Management of women with cervical cancer precursor lesions

An understanding of the natural history of HPV-induced precancer and cancer, and of the immune response to HPV and to these lesions, has significantly changed the management of lower genital tract neoplasia. New management guidelines incorporate this understanding, providing a more rational approach to diagnosis and treatment. Understanding that low-grade HPV-induced lesions are not true cervical cancer precursor has fostered expectant management of women with these lesions; however, management approaches are still hampered by the inability to better predict who is at risk for high-grade intraepithelial neoplasia and cancer and who is not; this is particularly problematic in the expectant management of CIN 1. In addition, the decision whether or not to treat these low-grade lesions may depend on a number of complex factors that take into account the woman's preferences and reliability for follow-up, as well as a host of issues related to costs and the reliability of the original diagnosis and the tests used for follow-up. Management options for high-grade cervical cancer precursor lesions are much more definitive, because the option of expectant management is given except in pregnancy and for adolescents with CIN 2. New markers that better predict which women with high-risk HPV are at highest risk for subsequent development of a true cervical cancer precursor lesion appear to be on the horizon and may make the management of low-grade lesions as clear as present guide lines for their high-grade cousins. Until that time, understanding all the issues involved in expectant and in active management of cervical HPV-induced lesions will help provide women with the best care possible.