[Wait-and-see policy versus loop excision after two consecutive Pap-2 cervical smears: over time less surgery and an equivalent outcome; no substantial contribution to be expected from the detection of high risk human papillomavirus].
OBJECTIVE
To determine the number interventions and outcomes in patients referred with two consecutive Pap 2 cervical smear results who were managed either by a wait-and-see policy or aggressively, and to determine whether triage with high-risk human papillomavirus (hr-HPV) detection, resulting in the referral of only hr-HPV positive patients, would lead to the detection of all patients with cervical intraepithelial neoplasia (CIN).


METHODS
Retrospective comparison and retrospective cohort study.


METHODS
282 patients referred in 1997/'99 with 2 consecutive Pap 2 cervical smears in the screening program were included. Patients referred to the UMC St Radboud Hospital (n = 140; mean age: 45 years) underwent a colposcopy during which only lesions suggestive for CIN 3 were treated. All other colposcopic lesions (CIN 2 or less) were not treated but followed prospectively. Patients referred to the Canisius Wilhelmina Hospital (CWZ) (n = 142; mean age: 44 years) underwent colposcopy during which all colposcopic lesions (including CIN 2 or less) were treated directly. The two groups were compared in terms of the final cytological follow-up, the number of loop excisions, and the number of patients with CIN. The mean follow up was 40 months. In the first group, the effect of triage using hr-HPV detection was also investigated retrospectively.


RESULTS
With the wait-and-see approach, statistically significantly fewer diathermic loop excisions were done: 13 versus 124. After the follow-up period there was no statistically significant difference between the two groups in terms of the number of patients with persisting Pap 2: 16 (11%) versus 12 (8%). Triage with hr-HPV detection would identify all patients with CIN 3, 50% of the patients with CIN 2, and none of the patients with CIN 1; of the 48 hr-HPV-positive women, 1 had a CIN 3 lesion and 3 had a CIN 2 lesion; of the remaining 92 women, 2 had a CIN 1 lesion and 3 had a CIN 2 lesion.


CONCLUSIONS
The wait-and-see approach led to fewer interventions, while the number of women with persisting Pap 2 smears was not higher than with the aggressive approach. Triage with hr-HPV may reduce the number of referrals and colposcopies, but follow-up remains necessary in all women regardless of hr-HPV status.
Bekkers
R L M
RL
Universitair Medisch Centrum St Radboud, Postbus 9101, 6500 HB Nijmegen. r.bekkers@obgyn.umcn.nl
Hanselaar
A G J M
AG
Melchers
W J G
WJ
van Schaik
J H M
JH
Boonstra
H
H
Massuger
L F A G
LF
D000328:Adult; D002584:Cervix Uteri / Q000473:pathology / Q000601:surgery / Q000821:virology; D015331:Cohort Studies; D003127:Colposcopy; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008403:Mass Screening; D008875:Middle Aged; D027383:Papillomaviridae / Q000302:isolation & purification*; D030361:Papillomavirus Infections / Q000175:diagnosis* / Q000473:pathology; D012189:Retrospective Studies; D016896:Treatment Outcome; D014218:Triage / Q000379:methods; D014412:Tumor Virus Infections / Q000175:diagnosis* / Q000473:pathology; D002583:Uterine Cervical Neoplasms / Q000473:pathology* / Q000601:surgery / Q000821:virology; D014626:Vaginal Smears; D002578:Uterine Cervical Dysplasia / Q000473:pathology* / Q000601:surgery / Q000821:virology