The importance of cauterization to maintain a healthy cervix. Long-term study from a private gynecologic practice

Deciphering the Multifactorial Susceptibility of Mucosal Junction Cells to HPV Infection and Related Carcinogenesis

Human papillomavirus (HPV)-induced neoplasms have long been considered to originate from viral infection of the basal cell layer of the squamous mucosa. However, this paradigm has been recently undermined by accumulating data supporting the critical role of a discrete population of squamo-columnar (SC) junction cells in the pathogenesis of cervical (pre)cancers. The present review summarizes the current knowledge on junctional cells, discusses their high vulnerability to HPV infection, and stresses the potential clinical/translational value of the novel dualistic model of HPV-related carcinogenesis.

Past and future of prophylactic ablation of the cervical squamocolumnar junction

HPV vaccination has the potential to prevent the vast majority of cervical cancer cases but cervical cancer screening remains the only prevention strategy in adult unvaccinated women. The range of primary screening tests has expanded to include, in addition to cytology, visual inspection with acetic acid (VIA) and HPV-testing. HPV-testing has the best sensitivity and negative predictive value, and a low-cost HPV test may make large-scale high-quality cervical cancer screening possible in low- and medium-income countries (LMICs). However, on account of its low specificity, HPV-testing would impose the additional burden of triaging HPV+ women using cytology, colposcopy, VIA, or other not yet affordable tests. If minimally invasive treatments that have proven efficacious in HPV+ women with cervical intra-epithelial (CIN) grade 2 and 3 lesions also reduced future cervical cancer risk in lesion-free HPV+ women, the treatment of all HPV+ women would become attractive in LMICs in which screening should be performed as infrequently as possible. In the pre-mass screening era, gynaecologists widely practiced prophylactic ablation of the columnar epithelium visible on the ectocervix (ectopy) and squamocolumnar junction (SCJ) in the hope of preventing cervical cancer. Favourable outcomes were reported, especially from Finland, but conclusive results were not reached on account of weaknesses in the study methods. Indirect support for prophylactic ablation is provided by the hypothesis that some cells of embryonic origin derived from the SCJ are the source of high-grade CIN and cervical carcinoma, and that they do not regenerate after SCJ ablation. SCJ cell elimination may avoid neoplastic transformation though not HPV reinfection. Randomised controlled trials are gold-standard, but if not feasible, an evaluation of the impact of prophylactic ablation could be done in the framework of large HPV-based screening programmes. Careful follow-up of lesion-free HPV+ women would provide much needed information on the risk-to-benefit ratio of prophylactic ablation.

Evidence for benefits from treating cervical ectopy: literature review

CONTEXT AND PURPOSE

Uterine cervical ectopy (cervical erosion) is today considered to be a physiological condition, but there still seems to be a strong tendency towards treating it. The purpose of this study was to review the medical literature for evidence regarding benefits from treating cervical ectopy.

METHODS

The following databases were reviewed: Medical Literature Analysis and Retrieval System Online (Medline), Excerpta Medica Database (Embase), Literatura Latino-Americana e do Caribe em Ciências da Saúde (Lilacs) and Cochrane Library databases. In addition, six medical textbooks were consulted.

RESULTS

The review showed that: 1) there is probably an association between ectopy and higher risk of Chlamydia trachomatis, human papillomavirus and human immunodeficiency virus infection; 4) there is probably an association between ectopy and cervical intraepithelial neoplasia; 5) there is an association between ectopy and mucous discharge and nocturia; and 6) there is no evidence of an association between ectopy and cervical cancer, or of protection against cervical cancer associated with ectopy treatment.

CONCLUSIONS

1) No data were found in the medical literature to support routine treatment for ectopy; 2) Treatment could be recommended for symptom relief, but more symptoms are attributed to ectopy than could be demonstrated in a controlled study; 3) Further studies to test the hypothesis of protection against cervical cancer associated with treatment are necessary.

Perspective on cervical cancer: why prevent?

Cervical carcinoma (CC) remains a significant health problem in the United States (U.S.) despite the progressive fall in the mortality rate during the past 60 years. However, CC is still the most common cancer among women worldwide and the leading cancer cause of death in many countries. In the U.S., the current age-adjusted incidence of CC is about 8 per 100,000 population, which compares to 54.6 in Peru and 4.2 in Israel. The lifetime risk for acquiring CC in the U.S. is about 1%, while the lifetime risk in Peru is more than 5 times greater. Recently some industrialized countries have reported a 2-3-fold increase in the death rate from CC among women less than 35 years of age. The primary strategy to reduce the incidence and death rate from CC is screening by cervical cytology. Because of the high incidence of CC precursor lesions, as well as the lack of specifically and sensitivity, CC screening has proven very costly. Nevertheless, in countries or regions where such screening has been repetitive and comprehensive, the mortality rate from CC has been reduced up to 80%, with most cases of CC occurring in non-compliant patients. The decrease in mortality results from detection of invasive cancer at an earlier, and therefore more curable stage, as well as detection and treatment of precursors which prevent the development of invasive carcinoma. Because the strategy involves detection of cancer precursors, the rate of abnormal Pap smears and the number of women requiring medical intervention is many times higher than the CC rate. The age-adjusted incidence of carcinoma in situ is reported to be 3-5-fold that of invasive cervical cancers. The age-adjusted incidence of all dysplasias is unknown, but it is reported that more than half (perhaps up to 90%) of mild and moderate dysplasias regress spontaneously. Considering that there are 15,000 cases of invasive cervical cancer diagnosed in the U.S. annually, cytologic screening involves the diagnosis and treatment of 750,000 or more women each year for precursor lesions. The impact of CC on the patient and society, as well as the role of other strategies for early diagnosis and prevention, will be briefly reviewed.

Discovering Asymptomatic Non-Precancerous Lesions with Cervical Cytologic Mass-Screening Campaigns: Is it a Benefit or a Cost?

A total of 3357 women (88.1 % married, 82.0 % parous) were examined at least once in the mass-screening program carried out by the Legnano Hospital Screening Center in Nerviano (a small town near Milan with 15,600 inhabitants) in 1974, 1977 and 1980. Married women with visible portio and adequate smear were 2758: a visibly healthy cervix was found only in 1143 subjects (41.4 %). A total of 1516 married women were examined at least in 2 consecutive campaigns: 1279 (84.4 %) reported « no gynecologic treatment in the previous 5 years » at the first campaign, and 899 (59.3 %) reported « no gynecologic treatment in the previous 3 years » at their second one. Of 350 women with « medical lesions » and 525 with « surgical lesions » recorded at the first visit, 111 (31.7 %) and 232 (44.2 %) reported, respectively, a « medical treatment » or a « surgical treatment » at the second visit. In women with « medical lesions » at the first visit, at the second visit a healthy cervix was found in 66.2 % of the treated women and in 72.6 % of the untreated patients. In those with « surgical lesions » a healthy cervix was successively found in 91.6 % of treated and in 40.7 % of the untreated patients.