Management and treatment of cervical intraepithelial neoplasia in the Netherlands after referral for colposcopy

Abstract

Introduction The aim of this study was to describe trends in the diagnosis and treatment of women referred from the national screening program with cervical intraepithelial neoplasia (CIN) in the Netherlands, and to compare these trends with national guidelines and identify potential areas for improvement for the new primary high‐risk HPV screening program. Material and methods We conducted a population‐based cohort study using data from the Dutch pathology archive. Women aged 29‐63 years who took part in the Dutch cervical screening program between 1 January 2005 and 31 December 2014 were selected. Three referral groups were identified: direct referrals and those referred after either one (first indirect referrals) or two (second indirect referrals) repeat cytology tests, totaling 85 239 referrals for colposcopy. The most invasive management technique and the most severe diagnosis of each screening episode was identified. Rates of management techniques were calculated separately by referral type, highest CIN diagnosis and age group. Results In all, 85.1% of CIN 3 lesions were treated with excision (either large excision or hysterectomy) and 26.4% of CIN 1 lesions were treated with large excision. Rates of overtreatment (CIN 1 or less) in see‐and‐treat management were higher for indirect referrals than for direct referrals and increased with age. Large excision rates increased with CIN diagnosis severity. Conclusions Despite guideline recommendations not to treat, CIN 1 lesions were treated in just over 25% of cases and approximately 15% of CIN 3 lesions were possibly undertreated. Given the expected increase in CIN detection in the new primary high‐risk HPV screening program, reduction in CIN 1 treatment and CIN 2 treatment in younger women is needed to avoid an increase in potential harm.

Benefit and burden in the Dutch cytology-based vs high-risk human papillomavirus-based cervical cancer screening program

“…This is in line with the Dutch guidelines, advising conservative management in women with CIN2 and who have not yet completed childbearing, which had been implemented in 2015. 9,23 The rate of histologic results indicating CIN1 increased to 143.4%, and women were managed conservatively after biopsy nearly 2.5 times more often in hrHPV-based screening than in cytology-based screening (1745 vs 696 per 100,000 screened women, respectively). The Dutch study from Aitken et al 20 revealed 2.2 times more CIN1 in hrHPV-based screening; however, they did not further differentiate between overdiagnosis or overtreatment.…”

A comparative study between results of different modalities of management of cervical intraepithelial neoplasia I

“…7 In one study, managements were given among CIN I patients expectant management 34.6%, local ablative methods 7.3% & LEEP 56.8% cases, whereas in this study, expectant treatment were received 25(33.3%), 53.3% were treated with either cold coagulation or other ablative method & 13.3% LEEP regarding their size & extent of lesions.8 Excision procedure done in this study were in 13.3% cases, where as in other study it was about 26.4%. 9 Persistence of disease were found in 2(13.3%) ladies those did not receive treatment & came for follow up within 12 months, 3(10.7%) who were treated with cold coagulation & 1(12.5%) lady who received treatment with LEEP in this study, whereas persistence & progression of disease in case of immediate treatment about 1.7% & 4.4% in non treatment group in another study, which are much lower than this study. 10 There is very little difference in the frequency of colposcopic abnormalities during the follow up period between 3 treatment groups.…”

Human telomerase RNA component (hTERC) gene expression and chromosome 7 ploidy correlate positively with histological grade of cervical intraepithelial neoplasia

“…An observational study of colposcopy practice in U.S. community‐based clinics found 87.2% of the patients as having low‐grade indications, namely atypical squamous cells of undetermined significance (ASCUS)/LSIL/HPV positive; additionally 13% of the patients were <25 years 9 . A nationwide study from the Netherlands reported that despite guidelines recommending not to treat, 26.4% of CIN1 lesions were treated with large excisions 16 . Maura et al 17 found 10% of almost 6 million French women who underwent a Pap smear to be <25 years old, although national guidelines recommended initiating screening from the age of 25 years.…”