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Treatment of Cervical Precancers: Back to Basics

Khan, Michelle J. MD, MPH; Smith-McCune, Karen K. MD, PhD

doi: 10.1097/AOG.0000000000000287
Contents: Current Commentary

Both ablative (cervical cryotherapy, laser ablation) and excisional methods (loop electrosurgical excision procedure, cold knife conization) can be effective at treating cervical precancer. Excisional procedures are associated with adverse obstetric outcomes including preterm delivery and perinatal mortality with the depth of excision potentially contributing to the adverse outcomes. Ablative therapies are now used much less commonly than loop electrosurgical excision procedure but have less of an effect on adverse obstetric outcomes and hence are effective alternatives for treating cervical precancer in reproductive-aged women. Morphometric data indicate that the vast majority of precancerous lesions are less than 5 mm deep, suggesting that treatments that reach 6–7 mm below the epithelium are adequate in women with satisfactory colposcopy. Cone biopsies, “top-hat” loop electrosurgical excision procedures, or the use of loop electrodes greater than 10 mm are therefore unnecessary for the majority of reproductive-aged women and increase risk of adverse obstetric outcomes. New consensus guidelines allow observation instead of treatment in appropriately selected young women. Until the association of excisional methods with adverse obstetric outcomes is clarified with more data, ablative methods should be revitalized and used by health care providers in appropriately selected patients. Treatment should be individualized based on patient’s age, fertility desires, and colpopathologic findings.

Treatment for cervical precancer can be individualized based on patient fertility intentions and colpopathologic characteristics; health care providers should offer both ablative and excisional treatment methods to patients.

Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, Alabama; and the Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, San Francisco, California.

Corresponding author: Michelle J. Khan, MD, MPH, Department of Obstetrics and Gynecology, University of Alabama at Birmingham, 176-F WIC 10261, 619 S 19th Street, Birmingham, AL 35249; e-mail: mjkhan@uabmc.edu.

Dr. Khan was supported in this work by training grant National Institutes of Health–National Institute of Allergy Infectious Diseases 5T32AI065388-05 and an institutional grant, UL1 RR024131, through the National Institutes of Health/National Center for Research Resources University of California San Francisco–Clinical and Translational Science Institute Strategic Opportunities Support program. Dr. Smith-McCune was supported in this work by the John Kerner Endowed Chair.

Financial Disclosure Dr. Smith-McCune serves as the Founding Chair of the Scientific and Clinical Advisory Board of OncoHealth Inc and receives reimbursement for that role with stock options. Dr. Khan did not report any potential conflicts of interest.

© 2014 by The American College of Obstetricians and Gynecologists.