Active monitoring, vs immediate treatment, of cervical intraepithelial neoplasia grade 2 (CIN2) may be justified in young women, according to a systematic review and meta-analysis published online February 27 in the BMJ.
“The results of our analysis show higher rates of regression and lower rates of progression of histologically confirmed CIN2 lesions than previously reported, particularly in women aged less than 30” and suggest that “[c]onservative management with active surveillance, instead of immediate local excision, is therefore justified in selected women, especially if further pregnancies are considered and compliance with surveillance is likely to be high (primum non nocere),” write Karoliina Tainio, MD, from the University of Helsinki and Helsinki University Hospital, Finland, and colleagues.
The investigators identified 36 studies that included 3160 women with histologically confirmed CIN2 who were not treated at diagnosis. All women were monitored for at least 3 months and had a diagnosis at the end of the study period.
The researchers included publications between January 1, 1973, and August 20, 2016. Rates of regression, persistence, and progression were evaluated as well as rates for nonadherence with active surveillance. Literature searches, data extraction, and risk of bias assessment were performed independently and in duplicate by two of the researchers, and heterogeneity between studies was assessed with the I2 metric of inconsistency.
Overall, the investigators found that rates of regression were high: 46% at 12 months (13 studies; 300/628 women; 95% confidence interval [CI], 36% – 56%; I2 = 81%) and 50% at 24 months (11 studies; 819/1470 women; 95% CI, 43% – 57%; I2 = 77%).
Progression rates increased with time — they were as low as 5% at 3 months (three studies; 7/133 women; 95% CI, 2% – 10%; I2 = 0%) and as high as 24% at 36 months (three studies; 105/370 women; 95% CI, 12% – 39%; I2 = 87%). The pooled persistence rate was 47% at 3 months (three studies; 56/145 women; 95% CI, 16% – 79%; I2 = 93%) and remained stable at approximately 30% for the remaining time points through 24 months.
The investigators also found, however, that 50% of the studies (18/36) met the criteria for high risk of bias, most often as a result of loss to follow-up. In addition, follow-up procedures varied greatly between studies with respect to colposcopic evaluation or histologic sampling.
The authors caution that the results should be interpreted with care given the substantial heterogeneity between studies as well as the possibility of lesion misclassification, a recognized problem in clinical practice.
“Although the risk of missing glandular or invasive disease and the risk of progression is relatively low, active surveillance should be offered only to women who would likely benefit from it,” the researchers conclude.
Reassuring Data, but Patient Selection Is Critical
“Although this meta-analysis might not have all the answers, it does provide the best information to date on likelihood of regression or progression after a diagnosis of CIN2,” writes Maggie Cruickshank, MBChB, MD, FRCOG, professor of obstetrics and gynecology, at the University of Aberdeen School of Medicine, United Kingdom, in an accompanying editorial.
Cruickshank suggests that the risk for progression to cancer may still be unacceptable for some and cautions that “data on the duration of ‘active surveillance’ was limited” and that there is still not “a clear definition of active surveillance in the context of CIN2.”
“Knowledge of the rates of regression from CIN2 are reassuring but they must be presented in a meaningful way alongside clear information about the effects of both surveillance and treatment, so women can make fully informed choices,” Cruickshank concludes.
Funding for this study was provided by the Sigrid Jusélius Fellowship, the British Society of Colposcopy Cervical Pathology Jordan/Singer Award, the Imperial College Healthcare Charity, Genesis Research Trust, the Imperial Healthcare NHS Trust National Institute for Health Research Biomedical Research Centre, the Academy of Finland, Competitive Research Funding of the Helsinki and Uusimaa Hospital District, the Jane and Aatos Erkko Foundation, the Sigrid Jusélius, and the Competitive Research Funding of the Helsinki and Uusimaa Hospital District. The authors and editorialist have disclosed no relevant financial relationships.
BMJ. Published online February 27, 2018. Full text, Editorial
For more news, join us on Facebook and Twitter
Tidak ada komentar:
Posting Komentar