Cancer Screening in the Young Female

Abstract

The United States Preventive Services Task Force Guidelines recommend that cervical cancer screening be instituted at the age of 21. The American College of Obstetricians and Gynecologists Practice Bulletin of December 2009 has also recommended that 21 should be the age when cervical cancer screening should be instituted. The reasons for this are quite clear, because several studies have clearly indicated that the incidence of invasive cervical cancer in females under the age of 21 is quite rare. Watson et al found that approximately 0.1% of cases of cervical cancer occur in this age group. The surveillance epidemiology and end results data from 2002 to 2006 suggest an incidence rate of 1–2 cases of cervical cancer per 1 million females aged 15–19 years. Many biologic factors expose the young female to infections from the human papillomavirus virus during sexual intercourse. In the overwhelming majority of cases, the active immune system of most young females rids the individual of this infection. In addition, within a 3-year period in more than 90% of cases the infection is eradicated. Therefore, what are we to make of the report of Zhao et al from the University of Pittsburgh Medical Center Pathology Laboratory Magee-Womens Hospital? During their retrospective study period encompassing July 1, 2002, to December 2007, 474 females aged 20 or younger were found to have a high-grade squamous intraepithelial lesion cytologic result. Of these, 335 had at least 1 cervical biopsy with or without endocervical curettage and were included in this analysis. The 335 young females with histopathology follow-up ranged in age from 13 to 20, with a mean age of 18.6 years. They had a follow-up for an average of 24 months. Histopathologic evidence of CIN was found in 91.2% of the young female patients with high-grade squamous intraepithelial lesion (HSIL) cytology, with 7.2% reporting CIN 3, 37% CIN 2, and 47.8% CIN 1. Thus, 44.2% of the young female patients with cytology suggesting the presence of HSIL had biopsy confirmation of HSIL, whereas the remaining patients demonstrated CIN 1 in 47.8% of cases, with the others having negative biopsies. Considering the relative lack of sensitivity of colposcopy, one can assume that the presence of HSIL in this population would in fact be higher than that detected by biopsy. Wright et al found a prevalence of 0.7% of HSIL smears in 10 090 tests performed. Our own laboratory reported a 0.3–0.5 prevalence of HSIL smears. The overwhelming majority of low-grade squamous intraepithelial lesions will spontaneously regress in this age group, as well as a high proportion of those found to have CIN 2 and 3 on cervical biopsy. In addition, to be considered is the potential damage of aggressive therapy in this age group. The most commonly used approach to the management of CIN 3 is loop electrosurgical excision of the cervical transformation zone (LEEP). This has been demonstrated to result in an increased risk for preterm birth, especially among females without previous preterm births.