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Posttreatment assessment of women at risk of developing high-grade cervical disease: proposal for new guidelines
Margot H Uijterwaal1, Mariëlle Kocken, Johannes Berkhof
1Departments of 1Pathology and 2Epidemiology and Biostatistics, VU University Medical Center, Amsterdam; 3Department of Obstetrics and Gynecology, University Nijmegen Medical Center, Nijmegen; 4Department of Women and Baby, University Medical Center Utrecht, Utrecht; and 5Department of Obstetrics and Gynaecology, Erasmus University Medical Center, Rotterdam, The Netherlands.
Objective:
Women treated for high-grade cervical disease (cervical intraepithelial neoplasia grade 2 or grade 3 [CIN2/3]) face a significant risk of developing post-treatment disease. Therefore, in most European countries, they are monitored by cytologic testing at 6, 12, and 24 months after treatment. Although testing for high-risk types of the human papillomavirus (hrHPV) in the follow-up seems to be a valuable supplementary method, its use is not yet fully explored.
Methods:
Besides reviewing the literature, we completed a long-term follow-up study describing the cumulative risk for CIN2/3 or cancer (CIN2+) of different hrHPV and cytology test results after treatment.
Conclusions:
High-risk HPV testing improves the sensitivity to detect posttreatment CIN2/3 (relative sensitivity=1.15, 95% confidence interval [CI]=1.06-1.25), but the highest sensitivity (95%, 95% CI=91%-98%) is reached by performing cotesting (both cytology and hrHPV). The CIN2+ risk after a single negative cotesting result taken 6 months after treatments was similar to the risk after 3 consecutive negative cytologic test results (5-y CIN2+ risk being 3.0% [95% CI=1.5%-6.1%] and 2.9% [95% CI=1.2%-7.1%], respectively). Women who test negative for cotesting at both 6 and 24 months after treatment have a minimal risk of developing CIN3+ in the next 5 years (0.0%, 95% CI=0.0%-3.0%).
Recommendations:
We propose a new posttreatment surveillance protocol, consisting of combined testing with both cytology and hrHPV at 6 and 24 months after treatment. After 2 negative cotesting results, women should be retested after 5 years.