Clinical Question

Is colposcopy with biopsy better than repeat cytology alone within six months to prevent invasive cervical neoplasia?

Bottom Line

Among women 22 to 27 years of age with an index cervical cytology showing abnormal squamous cells of undetermined significance (ASCUS) or low-grade squamous intraepithelial lesion (LSIL), the incidence of invasive cervical cancer did not differ between repeat cytology within six months or colposcopy with biopsy within six months. For women 28 years or older, there was an increased risk of invasive disease with the repeat cytology approach. Among the younger women, there was an increased incidence of invasive disease using an interval for cytology of seven to 12 months. An initial follow-up approach for the younger group using cytology only within six months would avoid 27% of colposcopic procedures in that group and save significant health care resources. Note that colposcopies that did not include any histologic specimen were classified as cytology only. (Level of Evidence = 2b)

Synopsis

This large cohort study from Sweden includes all women in the country 22 to 50 years of age who underwent cervical cancer screening between 1989 and 2011 (N = 2,466,671). Multiple national registries were linked and are believed to be complete. Women were followed from their first registered cytology until diagnosis of invasive cancer, total hysterectomy, emigration, death, or the end of 2011, whichever came first. Median follow-up was 9.9 years. Cervical cancers diagnosed within six months of the initial cytology were considered prevalent cancers. Cancers diagnosed between 0.5 and 6.5 years after the index cytology were considered incident cancers. The authors identified women with an index cytology showing ASCUS or LSIL and analyzed the follow-up. Follow-up was classified as cervical histology, cytology only (which included any colposcopy without biopsy), or no morphologic follow-up. Analysis of crude incidence by age showed differing risks for women 22 to 27 years of age (n = 71,449) vs. women 28 to 50 years of age (n = 119,528). Incident cervical cancer for the younger group did not differ whether initial follow-up was histologic or repeat cytology within six months (incidence rate ratio = 2.0; 95% confidence interval, 0.6 to 6.5), but was higher if cytology was performed at seven to 12 months (incidence rate ratio = 5.3; 95% confidence interval, 1.1 to 20.0). For older women, the risk of incident cancer after ASCUS or LSIL was much higher and the incident rate ratio within six months was apparently statistically significant, but it was not reported in the paper.

Study design: Cohort (retrospective)

Funding source: Government

Setting: Population-based

Reference:Sundström K, Lu D, Elfström KM, et al. Follow-up of women with cervical cytological abnormalities showing atypical squamous cells of undetermined significance or low-grade squamous intraepithelial lesion: a nationwide cohort study. Am J Obstet Gynecol. 2017;216(1):48.e1–48.e15.