February 27, 2018

expert reaction to study looking at regular monitoring rather than immediate treatment for certain cervical lesions

A systematic review and meta-analysis which looks at rates of regression, persistence, and progression of untreated cervical lesions, is published in the BMJ.

Prof Jack Cuzick FRS, Director of the Wolfson Institute of Preventive Medicine, Head of Centre for Cancer Prevention, and John Snow Professor of Epidemiology, QMUL, said:

“It has long been known that the clinical course of CIN2 is highly variable, and that only a small proportion will progress to higher grade lesions or cancer.  Its diagnosis is also highly variable with typically only a 50% agreement between pathologists on the same biopsy.  While more conservative management is highly desirable, better markers of progression are needed if we are to reliably identify progressive lesions.  One potential marker is p16 which can be done using an addition stain on an adjacent slide from the biopsy.  p16 is a marker of an active HPV infection, and lack of staining can reliably down grade some CIN2 lesions.  However when used on lower grade lesions it appears to upgrade a similar or greater number of them, so its ability to avoid overtreatment is not established, and it needs to be used only for selected cases.  Other markers of current interest are the genotype of the HPV infection (there are 13 high risk types, but they have differing risks of progression), the amount of HPV that is present (viral load), and the methylation status of the HPV genes and some related human genes, which appear to influence the progressive potential of the lesion.

“The role of these factors is being actively investigated, and hopefully will help to more reliably identify which CIN2 lesions are like to progress if left untreated, and which are likely to regress naturally as a result of the body’s immune response to the virus.”

Mr John Butler, Consultant Gynaecological Oncology Surgeon, The Royal Marsden NHS Foundation Trust, said:

“This study provides helpful information for the management of a subgroup of women with the cervical cancer pre-cursor cervical intraepithelial neoplasia (CIN2).  Standard management involves excision of the lesion which may be associated with complications from the procedure and any future pregnancies.  The aims of the national cervical cancer screening programme are to reduce the incidence of cervical cancer and improve cervical cancer survival.

“International Cancer Survival Comparisons report low survival in the UK compared to other similar countries.  Therefore whilst this study is of importance to a some patients who are considering their treatment options it is essential that every step is taken to maximise attendance at cervical cancer screening particularly in younger patients, increasing coverage of the cervical cancer vaccination programme, awareness of cervical cancer symptoms to help promote early diagnosis, and improving treatment quality.”

* ‘Clinical course of untreated cervical intraepithelial neoplasia grade 2 under active surveillance: systematic review and meta-analysis’ by Karoliina Tainio et al. published in the BMJ on Tuesday 27 February 2018.

Declared interests

None received.