NEW YORK — With revisions to the consensus guidelines for the management of women with cervical cytological abnormalities expected in 2006, experts are taking a hard look at ways the guidelines might be tailored to be more age specific.
Much less is known about the natural history of cervical intraepithelial neoplasia (CIN) in young women, compared with older women. The 2001 guidelines do not provide specific recommendations for adolescents and young women, and the result today “is that we are probably doing a lot more harm than good,” Thomas C. Wright, M.D., said at a gynecology conference sponsored by Mount Sinai School of Medicine.
Screening as it is practiced today is generating a large number of false positives, particularly among younger women. In adolescents aged 16-18 years, 1 in 10 will have a false positive result, and the cost implications of that are significant, he said.
Of course, false positives generate tremendous anxiety. “Today's 18-year-olds go on the Web, they know about HPV [human papillomavirus], they're afraid they are going to develop invasive cervical cancer. They are afraid they will be transmitting a disease to their boyfriends. There is a huge amount of concern associated with abnormal results in this population,” he said.
Why all the false positives? High-risk strains of HPV are “essentially ubiquitous” among sexually active young women. “I have looked at young women serially over a period of 2-3 years, and found that two-thirds became HPV-DNA positive,” said Dr. Wright, director of the division of gynecologic and obstetric pathology, Columbia University College of Physicians and Surgeons, New York City.
In another study, more than 80% of college-aged women were HPV positive when tested monthly, but the vast majority are transient infections and clear spontaneously. In a study from Rutgers University, New Brunswick, N.J., where two-thirds of the participants were HPV positive, by 1 year, 70% of infections had cleared, and by 2 years, 92% had spontaneously cleared. Other studies have shown similar results.
Certain aspects of follow-up and management have been evolving differently for younger women. Among 18-year-olds with Pap smears classified as atypical squamous cells of undetermined significance (ASCUS), 71% will be positive for high-risk HPV and two-thirds will continue to be abnormal on a repeat Pap smear. “Anything you do in this population means that the bulk of them are going to end up getting sent for colposcopy,” he said.
“We don't have a recommendation on how you should manage ASCUS, but I can tell you that in an 18-year-old it is probably not wise to be doing HPV-DNA testing. What we are doing at Columbia is following up with repeat cytology,” he said.
For low-grade squamous intraepithelial lesions (LSIL), the options are to repeat the Pap smear, perform HPV testing, or to do a colposcopy. “HPV testing in a young woman with LSIL is a complete waste of time, as 87% are going to be HPV-DNA positive. If you repeat the Pap smear, 81% are going to remain abnormal unless you wait years for the infection to clear,” he said. Most [physicians] believe adolescents with LSIL should undergo colposcopy, he said.
For high-grade squamous intraepithelial lesions (HSIL) in adolescents or young women colposcopy is recommended. “But if the lesions are not biopsy-confirmed cervical intraepithelial neoplasia (CIN) 2 or 3, rather than doing a loop electrosurgical excisional procedure, we can follow them by doing colposcopy and cytology at 4- to 6-month intervals provided the colposcopy is satisfactory, the endocervical curettage findings are essentially negative, and the patient accepts the risk of possible occult disease,” Dr. Wright said.