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What is the Impact of an HPV Vaccination Program on Cervical Cancer and CIN3 Incidence?

BACKGROUND AND PURPOSE:

  • Falcaro et al. (BMJ, 2024) examines the effectiveness of the HPV vaccination program in England across levels of socioeconomic deprivation

METHODS:

  • Observational study
    • NHS England’s National Disease Registration Service
  • Population
    • Women 20 to 64 years
    • Living in England between 2006 and 2020
  • Exposures
    • HPV vaccination
      • Introduced nationally in 2008
      • Routinely offered to girls aged 12 to 13 | Catch up campaigns targeted older teenagers <19 years
    • Socioeconomic status
  • Primary outcome
    • Incidence of invasive cervical cancer and CIN3

RESULTS:

  • 231.1 million women years of observation between 2006 and 2020
    • Cervical cancer diagnoses: 29,968 | CIN3 diagnoses: 335,228
  • The adjusted age standardized incidence rates of cervical cancer and CIN3 among women offered vaccination routinely at age 12 to 13 years were substantially lower than no vaccination
    • Cervical cancer: 83.9% (95% CI, 63.8 to 92.8) lower
    • CIN3: 94.3% (95% CI, 92.6 to 95.7) lower
  • By mid-2020, HPV vaccination had prevented
    • Cervical cancers: 687 (95% CI, 556 to 819)
    • CIN3s: 23,192 (95% CI, 22,163 to 24,220)
  • The highest rates of cervical cancer and CIN3 were observed for women living in the most deprived areas although benefit was seen among all levels of deprivation
  • In women offered catch-up vaccination, CIN3 rates decreased more in those from the least deprived areas than from the most deprived areas
    • Offered vaccination at age 16 to 18
      • Least deprived: 40.6% reduction | Most deprived: 29.6% reduction
    • Offered vaccination at age 14 to 16
      • Least deprived: 72.8% | Most deprived: 67.7%
  • There was a strong downward gradient in cervical cancer incidence from high to low deprivation in the unvaccinated group
    • This trend was no longer present among those offered the vaccine

CONCLUSION:

  • The HPV vaccination program in England has been very effective at reducing cervical cancer and CIN3 incidence
  • The program was effective across all socioeconomic deprivation groups, especially in cohorts that were routinely offered vaccination at a young age
  • The authors state

The English HPV vaccination programme was associated with substantially lower rates of cervical cancer and CIN3 in all fifths of socioeconomic deprivation, although the highest rates remained among women in the most deprived areas

Learn More – Primary Sources:

Effect of the HPV vaccination program on incidence of cervical cancer and grade 3 cervical intraepithelial neoplasia by socioeconomic deprivation in England: population based observational study

Meta-Analysis: What are the “Red Flag” Signs of Early Onset Colorectal Cancer?

BACKGROUND AND PURPOSE:

  • Rate of early-onset colorectal cancer (EOCRC; defined as diagnosis <50 years) is increasing
  • Demb et al. (JAMA Network Open, 2024) sought to determine the frequency of presenting red flag signs and symptoms among individuals with EOCRC

METHODS:

  • Systematic review and meta-analysis
  • Study inclusion criteria
    • Patients <50 years diagnosed with nonhereditary CRC
    • Reported on sign and symptom presentation or time from sign and symptom presentation to diagnosis 
  • Study design
    • Quality of the included studies and risk of bias was measured
    • Data on frequency of signs and symptoms were pooled using a random-effects model
  • Primary outcomes
    • Pooled proportions of signs and symptoms in patients with EOCRC
    • Estimates for association of signs and symptoms with EOCRC risk
    • Time from sign or symptom presentation to EOCRC diagnosis

RESULTS:

  • 81 studies | 24,908,126 patients <50
  • Most common presenting signs and symptoms (78 studies)
    • Hematochezia: pooled prevalence 45% (95% CI, 40 to 50)
    • Abdominal pain: pooled prevalence 40% (95% CI, 35 to 45)
    • Altered bowel habits: pooled prevalence 27% (95% CI, 22 to 33)
  • The signs and symptoms with the greatest association with EOCRC likelihood were
    • Hematochezia: estimate range 5.2 to 54.0
    • Abdominal pain: estimate range 1.3 to 6.0
    • Anemia: estimate range 2.1 to 10.8
  • Time from signs and symptoms presentation to EOCRC diagnosis
    • Mean 6.4 (range 1.8 to 13.7) months | 23 studies
    • Median 4 (range 2.0 to 8.7) months | 16 studies

CONCLUSION:

  • For patients with early onset colorectal cancer, the most common signs and symptoms were hematochezia and abdominal pain (nearly half of all patients) and altered bowel habits (over a quarter of all patients)
  • Hematochezia was associated with the highest risk of EOCRC
  • Delays in diagnosis were common, and were generally on the order of 4 to 6 months
  • The authors state

These findings and the increasing risk of CRC in individuals younger than 50 years highlight the urgent need to educate clinicians and patients about these signs and symptoms to ensure that diagnostic workup and resolution are not delayed

Adapting current clinical practice to identify and address these signs and symptoms through careful clinical triage and follow-up could help limit morbidity and mortality associated with EOCRC

Learn More – Primary Sources:

Red Flag Signs and Symptoms for Patients With Early-Onset Colorectal Cancer: A Systematic Review and Meta-Analysis

Is Newborn Screening for Spinal Muscular Atrophy Beneficial in a Real-World Setting?

BACKGROUND AND PURPOSE:

  • Disease-modifying drugs are now available for the treatment of spinal muscular atrophy (SMA), a motor neuron disorder associated with significant morbidity and mortality
  • Early identification and treatment are vital for best outcomes
  • However, there are few data that confirm the benefit of newborn screening vs a control group
  • Schwartz et al. (JAMA Pediatrics, 2024) compared outcome data for patients with SMA diagnosed through newborn screening with those diagnosed after clinical symptom onset

METHODS:

  • Nonrandomized controlled trial
    • SMARTCARE Registry
    • Disease-specific registry for patients with SMA
    • 70 participating centers in Germany, Austria, and Switzerland
  • Participants
    • Children born between January 2018 and September 2021 with genetically confirmed SMA and up to three SMN2 copies
  • Exposure
    • SMA screening through a newborn screening pilot project (2 states in Germany)
    • SMA diagnosis after clinical symptom onset
  • Primary outcome
    • Achievement of major milestones

RESULTS:

  • 234 children
    • Newborn screening: 18.8% | Clinical symptom onset: 81.2%
    • Female: 52.6%
  • Mean age at start of treatment with 1 of the approved disease-modifying drugs
    • Newborn screening: 1.3 (SD, 2.2) months
    • Clinical symptom onset: 10.7 (SD, 9.1) months
  • Major milestones
    • Ability to sit independently
      • Newborn screening: 90.9% | Clinical symptom onset: 74.2%
    • Ability to walk independently
      • Newborn screening: 63.6% | Clinical symptom onset: 14.7%

CONCLUSION:

  • Newborn screening for SMA is beneficial in a real-world setting
  • With screening, infants are diagnosed and treated in the first few months of life, while those who do not receive screening are not diagnosed until approximately a year of age
  • More children who were diagnosed through screening achieved major milestones like being able to sit and ambulate independently
  • The authors state

Patients identified by newborn screening showed better motor development, less need for ventilator support and tube feeding, and less disease burden

While patients still asymptomatic at treatment initiation have a good chance of achieving independent ambulation, this is rather unlikely for those who already exhibited clear symptoms of SMA at treatment onset

Learn More – Primary Sources:

Clinical Effectiveness of Newborn Screening for Spinal Muscular Atrophy: A Nonrandomized Controlled Trial

Is the Use of Antibiotics in Pregnancy or Early Infancy Linked to Childhood Neurodevelopmental Disorders?

BACKGROUND AND PURPOSE:

  • Choi et al. (BMJ, 2024) examined the association between antibiotic use during pregnancy or early infancy and the risk of neurodevelopmental disorders in children

METHODS:

  • Nationwide population-based cohort study and sibling analysis
    • National Health Insurance Service (NHIS) mother-child linked database
    • claims data of the entire population (>50 million) in South Korea
  • Population
    • All children born between 2009 and 2020
  • Exposures
    • Antibiotic exposure during pregnancy or early infancy (≤6 months)
  • Study design
    • Follow-up through 2021
    • 1:1 propensity score matching used to account for potential confounders
    • Hazard ratio (HR) estimated using Cox proportional hazard models
    • Sibling analysis was conducted to account for unmeasured familial factors
  • Primary outcomes
    • Autism spectrum disorder (ASD) | Intellectual disorder | Language disorder | Epilepsy

RESULTS:

  • Pregnancy analysis: 1,961,744 children | Infancy analysis: 1,609,774 children
  • In the overall cohort, antibiotic exposure during pregnancy was associated with increased risks for all four neurodevelopmental disorders
  • In sibling analysis, risks were attenuated towards the null
    • ASD: HR 1.06 (95% CI, 1.01 to 1.12)
    • Intellectual disorder: HR 1.00 (95% CI, 0.93 to 1.07)
    • Language disorder: HR 1.05 (95% CI, 1.02 to 1.09)
    • Epilepsy: HR 1.03 (95% CI, 0.98 to 1.08)
  • In the sibling analyses for antibiotic exposure in early infancy, there was no association between antibiotic exposure and
    • ASD: HR 1.00 (95% CI, 0.96 to 1.03)
    • Intellectual disorder: HR 1.07 (95% CI, 0.98 to 1.15)
    • Language disorder: HR 1.04 (95% CI, 1.00 to 1.08)
  • There was a slight increased risk of epilepsy in the sibling analysis for antibiotic exposure in early infancy
    • Epilepsy: HR 1.13 (95% CI, 1.09 to 1.18)
  • The results generally remained consistent across several subgroup analyses
  • In some subgroup analyses, elevated risks were observed including
    • Antibiotics use during very early life
    • Long term antibiotic use

CONCLUSION:

  • When controlling for familial factors and indications, antibiotic exposure in pregnancy and early life was not associated with autism, or intellectual or language disorders
  • However, there were increased risks for some subgroups: those who used antibiotics in very early life and those who used antibiotics long-term (more than 15 days)
  • There was a slightly elevated risk of epilepsy with antibiotic use in infancy which persisted even after adjustment for confounding
  • The authors state

In this large cohort study, exposure to antibiotics during pregnancy or early infancy was not associated with an increased risk of autism spectrum disorder, intellectual disorder, and language disorder in children

Learn More – Primary Sources:

Association between exposure to antibiotics during pregnancy or early infancy and risk of autism spectrum disorder, intellectual disorder, language disorder, and epilepsy in children: population based cohort study

Is Cesarean Delivery Linked to Lower Fecundability?

BACKGROUND AND PURPOSE:

  • While a link between cesarean delivery and lower fecundability has been proposed, evidence is inconclusive
  • The direction of the causal relationship, if one exists, is also controversial
  • Sima et al. (AJOG, 2024) assessed the bidirectional relationship between cesarean delivery and fecundability

METHODS:

  • Prospective cohort study
    • Norwegian Mother, Father, and Child Cohort (MoBA) Study
  • Participants
    • Pregnant individuals
  • Exposure
    • Forward association: Mode of previous delivery
    • Reverse association: Fecundability (number of cycles needed to conceive)
  • Primary outcomes
    • Forward association
      • Fecundability ratio: Probability of pregnancy per cycle
      • Relative risk (RR) of infertility: time to pregnancy ≥12 months
    • Reverse association
      • Relative risk of cesarean

RESULTS:

  • Forward cohort: 42,379 women | Reverse cohort: 74,024 women

Forward association analyses

  • The infertility rate was higher among women with a previous cesarean delivery
    • Vaginal delivery: 7.3% | Cesarean delivery: 9.9%
    • aRR 1.21 (95% CI, 1.10 to 1.33)
  • Women with a previous cesarean delivery also had a lower fecundability ratio
    • aRR 0.99 (95% CI, 0.88 to 0.93)

Reverse association analyses

  • Women who did not conceive within 12 or more cycles had a higher risk for cesarean delivery compared to women who conceived within the first 2 cycles
    • aRR 1.57 (95% CI, 1.48 to 1.66)
  • These associations remained after controlling for sociodemographic and clinical risk factors and were observed across parity groups

CONCLUSION:

  • Compared to women with a previous vaginal delivery, women with a previous cesarean delivery experienced lower fecundability ratios and higher risk of infertility
  • For those with infertility, there was also a higher risk of needing a cesarean delivery, suggesting a bidirectional relationship between fecundity and cesarean delivery

The authors state

We found evidence of a bidirectional relationship between CD and fecundability

This supports the idea that there may be common underlying explanatory mechanisms and that the surgical procedure itself may not or only partly directly influence fecundability

Learn More – Primary Sources:

The relationship between cesarean delivery and fecundability: a population-based cohort study

Does Maternal Bed Rest Improve Weight Gain for Small for Gestational Age Fetuses?

BACKGROUND AND PURPOSE:

  • The optimal management of small-for-gestational age (<10th percentile) fetuses remains unresolved
  • DeVore et al. (AJOG, 2024) sought to determine whether maternal bed rest was associated with increased fetal growth after the diagnosis of small-for-gestational-age (SGA)

METHODS:

  • Retrospective cohort study
  • Population
    • SGA: Estimated fetal weight (EFW) <10th percentile
    • Previous ultrasound with EFW > 10th percentile
  • Exposures
    • Maternal bed rest after SGA diagnosis
      • Left lateral recumbent position
    • 2 control groups who were not placed on bed rest with EFW <10% percentile
      • At sea level
      • 5000 feet above sea level
  • Study design
    • Fetal biometry was performed 2 weeks after the diagnosis
    • Two time periods were assessed
      • Before diagnosis to time of diagnosis
      • Time of diagnosis to 2 weeks after maternal bed rest
  • Primary outcome
    • Change in fetal biometric parameters
      • EFW | Head circumference | Abdominal circumference | Femur length

RESULTS:

  • 265 fetuses
  • Compared to controls, more fetuses in the maternal bed rest cohort achieved fetal weight >10th percentile 2 weeks after diagnosis (P<0.001)
    • Maternal bed rest: 75%
    • Control 1: 19% | Control 2: 12%
  • After 2 weeks of bed rest the median fetal weight percentile increased
    • At diagnosis: 6.8 (IQR, 4.4 to 8.4)
    • After 2 weeks of bed rest: 18.0 (IQR, 9.5 to 29.5)
  • Similar trends were noted for the head circumference, abdominal circumference, and femur length

CONCLUSION:

  • For women carrying a small for gestational age fetus <10th percentile, 2 weeks of bed rest resulted in significant fetal weight increase in the majority of patients
  • For women not prescribed bed rest, <20% of fetuses achieved >10th weight percentile
  • The authors state

All 265 fetuses in the bed rest group had a previous EFW of >10th percentile, thus demonstrating a deceleration of growth and separating them from fetuses who were constitutionally small

In the current study, 199 of 265 fetuses (75%) in the bed rest group accelerated their EFW to >10th percentile

Learn More – Primary Sources:

Maternal rest improves growth in small-for-gestational-age fetuses (<10th percentile)

How Successful Are Different Interventions for Cesarean Scar Pregnancy?

BACKGROUND AND PURPOSE:

  • Kaelin Atgen et al. (AJOG, 2024) compared the effectiveness and safety of different treatments options for cesarean scar pregnancies managed in the first trimester

METHODS:

  • International registry cohort study
    • CSP Registry
    • 19 countries
    • Set up in 2018
  • Population
    • Patients with live or failing cesarean scar pregnancy
    • Received active treatment (medical or surgical) <12w6d
  • Exposures
    • Active treatment types
  • Primary outcome
    • Successful treatment
      • Complete resolution of the pregnancy without the need for any additional medical interventions

RESULTS:

  • 460 patients
    • Live cesarean pregnancies: 281 | Failing: 179
  • Managed surgically: 58.7% | Managed medically: 26.7% | Managed with balloon: 10% | Other: 4.6%
  • Suction evacuation: 91.5% effective (95% CI, 87.8 to 95.2)
  • Surgical excision: 91.8% effective (95% CI, 83.3 to 99.9)
  • Balloon catheter treatment: 91.3% (95% CI, 83.5 5o 99.1)
  • Local gestational sac injection: 74.5% (95% CI, 64.1 to 85.1)
  • Systemic methotrexate: 59.4% successful (95% CI, 48.4 to 70.4)
  • Overall success rate: 91.5% (95% CI, 88.4 to 94.5)
  • Overall complication rate: 9.3% (95% CI, 6.6 to 11.9)
    • Ranged from 8.5% with suction evacuation to 23.9% with systemic methotrexate

CONCLUSION:

  • Management of cesarean scar pregnancy is usually successful (>90%), and complication rates are relatively low (~9%)
  • Suction evacuation had the highest success rate while systemic methotrexate was the least effective treatment option
  • The authors state

The effectiveness of all treatment options decreased with advancing gestational age

CSP should be treated as early as possible after confirmation of the diagnosis

Systemic methotrexate has a substantial risk for failing and a higher complication rate and should not be recommended as first-line treatment

Learn More – Primary Sources:

First-trimester cesarean scar pregnancy: a comparative analysis of treatment options from the international registry

RCT Results: Is Tranexamic Acid Equivalent to Oxytocin When Administered to Prevent Postpartum Blood Loss?

BACKGROUND AND PURPOSE:

  • Ragusa et al. (EClinicalMedicine, 2024) assessed the equivalence of tranexamic acid versus oxytocin in reducing postpartum blood loss

METHODS:

  • Phase III, randomized, open-label, longitudinal, multi-center, prospective clinical trial
    • Tranoxy Study
    • 2 Italian general urban hospitals
  • Participants
    • Full-term delivering vaginally
    • Low risk of postpartum hemorrhage
  • Interventions
    • OXY: 10 UI oxytocin IM within 5 min from childbirth
    • TRAN: 1-g slow IV infusion within 5 min from childbirth
  • Primary outcome
    • Equivalence of the two interventions at preventing total blood loss

RESULTS:

  • OXY: 127 women | TRAN: 104 women
    • Mean blood loss at time of delivery was similar between groups
  • Total mean blood loss was not significantly different between the OXY and the TRAN groups
    • OXY: 397.66 mL (95% CI, 334.36 to 460.96) | TRAN: 405.64 mL (95% CI, 344.23 to 467.04)
  • There was no significant difference between groups in the proportion of
    • Blood loss >1000 mL
      • OXY: 16.5%
      • TRAN: 16.3%
    • Blood loss >500 mL
      • OXY: 28.3%
      • TRAN: 39.4%
  • There were also no statistical differences between the two groups for
    • Hb levels at admission and discharge
    • Need for additional uterotonic or surgical therapies
    • Thrombotic complications at checkup (7 days post-birth)
    • Other adverse events (40 days post-birth)

CONCLUSION:

  • For patients with term vaginal births at low risk of PPH, tranexamic acid and oxytocin were equivalent in terms of postpartum blood loss prevention
  • Safety profiles for tranexamic acid and oxytocin were also similar
  • The authors state

This study demonstrates, for the first time, that tranexamic acid, administered alone and for slow intravenous infusion within 5 min of vaginal childbirth, is equivalent to intramuscular oxytocin in preventing postpartum blood loss in term patients at low risk of PPH

Thus, suggesting its potential use for PPH prophylaxis in the absence of uterine atony

Learn More – Primary Sources:

Tranexamic acid versus oxytocin prophylaxis in reducing post-partum blood loss, in low-risk pregnant women: TRANOXY STUDY, a phase III randomized clinical trial

Is Epidural Analgesia Linked to a Reduced Risk for Severe Maternal Mortality?

BACKGROUND AND PURPOSE:

  • Kearns et al. (BMJ, 2024) assessed the relationship between epidural analgesia and severe maternal morbidity (SMM)

METHODS:

  • Population-based cohort study
    • Linkage of 6 Scotland-wide administrative databases
  • Participants
    • Women in labor at 24w0d to 42w6d
    • Delivered vaginally or through unplanned cesarean
  • Exposure
    • Epidural analgesia
  • Study design
    • SMM was defined as ≥1 of 21 conditions used in the CDC criteria or a critical care admission
      • Either could occur at any point from delivery through 42 days postpartum
  • Primary outcome
    • SMM
  • Secondary outcomes
    • Composite of ≥1 of 21 CDC conditions and critical care admission (SMM plus critical care admission)
    • Respiratory morbidity

RESULTS:

  • 567,216 women
    • Received epidural analgesia: 22.0%
  • Incidence of SMM: 4.3 per 1000 births (95% CI, 4.1 to 4.4)
  • Epidural analgesia was associated with a reduction in
    • SMM: Adjusted relative risk (aRR) 0.65 (95% CI, 0.50 to 0.85)
    • SMM plus critical care admission: aRR 0.46 (95% CI, 0.29 to 0.73)
  • There was a trend towards reduced respiratory morbidity with epidural analgesia, but the analysis was underpowered
    • Respiratory morbidity: aRR 0.42 (95% CI, 0.16 to 1.15)
  • There was a greater risk reduction for SMM for the following
    • Medical indication for epidural analgesia (P<0.001)
      • No indication: aRR 0.67 (95% CI, 0.43 to 1.03)
      • Indication for epidural: aRR 0.50 (95% CI, 0.34 to 0.72)
    • Delivering preterm
      • Term or postterm: aRR 1.09 (95% CI, 0.98 to 1.21)
      • Preterm: aRR 0.53 (95% CI, 0.37 to 0.76)
  • The observed reduced risk for SMM with epidural analgesia increased as gestational age at birth decreased

CONCLUSION:

  • The use of epidural analgesia led to a 35% reduction in risk of SMM in the general cohort
  • Greatest beneficial effects of epidural analgesia were found among women with a medical indication for epidural analgesia and also those delivering preterm
  • Authors of a linked editorial state

Kearns and colleagues’ findings might serve as a catalyst for initiatives aimed at improving equitable access to epidural analgesia during labour, potentially mitigating SMM and improving maternal health outcomes across diverse socioeconomic and ethnic backgrounds

Learn More – Primary Sources:

Epidural analgesia during labour and severe maternal morbidity: population based study

Editorial: Unlocking maternal health: labour epidurals and severe morbidity

RCT Results: What is the Preferred Vaginal Prolapse Repair Method Following Hysterectomy?

BACKGROUND AND PURPOSE:

  • Menefee et al. (JAMA Surg, 2024) compared the efficacy and safety of 3 surgical approaches for vaginal vault prolapse after hysterectomy

METHODS:

  • Multisite, 3-arm, superiority and noninferiority randomized clinical trial
  • Participants
    • Women with symptomatic vaginal vault prolapse after hysterectomy
  • Interventions
    • Sacrocolpopexy
    • Transvaginal mesh
    • Transvaginal native tissue repair
  • Study design
    • Study visits every 6-month intervals up to 60 months
    • Analysis occurred when the last participant reached 36 months
    • Survival models were used to evaluate the primary outcome
  • Primary outcome
    • Time until composite treatment failure
      • Retreatment for prolapse | Prolapse beyond the hymen | Prolapse symptoms
  • Secondary outcomes
    • Patient-reported and objective symptom-specific results
    • Adverse events

RESULTS:

  • 296 participants completed follow-up
    • Mean age: 66.1 (SD, 8.7) years
  • Adjusted 36-month failure incidence
    • Sacrocolpopexy: 28% (95% CI, 20 to 37)
    • Transvaginal mesh: 29% (95% CI, 21 to 38)
    • Native tissue repair: 43% (95% CI, 35 to 53)
  • Sacrocolpopexy was superior to native tissue repair, though transvaginal mesh was not
    • Sacrocolpopexy vs native tissue repair: Adjusted hazard ratio (aHR) 0.57 (99% CI, 0.33 to 0.98) | P=0.01
    • Transvaginal mesh vs native tissue repair: aHR 0.60 (99% CI, 0.34 to 1.03) | P=0.02
  • Transvaginal mesh was noninferior to sacrocolpopexy
    • aHR 1.05 (97% CI, 0 to 1.65) | P=0.01
  • All 3 surgeries resulted in sustained benefits in subjective outcomes
  • Mesh exposure rates were low
    • Sacrocolpopexy: 3% | Transvaginal mesh: 5%
  • Rates of dyspareunia were similarly low

CONCLUSION:

  • For women undergoing surgical repair of vaginal prolapse following hysterectomy, sacrocolpopexy was superior to native tissue repair and transvaginal mesh was noninferior to sacrocolpopexy
  • Rates of adverse events were low overall
  • The authors state

This randomized clinical trial provides important guidance to clinicians and women considering surgical options for vaginal vault prolapse

All approaches were associated with high treatment satisfaction; improved symptoms, quality of life, and sexual function; and low rates of regret

Learn More – Primary Sources:

Apical Suspension Repair for Vaginal Vault Prolapse: A Randomized Clinical Trial

Could HPV Type Help Predict Which Women Would Benefit Most from Immediate Excisional Treatment for CIN?

BACKGROUND AND PURPOSE:

  • Damgaard et al. (AJOG, 2024) described HPV type–specific persistence/progression in women undergoing active surveillance for cervical intraepithelial neoplasia (CIN) 2

METHODS:

  • Historical cohort study
  • Population    
    • 23 to 40 years
    • diagnosed with CIN2
  • Exposures
    • Active surveillance
      • First record of a cervical biopsy within 2 years after index diagnosis
      • No prior loop electrosurgical excision procedure
  • Study design
    • HPV genotyping was performed on archived tissue samples
    • Relative risk (RR) for persistence/progression were calculated using a modified Poisson model
  • Primary outcome
    • Persistence/progression
      • CIN ≥2 on last and worst diagnosis on a biopsy or loop electrosurgical excision procedure specimen during follow-up

RESULTS:

  • 455 women
    • Age ≤30 at index diagnosis: 73.8%
    • High-grade index cytology: 48.8%
    • ≥CIN2 at follow-up: 52.2%
    • HPV-16-positive: 70.5%
    • Other HPV type positive: 29.5%
  • HPV-16 was associated with a significantly higher risk of persistence/progression
    • RR 1.64 (95% C, 1.37 to 1.95)
  • Among HPV-16 positive women, the risk of persistence/progression was highest with high-grade vs low-grade cytology
    • RR 1.29 (95% CI, 1.03 to 1.61)
  • There were no differences in risk across age groups

CONCLUSION:

  • Among women with CIN2, the presence of HPV-16 with high grade cytology was associated with the highest risk of progression/persistence
  • The authors state in regard to management of CIN2

… our findings suggest that HPV-16-positive women with a high-grade cytology may benefit from undergoing an immediate LEEP given their high risk of persistence/progression

Conversely, it may be safe to offer active surveillance to women with non-HPV-16 and an associated low-grade cytology because of the low risk of persistence/progression

Learn More – Primary Sources:

Human papillomavirus genotypes and risk of persistence and progression in women undergoing active surveillance for cervical intraepithelial neoplasia grade 2