The World Health Organization (WHO) has called for an accelerated global strategy to eliminate cervical cancer, with 194 countries, including China, committing for the first time to eliminate one cancer. To achieve this strategic goal, our country has a lot of work to do. Professor Wei Lihui, Professor Zhao Chao, Professor Li Mingzhu and other well-known experts in my country aimed at the difficulties of cervical cancer screening, abnormal shunt, and management of cervical low-grade and high-grade lesions in the secondary prevention of cervical cancer, combined with the current situation in my country , proposed how to implement cervical cancer screening and refined management of histologically confirmed cervical lesions.
Key points
I. Cervical cancer screening and Difficulties in screening abnormal triage
Cervical cancer screening is an important part of secondary prevention. The shunting methods for screening abnormalities include cytology, HPV typing, etc. Among them, visual screening (VIA) and colposcopy are also used as one of the shunting methods in the WHO guidelines. In my country, VIA is rarely used as a shunt method, but whether colposcopy should be used as a shunt method after primary screening remains to be discussed. The American ASCCP2019 guidelines put forward the concept of clinical threshold, that is, to evaluate the clinical threshold based on the results of previous screening and this screening, to assess the risk of developing into high-grade lesions at present and in the next 5 years, so as to adopt different management strategies. The current difficulties in assessing clinical thresholds in my country are that the screening coverage rate of the population is not high; the second is that there are many types of HPV detection reagents in my country; Accurately assess clinical thresholds. With the improvement of screening coverage in my country, the approval of HPV reagents for screening by the State Food and Drug Administration (CFDA) will be more helpful for us to explore the evaluation of clinical thresholds suitable for cervical lesions in China , towards a more refined management.
II. Difficulties in the management of low-grade squamous intraepithelial lesions
For patients with pathologically confirmed LSIL/CIN1 after primary screening, it is not clinically feasible. Immediate treatment is recommended, and follow-up observation is possible. If LSIL/CIN1 persists for more than 2 years, continuous follow-up or treatment can be selected. However, for those with high-risk factors, such as advanced age, HRHPV-positive persistent infection (especially HPV16, 18-positive), cervical canal LSIL/CIN1, and previous treatment history of cervical high-grade lesions, such as LSIL/CIN1 lasting 2 years, can be associated with The patient shared decision-making, and treatment was an acceptable option, depending on the type of lesion and transformation zone. Currently in clinical practice, due to the anxiety of patients and the concerns of doctors, many doctors performed cervical ablation or even excisional treatment after the first discovery of LSIL/CIN1, resulting in excessive treatment. How to evaluate high-risk LSIL/CIN1 with potential HSIL or disease progression risk in clinical practice is more important and needs further exploration.
III. Difficulties in the management of high-grade squamous intraepithelial lesions
For CIN2, in addition to conventional treatment, for young CIN2 with fertility requirements, Conservative observation can also be selected according to the extent of the lesion and the type of transformation zone. CIN3, on the other hand, is considered a true precancerous endpoint because of its higher risk of progression. WHO proposes that if the pathology report is CIN2~3, it should be treated according to CIN3. Models from earlier studies estimated that 15% to 23% of untreated CIN3 will develop invasive cancer with an average observation time of 13 years. A large number of subsequent studies have shown that the presence of CIN3 has a high risk of progression to invasive cancer and requires treatment.
Most scholars advocate cervical conization for HSIL, especially for those with pathologically confirmed CIN3. For young patients with fertility requirements, after adequate evaluation, invasive cancer and cervical glandular lesions are excluded, and the lesions and transformation areas are completely visible under colposcopy, and ablation therapy can also be carefully selected, but close follow-up is required after treatment. Because of the limitations of diagnostic and treatment techniques in different regions in my country, it is recommended to choose ablation surgery very carefully.
IV. Difficulties in the management of adenocarcinoma in situ of the cervix
With regard to the treatment of AIS, even if the resected specimen has no lesions Involvement, the risk of residual lesions cannot be completely excluded. Hysterectomy remains the standard of care for patients with AIS who do not wish to become pregnant. With the trend of younger age at diagnosis of AIS, many studies in recent years believe that when the margins are negative after conization and young patients with strict follow-up conditions, cervical conization can be used to preserve fertility. Research in my country has shown that positive margins and multifocal lesions after conization are risk factors for residual and recurrence of lesions after LEEP in cervical AIS patients. Age, reproductive needs, etc., and individualized follow-up plans.
V. The role of HPV vaccine after treatment of cervical precancerous lesions Precaution. Most guidelines or consensuses at home and abroad suggest that women who have treated cervical lesions can be vaccinated against HPV. The European Society of Gynecologic Oncology-European Colposcopy Federation (ESGO-EFC) position paper pointed out that in addition to local treatment for HPV-related diseases, vaccination can reduce the incidence of recurrence or subsequent HPV-related diseases; 2021 edition of “Human Papillomavirus Vaccine Clinical Application of the Chinese Expert Consensus” pointed out that the HPV vaccine is recommended for women of appropriate age who have received ablation or resection of HSIL in the past.
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The above content is quoted from: Strengthening the refined management of secondary prevention of cervical cancer［J］. Chinese Journal of Obstetrics and Gynecology. 2022,23(01): 1-3.
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