Imperial College London

Regular monitoring rather than treatment justified for some cervical lesions

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Cervical biopsy showing a low grade lesion

Women with low grade cervical lesions (CIN2, pictured) could benefit from active monitoring

Some women with abnormal cells on their cervix may benefit more from regular monitoring than immediate treatment, new research suggests.

The presence of abnormal cells on the surface of the cervix, called lesions, can be harmless but in some cases have the potential to develop into cervical cancer.

In a study, led by Imperial College London, researchers suggest that most moderate lesions clear up spontaneously, without treatment, particularly in younger women.

They found that regular monitoring, or 'active surveillance', rather than immediate treatment is justified for these types of lesions -- often called cervical intra-epithelial neoplasia grade 2 or CIN2.

According to the authors of the paper, published in The BMJ, the findings should help women to make more informed choices with their doctor, but they advise the results should be interpreted with caution due to the study limitations.

CIN is divided into grades 1, 2 or 3 based on how deep the cell changes go into the cervix. CIN has the potential to progress to cancer, but may also return to normal (regress) or remain unchanged.

A diagnosis of CIN2 is currently the cut-off point for treatment, but some studies have suggested that CIN2 lesions often regress completely without treatment and should be actively monitored instead, especially in younger women because treatment can be harmful for future pregnancies.

Reviewing the evidence

In the latest study, an international team of researchers led by Dr Maria Kyrgiou, a clinical senior lecturer in the Department of Surgery & Cancer at Imperial, set out to estimate rates of regression, persistence, and progression of untreated CIN2 lesions as well as compliance with active surveillance.

They analysed results from 36 studies involving 3,160 women with a laboratory-confirmed diagnosis of CIN2 who were actively monitored for at least three months. Differences in study design and quality were taken into account, and rates of regression, persistence, and progression were measured at 3, 6, 12, 24, 36, and 60 months.

After two years, 50% of the lesions had regressed spontaneously, almost one third (32%) persisted, and just under one in five (18%) progressed to CIN3 or worse. In women aged under 30, the rate of regression was even higher (60%), persistence was 23%, and progression was 11%.

Based on these estimates, the researchers explain that in 1,000 women aged under 30 with a diagnosis of CIN2, 600 will experience regression, 230 will remain unchanged, and 110 will progress within two years of active surveillance.

Active surveillance

Only 15 cases of cancer (0.05%) were reported, most in women aged more than 30. Compliance with surveillance was high -- around 90% over two years and similar patterns emerged after further analyses to test the strength of the results.

However, the researchers point to some limitations, such as the substantial differences between studies and possible misclassification of lesions. Although they were able to allow for some of these shortcomings, they cannot rule out the possibility that they may have influenced the results.

Dr Kyrgiou said: "Our research has shown that at least half of the moderate precancerous lesions of the cervix regress spontaneously without treatment, and the rates of regression may be higher in younger women. Regular monitoring ('active surveillance') rather than immediate treatment may be justified in selected cases of young women with moderate cervical lesions

"The decision on how to manage these lesions should be carefully discussed and should take into account the regression rates, the risk of cervical cancer, compliance with multiple clinic visits, pregnancy wishes and the possibility of simply delaying treatment.

"The findings should help women make more informed choices with their doctor, but study limitations mean that the results should be interpreted with caution."

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'Clinical course of untreated cervical intraepithelial neoplasia grade 2 under active surveillance: systematic review and meta-analysis' by Karoliina Tainio et al. is published in The BMJ.

This article is based on materials provided by The BMJ.

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Ryan O'Hare

Ryan O'Hare
Communications and Public Affairs

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Email: r.ohare@imperial.ac.uk

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