Treatment of cervical precancers: back to basics

Both ablative (cervical cryotherapy, laser ablation) and excisional methods (loop electrosurgical excision procedure, cold knife conization) can be effective at treating cervical precancer. Excisional procedures are associated with adverse obstetric outcomes including preterm delivery and perinatal mortality with the depth of excision potentially contributing to the adverse outcomes. Ablative therapies are now used much less commonly than loop electrosurgical excision procedure but have less of an effect on adverse obstetric outcomes and hence are effective alternatives for treating cervical precancer in reproductive-aged women. Morphometric data indicate that the vast majority of precancerous lesions are less than 5 mm deep, suggesting that treatments that reach 6-7 mm below the epithelium are adequate in women with satisfactory colposcopy. Cone biopsies, "top-hat" loop electrosurgical excision procedures, or the use of loop electrodes greater than 10 mm are therefore unnecessary for the majority of reproductive-aged women and increase risk of adverse obstetric outcomes. New consensus guidelines allow observation instead of treatment in appropriately selected young women. Until the association of excisional methods with adverse obstetric outcomes is clarified with more data, ablative methods should be revitalized and used by health care providers in appropriately selected patients. Treatment should be individualized based on patient's age, fertility desires, and colpopathologic findings.