Regular smear tests rather than colposcopy is the best way of monitoring low-grade cervical lesions

Results of a US study in this week’s issue of THE LANCET suggest that regular smear tests rather than colposcopy is the best way of monitoring low-grade cervical lesions among adolescents and young women.

Around 70% of sexually active women become infected with human pappiloma virus (HPV); around a quarter of women with HPV infection develop low-grade squamous intra-epithelial lesions (LSIL); although LSIL are usually benign and disappear over time, they can develop into high-grade lesions, a precursor of cervical cancer.

Anna-Barbara Moscicki (University of California San Francisco, USA) and colleagues assessed the probability of LSIL regression in young women, and examined the factors associated with regression. female adolescents aged 13–22 years were examined every 4 months by cytology (smear test), colposcopy (internal examination of the vagina and cervix), and HPV DNA status. Regression was defined as at least three consecutive normal smears.

187 women out of 900 originally enrolled in the study developed LSIL. 60% of these women were free of LSIL after 1 year; 90% had regressed naturally 3 years after identification of LSIL.

Dr Moscicki comments: “Our data suggest that most LSILs will regress spontaneously in immunocompetent young women, lending support to a practice of monitoring these cytological lesions. Follow-up HPV status was a strong predictor of regression, but HPV status at time of LSIL diagnosis was not. The finding that persistence of multiple HPV types slows rates of regression should be examined more closely.”

In an accompanying commentary (p 1642), Anne Szarewski and Peter Sasieni (Cancer Research UK) conclude: “Moscicki and colleagues have clearly shown just how common and essentially meaningless LSIL is in young women. They suggest that “the strategy of colposcopy for all adolescents and young women with LSIL is unwarranted”. We would go further. Evidence suggests that there is considerable anxiety and psychosexual morbidity associated with cervical screening and colposcopy. If this is the case in general, how much more so in young women? How might this affect their future emotional and sexual development? Since there is no point in treating LSIL in young women, we should reflect on the basic tenet of medicine: at least do no harm. We see absolutely no role for colposcopy in adolescents as part of routine management.”

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