title: Referral compliance, outcome and predictors of CIN after repeated borderline cervical smears in the Netherlands.
abstract: BACKGROUND
  Borderline cytological abnormalities are diagnosed very frequently but have limited predictive value for high-grade cervical lesions, resulting in high costs, patient anxiety and over treatment. A conservative management strategy for the Dutch diagnostic equivalent of borderline nuclear changes (BNC) was introduced in the Netherlands in 1996, with repeat cytology at 6 and 18 months and referral for colposcopy if BNC is persistent.
  
  
  OBJECTIVE
  To analyse compliance with the current guidelines for referral, as well as the outcome after repeated BNC. Concurrently we investigated whether other variables are predictive of high-grade lesions.
  
  
  METHODS
  We retrieved 1898 eligible cases of repeated BNC with 4 years follow-up from the national pathology database (PALGA) and performed a nationwide survey.
  
  
  RESULTS
  The management strategy for women with repeated BNC in the Netherlands has been accepted and supported. Seventy-seven per cent (77%) of the patients had visited a gynaecologist within 1 year and only 4.3% were lost to follow-up. We found that 25.2% of the patients had a low-grade lesion or worse (CIN 1+) and 10.2% had a high-grade lesion or worse (CIN 2+), among which were four malignancies. The only variable associated with CIN or worse was age. Women under 40 years were found to be at a higher risk.
  
  
  CONCLUSIONS
  This finding may be used for prioritizing women for colposcopy on the basis of their age. More stringent use of the diagnosis of BNC, higher thresholds for colposcopically directed biopsy and introduction of HPV triage, combined with more specific new techniques or combination of techniques such as molecular markers for P16, MIB-1 and L1 may reduce the unnecessary high referral rate and over treatment of healthy women.
authors.affiliation: Department of Pathology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands. b.siebers@pathol.umcn.nl
authors.forename: A G
authors.initials: AG
authors.lastname: Siebers
authors.forename: L F A G
authors.initials: LF
authors.lastname: Massuger
authors.forename: J
authors.initials: J
authors.lastname: Bulten
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D002467:Cell Nucleus / Q000473:pathology; D002648:Child; D005260:Female; D006801:Humans; D008875:Middle Aged; D009426:Netherlands / Q000453:epidemiology; D010349:Patient Compliance; D011237:Predictive Value of Tests; D012017:Referral and Consultation; D002578:Uterine Cervical Dysplasia / Q000453:epidemiology / Q000473:pathology*; D002583:Uterine Cervical Neoplasms / Q000453:epidemiology / Q000473:pathology*; D014626:Vaginal Smears / Q000523:psychology*