See-and-treat: striking a balance between over- and under-treatment.

Abstract

Secondary prevention of cervical cancer based on cervical cytology generally employs a multi-visit approach: screening with cytology, diagnosis with colposcopically directed biopsy, and treatment. Updated screening and management guidelines emphasise the precision of diagnosis and use estimates of risk to avoid overtreatment or undertreatment. The need to return for multiple visits presents an obstacle for many women and may prevent them from completing the process from screening to treatment. A recent analysis of a population-based screening registry in New Mexico found that 16.3% of women with cervical smear tests indicating high-grade squamous intraepithelial lesions had no follow up within a 12-month period. Those with low-grade smears had higher rates of loss to follow up. Furthermore, among those with a high-grade smear who had a biopsy confirming cervical intraepithelial neoplasia (CIN) 3 or worse, only 60.0% received excisional treatment within 1 year (Kinney et al. Gynecol Oncol 2014;132:628–35). The see-and-treat approach can reduce loss to follow up between biopsy and treatment. Women with abnormal cytology are examined colposcopically and treated with an outpatient loop electrosurgical excision procedure in a single visit, so bypassing a visit for biopsy. There is tension between the multivisit approach with its inherent risk of undertreatment from loss to follow up and see-and-treat, in which the lack of a colposcopically directed biopsy often leads to overtreatment. Overtreatment may take two forms, treatment of a cervix with less than final histology results of no CIN or CIN1, and treatment of high-grade squamous intraepithelial lesions that, if observed over time would have spontaneously regressed. Ebisch et al. in this issue of BJOG analyse the impact of cytology and colposcopic impression on overtreatment, i.e. ultimate histology of no CIN or CIN1 (BJOG 2015;doi: 10.1111/1471-0528.13530). They extracted data from 13 studies and show a relatively low (11.6%) rate of overtreatment in women with both high-grade cytology and a high-grade colposcopic impression. The overtreatment rate in this group of women was significantly lower than in those with high-grade cytology and a low-grade colposcopic impression (29.3%) or those with low-grade smear regardless of whether the colposcopic impression was high-grade (46.4%) or low-grade (72.9%). The management guidelines of the American Society for Colposcopy and Cervical Pathology (ASCCP) recommend see-and-treat as an acceptable option in cases of a high-grade smear, when possible perinatal risks from excision are not a consideration. (Massad et al. J Low Genit Tract Dis 2013;17:S1–27). Colposcopic impression is not part of the ASCCP metric, but human papillomavirus status, if known and in the rare case that it is negative, may be considered. Ebisch's data suggest that colposcopic impression may indeed have a role to play when a high-grade smear is associated with a low-grade colposcopic impression. In these women, as part of shared decision-making, biopsy may be the better option. Clearly see-and-treat is an important option in selected women; it can reduce incomplete care. Can we further reduce overtreatment? Additional research is needed to evaluate the possible role of biomarkers such as human papillomavirus genotypes or immunostains, or newer imaging modalities. More and larger studies evaluating the role of the colposcopic impression are also needed. Full disclosure of interests available to view online as supporting information. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.