ATLANTA — Current cervical cancer screening guidelines may be insufficient for a subgroup of adolescent girls with high-grade dysplasia who are at risk for the development of invasive lesions, Dr. Michelle Vichnin reported at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.
The American Cancer Society and the American College of Obstetricians and Gynecologists recommend that cervical cancer screening should begin approximately 3 years after the first vaginal intercourse, but no later than 21 years of age.
In light of recent data suggesting that waiting even 3 years may be too long in adolescents living in a high-risk urban setting, Dr. Vichnin and colleagues at the Hospital of the University of Pennsylvania in Philadelphia conducted a retrospective study to quantify how many adolescent girls aged 21 years or younger who were evaluated at the hospital's colposcopy clinic over a 2-year period developed high-grade dysplasia on pap smears and cervical biopsies, and to determine whether the lesions would have gone undetected if the recommended screening guidelines had been strictly followed.
The investigators reviewed the charts of 275 adolescent girls for demographic information, including age, race, gravidity and parity, history of prior sexually transmitted diseases, age at first vaginal intercourse, and age at first abnormal Pap smear. They then compiled these data along with the Pap smear, colposcopy, and biopsy results, said Dr. Vichnin. “Records that did not have age at first intercourse were considered incomplete and were not included in the final analysis,” she said.
Of the 275 patient charts included in the initial review, only 195 had complete information for analysis. Of these, 96% of the patients were African American, 88% had at least one pregnancy, and 73% had given birth to at least one child, Dr. Vichnin reported. The average age at first intercourse was 14.9 years and the average age at first abnormal Pap smear was 18 years. Prior history of sexually transmitted diseases was confirmed in 62% of the patients, she said.
The final data analysis showed that 34 of the 195 young women had biopsy-proven cervical intraepithelial neoplasia grade 2 or 3 (CIN2, CIN3) disease. Of these 34 patients, 9 developed high-grade disease in less than 3 years from initiation of intercourse and 4 developed high-grade disease at 3 years, said Dr. Vichnin. “This is a significant number of patients with biopsy-confirmed high-grade disease,” said Dr. Vichnin.
For the purposes of this investigation, “we considered patients lost to follow-up if they were not seen within 12 months after initial presentation to the colposcopy clinic,” Dr. Vichnin said. “We have a very good follow-up protocol that includes letters, certified letters, and phone calls by nurses dedicated specifically to the colposcopy clinic, so if patients didn't come back, it isn't because we didn't try to get them in.” Patients were deemed noncompliant with treatment if they failed to initiate treatment or follow-up evaluation within 3 months, she said.
Of the girls diagnosed with CIN2 or CIN3 disease, “nearly half [49%] were either lost to follow-up or noncompliant with treatment recommendations,” said Dr. Vichnin. “This leaves a large number of girls who are vulnerable to progression to cervical cancer untreated.”
The findings show “a small but significant rate of progression to high-grade disease within 3 years of initiation of intercourse among these urban adolescent females and a high rate of failure to follow up on treatment recommendations,” said Dr. Vichnin. “We're concerned that the 3-year waiting period for these high-risk adolescents is potentially dangerous, and so we are advocating for closer scrutiny in this population to guard against the development of invasive lesions,” Additionally, she said, “further studies are needed to confirm our findings and to appropriately amend current guidelines for this unique population.”