gynecology and Obstetrics (FIGO) cancer staging between the two groups of diagnosed cervical cancer patients.

Researchers stratified the results based on age at the diagnosis of CIN2 (≥30 years or <30 years). The analysis showed that the majority of cervical cancer cases (71, 68%) were diagnosed in women aged ≥30 years, aligning with a 3-4 times higher cumulative risk of cervical cancer in the first two years for both groups.

Moreover, after 20 years of follow-up, the cumulative risk for the ≥30 years age group in the active monitoring group was three times that of the <30 years age group, at 5.30% and 1.52%, respectively. For the LLETZ treatment group, the cumulative risk for the ≥30 years age group was twice that of the <30 years age group, at 1.27% and 0.55%, respectively.

In conclusion, this study, based on follow-up data from 27,524 CIN2 women, indicates a low absolute risk of cervical cancer for women with CIN2. Furthermore, despite no significant differences in the first 2 years of follow-up, the cumulative risk of cervical cancer for women in the active monitoring group is nearly four times higher than that for women in the LLETZ treatment group after 20 years of follow-up.

The paper underscores that the increased risk of cervical cancer in women undergoing active monitoring is primarily driven by those diagnosed at ≥30 years of age. The results of this study hold crucial value for clinical counseling of women with CIN2 who have previously undergone active monitoring, suggesting a potential need for extended follow-up in the future.

Active Monitoring vs. Surgery for Moderate Cervical Lesions: Long-term Cancer Risk Revealed

Reference:
[1] Kathrine Dyhr Lycke et al., Untreated cervical intraepithelial neoplasia grade 2 and subsequent risk of cervical cancer: population based cohort study. THE BMJ (2023). DOI: 10.1136/bmj-2023-075925

(source:internet, reference only)

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