Cervical Dysplasia in Adolescents

Prevalence of oncogenic human papillomavirus in pregnant adolescents, association with colpocytological changes, risk factors and obstetric outcomes

PURPOSE

The authors aim to carry out an investigation on the impact of cervical oncogenic Human Papillomavirus (HPV) detection in pregnant adolescents, to clarify the prevalence and risk factors, considering the importance and lack of data on this topic in Brazil.

METHODS

A cross-sectional study was conducted with adolescents receiving prenatal care in a tertiary hospital in São Paulo, Brazil, with routine Pap smear and oncogenic HPV detection test in the uterine cervix. The authors sought to associate the results of these tests with demographic and obstetric variables.

RESULTS

A total of 303 pregnant adolescents whose mean age was 15.30 ± 1.22 years comprised the study subjects. The frequency of high-risk HPV cervical detection was 50.50%. Multivariate analysis revealed that a large number of partners in their lifetime (OR = 1.27) and having a religion (OR = 2.05) were risk factors for cervical detection of oncogenic HPV, while schooling appeared as a protective factor (OR = 0.85). There was an association between this detection and colpocytological alterations, reaching almost 30% of patients, but without association with obstetric and neonatal outcomes.

CONCLUSION

The prevalence found is one of the highest in Brazil and worldwide. A greater number of partners during their lifetime and having religion were detected as possible factors associated with cervical HPV detection. Detection of cervical HPV-DNA did not influence obstetric and neonatal outcomes. The findings of this study reinforce the need to implement educational measures capable of modifying the incidence of sexually transmitted infections in this population and capable of promoting adherence to HPV vaccination programs.

Cervical Cancer Screening of Adolescents and Young Women: Further Evidence Shows a Lack of Clinical Value

STUDY OBJECTIVE

To assess the prevalence of cytological abnormalities among young people from a large population in the city of São Paulo (Brazil).

DESIGN

Retrospective, observational analysis of data from the institution's data processing center.

SETTING

A private laboratory in São Paulo (Brazil).

PARTICIPANTS

Comparison of 3 different groups (ie, adolescent women [aged ≤19 years], young adult women [aged between 20 and 24 years], and adult women [aged 25 years and older]).

INTERVENTIONS

Assessment of results from all cervical-vaginal smears collected for cytology between January 2010 and December 2015.

MAIN OUTCOME MEASURES

Comparative analysis of cytological abnormalities in the 3 different groups.

RESULTS

A total of 1,026,671 satisfactory cytology tests were performed. The proportion of cytological abnormalities was found to decrease with age (P < .001) and was similar in the groups comprised of adolescents and young adults, with 3.405/ 20.921 (16.3%) and 13,635/ 78,277 (17.4%), respectively, and 74,320/ 927,473 (8.0%) in the group of adult patients (P < .001). Among the positive cytologies in the group of adolescents, 3,331/ 3,405 (97.8%) represented low-grade lesions and 74/ 3,405 (2.2%) high-grade lesions, whereas among adults older than 25 years old, these figures were 69,092/ 74.320 (93%) and 5,228/ 74.320 (6.9%), respectively. No cases of cancer were found in the group of adolescents.

CONCLUSION

Cytological screening of young people is not recommended because of the low prevalence of high-grade cytological abnormalities in this population, with cancer being a rare event. This inadvertent screening could lead to unnecessary complementary exams and overtreatment, which could compromise the reproductive future of these young women.

Post-Colposcopy Management and Progression Predictors of Biopsy-Proven CIN1 in Women Under 25 Years

OBJECTIVE

The post-colposcopy management and outcome of cervical intraepithelial neoplasia grade 1 (CIN1) in women under 25 years of age was reviewed, and potential predictors for progression were identified.

METHODS

Women under 25 with biopsy-proven CIN1 between January 1, 2010, and December 31, 2012 who were seen in the colposcopy clinic at the Queen Elizabeth II Hospital in Halifax, Nova Scotia were retrospectively reviewed. The regression, persistence, and progression rates of CIN1 were evaluated, and the relevant behavioural and biologic factors were reviewed.

RESULTS

Of the 326 women with a biopsy-proven CIN1, 234 (71.8%) women returned to the regular screening program, and 92 women remained in the colposcopy clinic during follow-up, with a median follow-up time of 26 months. Sixty-two percent of the women had no cervical abnormality, 23.6% of the women had persistent CIN1, and 14.4% of the women showed progression. Eight percent showed progression to CIN2 with a median time of 13 months, whereas 6.4% showed progression to CIN3+ within a median time of 17.5 months. The extent of the lesion (hazard ratio 2.33; 95% CI 1.17-4.64, P = 0.02) and the Pap test result at the initial visit (hazard ratio 2.16; 95% CI 1.22-3.82, P = 0.008) were significantly associated with progression to CIN2+.

CONCLUSION

On the basis of the 6% risk of CIN3+ and the median time to progression of 17.5 months, follow-up with cytology at 12 months seems acceptable. The extent of the lesion and the Pap test result at the initial visit were identified as risk factors for progression of CIN1.

How will transitioning from cytology to HPV testing change the balance between the benefits and harms of cervical cancer screening? Estimates of the impact on cervical cancer, treatment rates and adverse obstetric outcomes in Australia, a high vaccination coverage country

Primary HPV screening enables earlier diagnosis of cervical lesions compared to cytology, however, its effect on the risk of treatment and adverse obstetric outcomes has not been extensively investigated. We estimated the cumulative lifetime risk (CLR) of cervical cancer and excisional treatment, and change in adverse obstetric outcomes in HPV unvaccinated women and cohorts offered vaccination (>70% coverage in 12-13 years) for the Australian cervical screening program. Two-yearly cytology screening (ages 18-69 years) was compared to 5-yearly primary HPV screening with partial genotyping for HPV16/18 (ages 25-74 years). A dynamic model of HPV transmission, vaccination, cervical screening and treatment for precancerous lesions was coupled with an individual-based simulation of obstetric complications. For cytology screening, the CLR of cervical cancer diagnosis, death and treatment was estimated to be 0.649%, 0.198% and 13.4% without vaccination and 0.182%, 0.056% and 6.8%, in vaccinated women, respectively. For HPV screening, relative reductions of 33% and 22% in cancer risk for unvaccinated and vaccinated women are predicted, respectively, compared to cytology. Without the implementation of vaccination, a 4% increase in treatment risk for HPV versus cytology screening would have been expected, implying a possible increase in pre-term delivery (PTD) and low birth weight (LBW) events of 19 to 35 and 14 to 37, respectively, per 100,000 unvaccinated women. However, in vaccinated women, treatment risk will decrease by 13%, potentially leading to 4 to 41 fewer PTD events and from 2 more to 52 fewer LBW events per 100,000 vaccinated women. In unvaccinated women in cohorts offered vaccination as 12-13 year olds, no change to lifetime treatment risk is expected with HPV screening. In unvaccinated women in cohorts offered vaccination as 12-13 year olds, no change to lifetime treatment risk is expected with HPV screening. HPV screening starting at age 25 in populations with high vaccination coverage, is therefore expected to both improve the benefits (further decrease risk of cervical cancer) and reduce the harms (reduce treatments and possible obstetric complications) associated with cervical cancer screening.

Practice Bulletin No. 168: Cervical Cancer Screening and Prevention

The incidence of cervical cancer in the United States has decreased more than 50% in the past 30 years because of widespread screening. In 1975, the rate was 14.8 per 100,000 women. By 2011, it decreased to 6.7 per 100,000 women. Mortality from the disease has undergone a similar decrease from 5.55 per 100,000 women in 1975 to 2.3 per 100,000 women in 2011 (1). The American Cancer Society (ACS) estimated that there would be 12,900 new cases of cervical cancer in the United States in 2015, with 4,100 deaths from the disease (2). Cervical cancer is much more common worldwide, particularly in countries without screening programs, with an estimated 527,624 new cases of the disease and 265,672 resultant deaths each year (3). When cervical cancer screening programs have been introduced into communities, marked reductions in cervical cancer incidence have followed (4, 5).New technologies for cervical cancer screening continue to evolve, as do recommendations for managing the results. In addition, there are different risk-benefit considerations for women at different ages, as reflected in age-specific screening recommendations. In 2011, the ACS, the American Society for Colposcopy and Cervical Pathology (ASCCP), and the American Society for Clinical Pathology (ASCP) updated their joint guidelines for cervical cancer screening (6), as did the U.S. Preventive Services Task Force (USPSTF) (7). Subsequently, in 2015, ASCCP and the Society of Gynecologic Oncology (SGO) issued interim guidance for the use of a human papillomavirus (HPV) test for primary screening for cervical cancer that was approved in 2014 by the U.S. Food and Drug Administration (FDA) (8). The purpose of this document is to provide a review of the best available evidence regarding the prevention and early detection of cervical cancer.

Findings and Outcomes in a Prevaccination Cohort of Women Younger Than 25 Years Attending a Tertiary Colposcopy Service

OBJECTIVE

To describe clinical presentation and treatment in women younger than 25 years referred to the Royal Women's Hospital colposcopy clinic, before implementation of the National Human Papillomavirus Vaccination Program.

METHODS

Retrospective cohort analysis of women younger than 25 years referred to a tertiary hospital colposcopy clinic between 1998 and 2007. Clinical presentation and correlation between cervical cytology, biopsy, and histology at treatment was examined.

RESULTS

Approximately 14,635 colposcopies were undertaken in 4104 women (median age, 22 years); 3051 had abnormal referral cytology, of whom, 23.8% had high-grade disease on punch biopsy. High-grade disease was found in 15.1% of those with possible low-grade or low-grade cytology (293/1932), 42.4% of those with possible high-grade or high-grade cytology (474/1119). Sensitivity and specificity of colposcopy for high-grade disease (high-grade epithelial abnormality, adenocarcinoma in situ, cervical cancer up to 2 years follow-up) was 60.0% and 82.3%, respectively. Thirty-nine percent (n = 1180) with abnormal cytology had treatment, of which, 66.6% was ablative. Histological CIN3+ was found in 53.8% of those with a previous high-grade punch biopsy (126/234) at excisional treatment, and 23.0% of those with a previous low-grade punch biopsy (20/87) (relative risk, 2.3 [CI, 1.6-3.5]). Four cancers were detected (0.1% of the total cohort, 0.5% of those with a high-grade biopsy, and 1.7% of those with a high-grade biopsy who underwent excisional treatment.)

CONCLUSIONS

Before vaccination, young women experienced a high real-time burden of high-grade disease and high rates of intervention. These baseline data contribute to monitoring of HPV vaccination and revised cervical screening strategies.

Evolução do sistema público de saúde no Brasil frente ao estágio atual da prevenção do câncer de colo uterino em mulheres jovens e adolescentes

O câncer de colo uterino representa um problema de saúde pública em nível mundial, estando em grande parte dos casos relacionado com a infecção pelo papiloma vírus humano. O exame de Papanicolau é ainda o principal instrumento para o rastreamento das lesões precursoras. Contudo no Brasil, tal meio diagnóstico-preventivo é preconizado apenas para mulheres na faixa etária entre os 25 e 64 anos. Desse modo, este trabalho teve por objetivo prover uma revisão/atualização crítica da evolução e princípios do sistema de saúde público brasileiro diante da situação atual da prevenção do câncer de colo uterino em mulheres jovens e adolescentes. Ressalta-se que os problemas de saúde do Brasil passaram do período colonial, marcado pelas doenças pestilenciais, para a atualidade com a emergência de doenças crônicas a exemplo dos cânceres. Além disso, a literatura científica reporta taxas preocupantes para a ocorrência de alterações citopatológicas cérvico-vaginais em mulheres jovens e adolescentes no país defronte a diversos agravos neste contexto.  Assim sendo, a gestão da saúde no Brasil necessita de amplos ajustes  visando principalmente a inserção de mulheres e adolescentes de 10 a 24 anos nos programas de diagnóstico precoce do câncer de colo uterino.

Inflammatory cervicovaginal cytology is associated with disease activity in juvenile systemic lupus erythematosus

To evaluate cervicovaginal cytology in adolescents with juvenile systemic lupus erythematosus (JSLE) and to compare them to controls. Fifty-two female adolescents with JSLE (ACR criteria) were compared to 52 age-matched healthy controls. All Pap smears were evaluated by the same cytopathologist blinded to gynecology examination (Bethesda 2001). The mean age of JSLE patients and controls were similar (16.17 ± 1.94 versus 16.13 ± 2.16 years, P = 0.92). The cervicovaginal cytology was found to be similar in both groups, although sexual intercourses in the last month were less frequent in JSLE than controls (23% versus 59.6%, P = 0.0003). Only one patient (2%) with JSLE versus two controls (4%) had cervical dysplasia (LGSIL) and human papilomavirus ( P = 1.0). Candida spp vaginitis was observed in seven JSLE (14%) versus none in controls ( P = 0.012) and was associated with immunosuppressive drugs ( P = 0.01) and high dose of prednisone ( P = 0.002). Of interest, inflammatory cervicovaginal cytology was observed in 21 (60%) of patients with SLEDAI ≥ 4 and only four (23%) of those with SLEDAI < 4 ( P = 0.001). Likewise, a higher frequency of inflammatory changes was also observed in virgin JSLE (57% versus 8%, P = 0.005). Our findings supports the notion that female genital tract may be a potential target organ in SLE since cervical inflammation is associated to disease activity independently of sexual activity. Lupus (2007) 16, 430—435.

High-risk human papillomavirus in Galicia, Spain: prevalence and evaluation of the sample representativeness

BACKGROUND

The prevalence of high-risk genotypes of the human papillomavirus (HR-HPV) in Galicia remained unknown before the introduction of the HPV vaccine. The objective of this study was to estimate this prevalence in non-vaccinated women when vaccination against HR-HPV started. Sample representativeness was also evaluated.

METHODS

Female volunteers aged 16-64 years, residents in Galicia, Spain, completed a questionnaire and provided biological samples for a virological study and for cytology. The sample was weighted; prevalence rates were estimated and are shown with 95% confidence intervals.

RESULTS

Virological results were available for 1703 women. HR-HPV prevalence was 10.1%, decreasing notably at ages above 30 years. HPV-16 was the most frequent genotype and 3.6% of women were infected by more than one genotype. No adjustment was necessary to generalize the results of the study.

CONCLUSIONS

In Galicia in 2009 there would be 96 400 women aged 16-64 years infected with HR-HPV. It is possible to estimate HR-HPV prevalence in a population starting from a volunteer sample.

Compliance with cervical cancer screening and human papillomavirus testing guidelines among insured young women

OBJECTIVE

In December 2009, the American Congress of Obstetricians and Gynecologists (ACOG) recommended that women under 21 years old should not receive cervical cancer screening (Papanicolaou tests) or human papillomavirus (HPV) tests. This study examined whether clinicians stopped administering Papanicolaou and HPV tests among women younger than 21 years of age after new ACOG guidelines were issued.

STUDY DESIGN

This study was a retrospective secondary data analysis of administrative claims data that included insurance enrollees from across the United States that examined the frequency of Papanicolaou tests and HPV tests among 178,898 nonimmunocompromised females 12-20 years old who had a paid claim for a well-woman visit in 2008, 2009, or 2010. Young women with well-woman examinations in each observed year were examined longitudinally to determine whether past diagnoses of cervical cell abnormalities accounted for Papanicolaou testing in 2010.

RESULTS

The proportion of women younger than 21 years old that received a Papanicolaou test as part of her well-woman exam dropped from 77% in 2008 and 2009 to 57% by December of 2010, whereas HPV testing remained stable across time. A diagnosis of cervical cell abnormalities in 2009 was associated with Papanicolaou testing in 2010. However, a previous Papanicolaou test was more strongly associated with a Papanicolaou test in 2010.

CONCLUSION

These data show that some physicians are adjusting their practices among young women according to ACOG guidelines, but Papanicolaou and HPV testing among insured women younger than 21 years of age still remains unnecessarily high.

Should cervical cancer screening begin at age 21 for everyone? A quantitative analysis in a high-risk, low-income, African American/Hispanic young-adult population

The American College of Obstetricians and Gynecologists has recommended modifying the baseline cervical cancer screening age from earlier of three years after first sexual intercourse or age 21 to age 21. In this study, we tracked abnormal cytologic diagnoses, with an emphasis on high-grade cervical lesions, in a high-risk, low-income, African American/Hispanic young-adult population. The intention was to assess if delaying cancer screening to 21 years of age would be effective in this subpopulation. A search of the cytopathology database between January 1, 2001 and December 31, 2009 was performed to identify all women with their first abnormal cytologic diagnosis prior to turning 21 years of age. All of the available follow-up cytologic and/or histologic diagnoses, made both prior to and after turning 21 years of age, were recorded and the results analyzed. Amongst the 8,011 total number of women under 21 years of age screened for cervical cancer at our institution from January 1, 2001 to December 31, 2009 the overall abnormal cytology rate was 25%, with a rate of 1% for HSIL, 3% for ASC-H/LG-H, and 22% for LSIL/ASC-US. The youngest subject diagnosed with HSIL was 14 years of age. Not a single study subject developed invasive cervical cancer prior to turning 21 years of age. In spite of the limitations of the study, we found that for patients served by our institution, delaying cervical cancer screening until 21 years of age is effective for the detection of early precancerous lesions.

Should high-risk adolescents have Papanicolaou tests?

BACKGROUND

The current American College of Obstetricians and Gynecologists guidelines state that cervical cancer screening should begin at age 21 years, regardless of sexual or obstetric history. However, previous studies have demonstrated that there is a small but significant subset of high-risk adolescents with extensive sexual and obstetric history who harbor a significant squamous cervical lesion. The objective of the current study was to use histologic and demographic data from adolescents (aged <21 years) who received Papanicolaou (Pap) tests to determine whether they benefited from early cervical cancer screening.

METHODS

Adolescent girls who had Pap tests between 2000 and 2010 were included in the study. Demographic data, including obstetric history, number of sexual partners, age of first coitus, age at first pregnancy, menarche, smoking history, and Chlamydia and syphilis infection, were analyzed for associations with levels of cervical dysplasia.

RESULTS

Of 56,785 adolescent Pap tests, 277 (0.5%) were diagnosed as high-grade squamous HSIL, and 56 of those Pap tests (20%) were from patients who had grade 3 cervical intraepithelial neoplasia (CIN-3) on subsequent biopsy and/or excision. One patient had microinvasive cervical carcinoma identified on loop electrosurgical excision procedure at age 27 years after an HSIL Pap test. Increased parity was associated significantly with higher rates of CIN-3.

CONCLUSIONS

The study findings indicated that current American College of Obstetricians and Gynecologists guidelines to begin Pap testing at age 21 years are appropriate for the majority of adolescents, because the rate of HSIL is very low, and the risk for invasive carcinoma is minimal. Although higher parity was associated with a significantly increased grade of CIN, the conclusions are questionable because of the significant amount of missing demographic data points. That being said, this study should lead to other similar studies to determine any association of higher grade CIN with adolescent sexual and obstetric history.

Human papillomavirus in adolescents: lessons learned from decades of evaluation

Knowledge regarding the natural history of human papillomavirus (HPV) infection and its clinical sequelae in adolescents has increased significantly over the last decade; as a result, there have been world-wide recommendations for less aggressive Pap screening and management of cervical dysplasias in young women. It is important that adolescent health providers understand these issues, as knowledge of HPV and its sequelae in the Australian community is limited, despite the introduction of a national immunisation programme. Parents and young women have expressed a desire for further information to make informed choices. This paper reviews the natural history of HPV infection in adolescents and the evidence behind new conservative guidelines for cervical screening, plus prophylactic vaccination in young women.

Abnormal cervical cytology in pregnant adolescents

A retrospective, cohort study of pregnant adolescents with abnormal cervical cytology including: atypical squamous cells of undetermined significance (ASCUS), low-grade squamous intraepithelial lesions (LSIL) and high-grade squamous intraepithelial lesions (HSIL) was done to determine the regression, persistence and progression of abnormal cervical cytology in adolescent pregnancies. Follow-up cervical cytology within 1 year was assessed. Results suggest that pregnant adolescents have a high regression rate of abnormal cervical cytology. The likelihood of regression, persistence, or progression, is independent of the initial cytological diagnosis.

Age trends in the prevalence of cervical squamous intraepithelial lesions among HIV-positive women in Cameroon: a cross-sectional study

Background

Cervical squamous intra-epithelial lesions (SIL) are more frequent in HIV-positive women overall. However the appropriate age at which to begin and end cervical cancer screening for early detection of lesions in HIV-positive women is not clear. We assessed the age-specific prevalence of any SIL and SIL requiring colposcopy in HIV-positive women in Cameroon.

Methods

We enrolled, interviewed and conducted conventional cervical cytology in 282 women, aged 19–68 years, initiating antiretroviral therapy in three clinics in Cameroon. In bivariable analyses, the crude relationship between age and the presence of lesions was assessed using locally weighted regression (LOWESS) methods. In multivariate analyses, generalized linear models with prevalence as the outcome, an identity link and a binomial distribution, were used to estimate prevalence differences. Bias analyses were conducted to assess the potential effect of inaccuracies in cytology.

Results

SIL were detected in 43.5% of the 276 women with satisfactory samples, 17.8% of whom had ASC-H/HSIL. On average, women aged 26 to 59 tended to have a slightly higher prevalence of any SIL than other women (Prevalence difference PD: 6.5%; 95%CI: -11.4, 24.4%). This PD was a function of CD4 count (heterogeneity test p-value =0.09): amongst patients with CD4 counts less than 200cells/uL, the prevalence was higher in patients aged 26–59, while there was essentially no difference amongst women with CD4 counts greater than 200 cells/uL. ASC-H/HSIL were present in women as young as 19 and as old as 62. Overall the prevalence of ASC-H/HSIL increased by 0.7% (95%CI: -3.8%, 5.1%) per decade increase in age.

Conclusion

Both severe and less severe lesions were prevalent at all ages suggesting little utility of age-targeted screening among HIV-positive women. Nevertheless, the long-term evolution of these lesions needs to be assessed in prospective studies.

[Management of high grade squamous intraepithelial lesion of the cervix of adult women]

Cervical cancer is the second most common cancer among women worldwide, despite having great potential for prevention and cure when early diagnosed and treated, which can reduce the mortality rate among the affected. Since there is no consensus among the therapeutic measures in high grade cervical squamous intraepithelial lesions (HGSIL), we discuss its approach when dealing with adult women who have HGSIL and the follow-up after the adopted procedure. We performed electronic searches of MEDLINE (through PubMed), National Guidelines Clearinghouse, Google Scholar and Lilacs. The guidelines identified were evaluated according to their validity and recommendations. In relation to after-care, the European use cytology every 6 months, the Australians, cytology and colposcopy every 6 months, the Americans advocate the realization of hybrid capture in six to 12 months or cytology every 6 months. The Brazilian Guidelines Project, on its turn, recommends that clinical reassessments and Pap smear should be performed every three or four months during the first two years of follow-up. Studies comparing the method "See and Treat" with the three steps one (histology, colposcopy, biopsy) concluded that the latter is indicated for women ASCUS/LSIL before undergoing the excision of the transformation zone (ETZ), while the "View and Treat" is indicated in women with proven HGSIL in cytology and suggestive in colposcopy, because it presents advantages such as low cost and immediate solution. All the guidelines are unanimous in stating that when facing proven HGSIL, excision of the injury through ablation or conization or ETZ is indicated.

Follow-up findings in young females with high-grade squamous intraepithelial lesion papanicolaou test results

CONTEXT

New guidelines discourage cervical screening and procedures in young females, given available human papillomavirus vaccines, concerns regarding procedure-associated harms, and the rarity of cervical cancers.

OBJECTIVE

To analyze histopathologic follow-up data on a large number of young females with high-grade squamous intraepithelial lesion (HSIL) Papanicolaou (Pap) test results.

DESIGN

Hospital records were searched for HSIL Pap test results in females 20 years or younger between January 2002 and December 2007. Histopathologic and Pap test follow-up, age group variations, and impact of Pap test transformation zone/endocervical sampling were analyzed.

RESULTS

Four hundred seventy-four females aged 20 years or younger had HSIL Pap test results during the study period. Three hundred thirty-five young females with at least one cervical biopsy were included. The average age was 18.6 years (range, 13-20 years). The average follow-up period was 24 months (range, 0.1-75 months), with a median of 22 months. Histopathologic detection rates were 44.2% for cervical intraepithelial neoplasia (CIN) 2/3 and 47.8% for CIN 1. The average period between the HSIL Pap test result and an initial diagnosis of CIN 2/3 was 5 months (range, 0.1-62 months), with a median of 2 months. Neither invasive carcinoma nor adenocarcinoma in situ was identified. Presence or absence of a transformation zone/endocervical sample did not significantly impact CIN 2/3 risk (44.5% versus 38.9%, P = .64).

CONCLUSIONS

Histopathologic CIN 2/3 was documented in 148 of 335 (44%) of biopsied young females with HSIL Pap results, likely reflecting both the reported high likelihood of HSIL regression in younger females and the challenge of colposcopic sampling of relatively short-lived smaller CIN 2/3 lesions. Although no cases of invasive carcinoma were identified in this study, updated guidelines pose new risks for maturing females with undetected cervical precancer.

Histology of loop electrosurgical excision procedures performed on women younger than 21 years and 65 years or older

OBJECTIVE

To examine the prevalence and histology of loop electrosurgical excision procedures (LEEPs) done on women who are outside the age limits of the updated guidelines for cervical cytologic screening.

MATERIALS AND METHODS

A database of all LEEPs performed between October 2004 and November 2009 was created. All data on age, human immunodeficiency virus status, cytology and histology before the procedure, and histology of the LEEP specimen were collected.

RESULTS

There were 939 LEEPs performed during the study period, and data on 64 cases were excluded because of inadequate information. Fifty-four LEEPs were performed on women who were either younger than 21 years and those 65 years or older. All LEEPs were performed under traditionally accepted indications, except for 1 LEEP, which was excluded. None of the women gave a history of human immunodeficiency virus infection, and none of the older women had a history of abnormal cervical cytologic result before the index case. Of the procedures performed on the adolescents, 24 demonstrated high-grade lesions on LEEP (51.1%). Of the 6 procedures performed on older women, 4 LEEP specimens demonstrated high-grade lesions (66.7%). There were no cancers.

CONCLUSIONS

We treated many women with LEEP excision who would not have been screened using current 2009 guidelines. Most of these women had high-grade lesions. The new guidelines may not be applicable to all population groups.

Prevalence and patient characteristics associated with CIN 3 in adolescents

OBJECTIVE

We sought to identify patient characteristics associated with cervical intraepithelial neoplasia (CIN) 3 in adolescents.

STUDY DESIGN

A cross-sectional cohort study was done using a colposcopic database. Data collected included demographic and clinical information as well as cytologic and histologic results. Variables associated with CIN 3 in the univariable analysis (P ≤ .10) were included in a multivariable logistic regression model.

RESULTS

Of 614 adolescents evaluated, 48 (8%; 95% confidence interval, 6-10%) had CIN 3. No cancers were detected. In the univariable analysis, parity, ≥ 4 lifetime male sexual partners, and a history of sexually transmitted infections were associated with an increased risk of CIN 3. In the final model, only ≥ 4 sexual partners (compared to <4; adjusted odds ratio, 3.66; 95% confidence interval, 1.26-10.61) was significantly associated with the finding of CIN 3.

CONCLUSION

CIN 3 was infrequently encountered in adolescents, and those with multiple sexual partners were at increased risk for CIN 3.

Prognosis of intraepithelial cervical lesion during adolescence in up to two years of follow-up

Our objective was to describe the evolution of cervical SIL within 24 months of the initial diagnosis, in a cohort study of 147 sexually active adolescents attending a public health service in Rio de Janeiro, between 1993 and 2006. The participants were divided in two groups, according to whether cervical biopsy was performed or not. The median of the interval between sexual debut and the atypical cytopathology was 12 months and in 8.2% of patients there was a diagnosis of HSIL at the first abnormal smear. After a two-year follow-up by cytology, the regression (ASCUS 91%, LSIL 63.6%, HSIL 50%) and progression (LSIL 6.1%) were verified. In the group undergoing biopsy, the final histological regression reached 59.4% for CIN1 and 71.4% for CIN2, while the progression from CIN1 to CIN 2/3 was 3.1%. Our results corroborate the recommendation for conservative management in compliant adolescents due to a high regression rate. However, there should be maintained a careful follow-up based on the possible evolution of the lesion.

The impact of a multidisciplinary conference in the management of cervical cytological and histological abnormalities: a university hospital experience

OBJECTIVE

This study evaluates the impact of a cytology-colposcopy correlation conference (CCCC) on the management of preinvasive cervical lesions in a university hospital.

METHODS

This is a retrospective analysis of 130 consecutive cases from the colposcopy clinic at our University Health Center that were presented in the CCCC during a period of 1 year (November 2006 to October 2007). Variables examined to assess the usefulness of CCCC included the actual number of times there was a recorded change in the diagnosis or management recommendation secondary to presentation in the conference. The algorithms from the 2001 American Society of Colposcopy and Cervical Pathology consensus guidelines for the management of cytologic and histologic abnormalities were used to identify the patients in whom the conference recommendations were a deviation from the standard society recommendations.

RESULTS

The diagnosis was changed on review of the original cytology or biopsy 24 times (13%), downgraded 13 times (7%), and upgraded 11 times (6%). The conference recommendations were a modification of the standard 2001 American Society of Colposcopy and Cervical Pathology guidelines 38 times (21%) in 34 patients. The most common triage change was the recommendation for observation of unexplained high-grade cytology with negative or lower-grade biopsy (73%), followed by observation of high-grade lesion on biopsy (27%). This recommendation, while an option in the 2006 guidelines, was not given as a choice in the 2001 guidelines.

CONCLUSIONS

The CCCC at our institution provided significant input into the management of patients with preinvasive cervical lesions, anticipating some of the changes made in the 2006 guidelines.

[How did I contract human Papillomavirus (HPV)?]

More than 120 genotypes have been identified among the Papillomavirus (HPV) family. These viruses are ubiquitary with skin or mucous membrane tropism and cause various pathologies from wart to neoplasia. HPV family is classified according to their tropism. Genital HPV infection is considered as the most frequent sexually transmitted disease in the world. Seventy-five percent of women will be in contact with HPV at least one time in their life. HPV is usually transmitted through direct skin-to-skin contact, more often during penetrative genital contact. Other types of genital contact in the absence of penetration can lead to HPV infection, but those routes of transmission are much less common than sexual intercourse. However, virgins (<2 % of cases) and young children can present HPV infection, suggesting other routes of transmission than sexual intercourse. HPV infection could occur during delivery; vaginal deliveries appear to promote this transmission in comparison with cesarean section. But cesarean section do not completely protect against contamination risk. In utero, vertical transmission has been suggested by different studies but with lack of evidence. HPV infection can be detected on inanimate objects, such as clothing or environmental surfaces. However, transmission is not known to occur by this route. More detailed knowledges of the transmission route of HPV infection will enable to get prevention more effective.

[Cervical screening: toward a new paradigm?]

OBJECTIVES

Analysis of the trials which compare the virologic testing (HPV testing) and the cytology in the cervical screening.

MATERIAL AND METHODS

The MedLine database was consulted using the Keywords: "cervical screening", "pap smear", "liquid based cytology", "HPV testing", "adults", "adolescents", "cervical intraepithelial neoplasia (CIN)", "uterine cervix cancer". Articles were selected according their concern about the debate of the uterine cervix cancer screening in France.

RESULTS

The HPV testing seems interesting allowing a decreasing delay in the diagnosis of CIN (more diagnosis of CIN2+ in the first round and less during the second one). But, when the two rounds are added, the number of CIN2+ are identical in the two arms (cytology and HPV testing) in all the trials (except the Italian NTCC trial). A negative HPV testing protects the women much longer than cytology can do: a delay of five years between two rounds seems ideal. The HPV testing alone increases the detection rate of cervical lesions, which could regress spontaneously and may induce an overtreatment, especially in the youngest population: a triage is necessary and the cytology appears to be the best way to select the candidates for colposcopy in case of positive HPV testing and cytology. The HPV infection presents some particularities in adolescent females: for this reason, the HPV testing should not be used in this special population. In vaccinated women, a consensus for the screening is necessary.

CONCLUSION

The health care providers in France have to understand the characteristics of the HPV testing: its advantages compared to the cytologic screening are only evident in case of an organization of the screening in France and even in Europe.

Cervical dysplasia and associated risk factors in a juvenile detainee population

STUDY OBJECTIVE

Canada has licensed a human papilloma virus (HPV) vaccine for adolescent females, with the goal of decreasing the incidence of HPV infection and associated cervical cancer. This study identifies the juvenile detainee population as a high-risk group for HPV infection and therefore an important target for primary prevention.

DESIGN

A retrospective chart review.

SETTING

Sundance Juvenile Detention Center, Kingston, Ontario, Canada.

PARTICIPANTS

Female detainees admitted between 2003 and 2006.

MAIN OUTCOME MEASURES

Papanicolaou (Pap) test results, sexually transmitted infection (STI) rates, and associated risk factors were collected from 119 charts.

RESULTS

Of 57 recorded Pap smears, 46 (80.7%) were normal, 5 (8.8%) were reported as atypical squamous cells of unknown significance, and 6 (10.5%) were reported as low-grade squamous intraepithelial lesion. Of the women tested, 4% were positive for gonorrhea, 10% for chlamydia, 32% for bacterial vaginosis, and 5% for trichomonas; none were positive for syphilis. Of the girls, (91) (77%) had negative HIV and hepatitis B tests, two girls were hepatitis-C-positive, three had clinical evidence of genital herpes, and one showed evidence of pelvic inflammatory disease. There were 75 (63%) girls who reported sexual activity; 87% of them used contraception or protection of some kind, albeit inconsistently. Of these young females, 12 (10%) had engaged in prostitution and 13 (11%) had allegedly been raped or sexually assaulted.

CONCLUSIONS

Female juvenile detainees in Kingston, Ontario, have higher rates of STIs, associated risk factors, and abnormal Pap tests than the general female adolescent population. This new information confirms that this population is at risk for HPV infection and subsequent cervical cancer.

Follow-up compliance of adolescents with cervical dysplasia in an inner-city population

STUDY OBJECTIVE

Adolescent compliance with cytologic and histologic cervical abnormalities is poor. Recent changes in abnormal cytology follow-up and colposcopy indications in young women may delay the diagnosis of cervical dysplasia. The objective of our study was to determine the compliance with follow up. We also wanted to summarize regression or progression of disease, and to determine if the new guidelines could affect severity and time of diagnosis.

DESIGN

Retrospective review of medical records from adolescent patients (defined as women aged 12 to 21) who had a colposcopy between January 2004 and December 2006. Patients were excluded if they were 22 or older or if they had a previously abnormal cytologic evaluation.

MAIN OUTCOME MEASURES

Colposcopy records between January 2004 and December 2006 were identified by CPT code from a computerized database. Cytology and histology results, follow-up compliance rates, and demographic data were collected. Data were analyzed with a power>85% and a P value </= .05 for significance.

RESULTS

Of the 210 records reviewed, 61.9% had atypical squamous cells of undetermined significance high-risk HPV, 33.7% had low-grade squamous intraepithelial lesion, and 4.5% had high-grade squamous intraepithelial lesions. Colposcopy was performed in 55.9%, and 15.2% required surgical intervention. Loop electrosurgical excision procedure (LEEP) was used in 87.5% of patients, and 12.5% had a cold knife cone. Mean time to follow in patients with a surgical intervention was 12.72 months and 11.02 months for those without (P=.371).

CONCLUSION

There appears to be no difference in compliance with follow-up, regardless of severity of disease or surgical intervention. There was no significant progression of disease and a high regression rate of abnormalities. This information supports the current American College of Obstetricians and Gynecologists and American Society for Colposcopy and Cervical Pathology guidelines to delay aggressive intervention in adolescents.

Caring for women with abnormal papanicolaou tests during pregnancy

The Papanicolaou (Pap) test is one of the best screening tests available for cancer detection and has achieved widespread acceptance among women. Pregnancy provides a valuable opportunity to educate and screen women for cervical cancer when receiving prenatal care. However, evolving knowledge about the course of human papillomavirus infection (HPV) in women, new technologies, and the advent of vaccines are driving radical changes in practice and new ways to consider cervical cancer screening. Modifications in the 2006 Consensus Guidelines for the Management of Women with Abnormal Cervical Cancer Screening Tests are most evident among adolescents. Because of high rates of HPV regression, pregnant adolescents with minor Pap abnormalities may now be followed rather than referred for immediate colposcopy. Postponing colposcopy in pregnant, reproductive-age women with minor Pap changes until after delivery is now acceptable. Pregnant immunocompromised women with abnormal Pap tests are followed similarly to pregnant women in the general population. While a strong evidence base is gradually emerging to support guideline revisions, the highest quality evidence may not yet be available for all recommendations. Midwives can keep abreast of the science while using clinical judgment to provide safe and expert cancer screening care to women.

Incidence of cervical intraepithelial lesions in a population of adolescents treated in public health services in Rio de Janeiro, Brazil

This study aimed to estimate the incidence and types of cervical cytopathological findings in adolescents who were treated in public health services between 1993 and 2006. This is a cohort study, with the following inclusion criteria: < 20 years of age, sexually-active, without cervical lesions upon entry into the study or sexually active < 1 year. The data were collected from 403 adolescents' medical records. Incidence density of cytopathological alterations was estimated and the actuarial method was used to calculate the 5-year incidence during follow-up after sexual initiation. In the first year of sexual activity, the incidence of cervical lesions was 24.1%. The incidence decreased to 3-8% over the following 4 years. The incidence density was 4.7 cases per 100 persons per year. The first abnormal cytological diagnosis showed atypical squamous cells of undetermined significance (ASCUS) in 5.5% (22) of patients, low-grade squamous intra-epithelial lesions (LSIL) in 28% (113), and high-grade squamous intraepithelial lesions (HSIL) in 3% (12). Eight (67%) cases of HSIL occurred during the first year of sexual activity. The incidence of cytopathological findings at beginning of sexual life is high, suggesting the importance of including sexually-active adolescents in cervical cancer prevention programs.

Cervical cancer screening in the early post vaccine era

The Pap test is the foundation of cervical cancer screening in North America and most industrialized countries. It has been widely used in the United States since the 1950s. But are our current screening guidelines still justified? In this article, the author reviews the current recommendations for cervical cancer screening by the American Cancer Society (ACS) and the American College of Obstetricians and Gynecologists (ACOG) and the evidence supporting them, reviews the relative efficacy of liquid-based cytology versus the conventional Pap smear, and discusses the role of HPV DNA testing in primary screening.

Lesões intra-epiteliais cervicais em adolescentes: estudo dos achados citológicos entre 1999 e 2005, no Município do Rio de Janeiro, Brasil

A freqüência das lesões precursoras do câncer cervical vem crescendo entre a população de adolescentes, possivelmente, em conseqüência da diminuição da idade de início da vida sexual e do aumento no número de parceiros sexuais. Com o objetivo de analisar o comportamento das lesões precursoras do câncer cérvico-uterino entre adolescentes do Município do Rio de Janeiro, Brasil, estudou-se, de forma retrospectiva, 1.516.407 exames citológicos provenientes de unidades do Sistema Único de Saúde entre 1999 e 2005. Foram comparadas, ao longo do período, a distribuição das alterações citológicas e a tendência temporal dessa distribuição entre adolescentes e mulheres adultas. No período, observou-se maior freqüência de anormalidades citológicas no grupo de adolescentes, predominando as lesões de baixo grau. A prevalência de alterações cervicais em adolescentes duplicou, passando de 6,4% para 12,4%, enquanto, nas mulheres adultas, aumentou de 4% para 6,1%, sendo estimado incremento anual médio entre as adolescentes e mulheres adultas de, respectivamente 0,008% e 0,003%. Com base neste estudo e na literatura consultada, sugerimos a inclusão das adolescentes no grupo prioritário para rastreio citológico periódico do "Programa Viva Mulher".

Preventing cervical cancer: the Pap test and the HPV vaccine

Women look to their internists and other primary care physicians to provide preventive health care. Periodic Pap tests are as much a part of a woman's ongoing health care as periodic lipid assessments, mammograms, screening for colon cancer, or any of the other recommended screening assessments. This article provides primary care physicians with the information needed to perform Pap tests at the appropriate intervals, or if not set up to do Pap tests themselves, to make the appropriate referrals. Also provided is the necessary information to counsel women with abnormal Pap tests who may need colposcopy or other follow-up evaluation. Finally, the role of the HPV vaccine in the prevention of cervical cancer is summarized.

An audit of Colposcopy referrals from a GU/STD clinic

BACKGROUND

Cervical cancer is increasing at 1.5% per year in Ireland with 50% mortality giving 2.2% of all cancer deaths. In the Mid-West region a pilot screening programme has begun to screen all women 25-60 years. 66% of Genitourinary/Sexually transmitted disease (GU/STD) clinics' abnormal smears are <25 years. Requests to abandon "opportunistic" screening prompted this GU/STD clinic audit.

METHODS

221(8.4%) patients referred to colposcopy over 4 years were audited. Retrospective analysis was carried out on GU/STD clinic files, hospital files and computer records for biopsy reports. Ethical approval was prospectively granted.

RESULTS

2637 smears were carried out from November 1999 - September 2003.221 patients referred to colposcopy were audited.1%, 3%, 5% had severe, moderate and, mild dyskaryosis, respectively, on cervical screening while 0.8%, 1.2%, 1.5% had CIN3, CIN2, CIN1 abnormalities, respectively, on biopsy with 3.5% having no abnormality (Cervical Intraepithelial Neoplasia = CIN).53% referred to colposcopy were <25 years.

CONCLUSION

2% had high grade lesions. 37% of high grade lesions are <25 years.Of the high grade lesions 13% had Chlamydia trachomatis (27% of CIN3) and 44% had HPV despite Relative Risks (RR) being 0.75 and 1.09 respectively. Older women had higher grade changes. No statistical difference was found for progression, regression and persistence in those over and under 25.

Adolescent cervical dysplasia: histologic evaluation, treatment, and outcomes

OBJECTIVE

The purpose of this study was to evaluate histologic findings and outcomes among adolescents with cervical dysplasia.

STUDY DESIGN

Patient charts (2001-2005) were reviewed. Prevalence of cervical intraepithelial neoplasia (CIN) grades 2 and 3 and progression and regression were recorded.

RESULTS

Five hundred one patients were identified. On biopsy, 324 patients (65%) had CIN 1 or less, and 177 patients (35%) had CIN > or = 2. Twenty-nine percent of the patients with CIN 2 opted for conservative treatment vs excision. Over 18 months, the condition of 65% of the patients regressed; the condition of 20% of the patients was stable, and the condition of 5% of the patients progressed without cancer. Of the patients who underwent excision (follow-up median, 26 months), 84% experienced regression of their condition; the condition of 11% was persistent, and 5% progressed with no cancer.

CONCLUSION

CIN > or = 2 is present in 35% of our cohort. Most had CIN 2, and most experienced regression. Our observation supports continued vigilance in the evaluation of adolescents but suggests that less intervention for CIN 2 may be acceptable.

Cervical Intraepithelial Neoplasia in Adolescent Women

OBJECTIVE

We sought to estimate the incidence of cervical intraepithelial neoplasia (CIN) and treatment outcomes in adolescents with abnormal cytology.

METHODS

Adolescent women (ages 14-21 years) referred to colposcopy clinic for abnormal cytology from 1992 to 2004 were identified by computerized database. Only adolescents with biopsy-proven CIN were evaluated. Demographic and risk factor data were obtained from medical records. Referral cytology, histology on biopsy and loop electrosurgical excisional procedure (LEEP), and follow-up cytology were analyzed and compared. Statistical analysis was performed by chi(2) or Fisher exact test, Student t tests, and logistic regression.

RESULTS

Of 1,678 adolescents, 517 had biopsy-proven CIN and follow-up. Seventy-seven patients were referred with atypical squamous cells of undetermined significance (ASCUS) cytology; 174 patients were referred with low-grade squamous intraepithelial lesions (LSIL), 258 with high-grade squamous intraepithelial lesions (HSIL) and eight with atypical glandular cells (AGC). The rate of CIN 2/3 in patients with ASCUS, LSIL, and HSIL was 35% (95% confidence interval 24-46%), 36% (29-43%), and 50% (44-56%), respectively. A total of 192 patients with biopsy-proven CIN 2/3 underwent a LEEP. No patients were diagnosed with cervical carcinoma. Fifty-five percent (95% confidence interval 48-62%) of patients had abnormal cytology on follow-up, suggesting recurrence or reinfection.

CONCLUSION

Adolescents with abnormal cytology have a high incidence of CIN2/3 and high rates of abnormal cytology after LEEP. Cervical intraepithelial neoplasia 2/3 is common in adolescents with abnormal cytology, yet no cases of cancer were identified. Importantly, LEEP fails to meet its therapeutic goals given a high incidence of abnormal follow-up cytology and may represent overly aggressive therapy because the majority of human papillomavirus infections are transient with high regression rates.

LEVEL OF EVIDENCE

III.

Cervical cancer prevention in the era of prophylactic vaccines: A preview for gynecologic oncologists

OBJECTIVE

The recent approval of a vaccine to prevent HPV infection is an important advance in cervical cancer prevention. This article is intended to provide gynecologic oncologists with a comprehensive background in modern cervical cancer prevention strategies.

METHODS

We describe and contrast the quadrivalent and bivalent vaccines. More established cervical cancer prevention strategies are reviewed, with comments on the impact of HPV vaccination. Clinical guidance is provided for use of the approved quadrivalent vaccine. Safety and side effects of both vaccines are reviewed and future questions and challenges are explored.

RESULTS

It is vitally important that both vaccinated and unvaccinated women continue to fully engage in cervical cancer prevention, including cervical cancer screening, follow-up of abnormal screens, and treatment of premalignant lesions. A quadrivalent virus-like particle vaccine has now been approved for use in girls and women ages 9 to 26. A bivalent vaccine may be available soon. Vaccine efficacy in clinical trials has been outstanding, with 100% protection against HPV-type-specific cervical intraepithelial neoplasia (CIN) II and III.

CONCLUSIONS

Comprehensive cervical cancer protection now includes prophylactic vaccination for girls and young women in addition to screening and treatment of premalignant changes. Gynecologic oncologists will continue to play an important role in promoting optimal prevention practices.

Human papillomavirus triage for young women with atypical squamous cells of undetermined significance

OBJECTIVE

Human papillomavirus testing is a cost-effective strategy for the management of atypical squamous cells of undetermined significance. Young women have a high prevalence of transient human papillomavirus infections and low incidence high-grade cervical lesions, which may limit the usefulness of human papillomavirus testing in this cohort. We sought to estimate the usefulness of human papillomavirus testing for young women with atypical squamous cells of undetermined significance.

METHODS

A retrospective study of women with atypical squamous cells of undetermined significance was undertaken. Reflex human papillomavirus results and pathologic follow-up were evaluated. Age-stratified rates of human papillomavirus positivity, rates of high-grade dysplasia, and sensitivity and specificity were estimated.

RESULTS

A total of 1,290 women with atypical squamous cells of undetermined significance cytology were identified. The rate of human papillomavirus positivity decreased with age from 55% for those aged 25 years or younger to 12% for women aged older than 50 years (P < .001). The cumulative rate of high-grade lesions increased with age; 12% for patients aged 25 years or younger compared with 24% for women aged older than 50 years (P = .05). A negative human papillomavirus test more effectively excluded high-grade disease in the young women. No high-grade lesions were detected in the human papillomavirus negative women aged 25 years or younger compared with 3.8% of those aged older than 50 years (P = .04). The sensitivity for detection of high-grade disease was higher in women aged younger than 25 years compared with those aged older than 50 years (100% compared with 50%), whereas specificity was lower (14% compared with 44%).

CONCLUSION

Given the high prevalence of human papillomavirus and low occurrence of high-grade lesions in young women with atypical squamous cells of undetermined significance, a human papillomavirus-based triage strategy will result in the referral of a large number of women for colposcopy and may limit its cost-effectiveness.

LEVEL OF EVIDENCE

III.