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1. In Response

   • S. Deblina Datta, MD
   • Atlanta, GA

   Centers for Disease Control and Prevention

   Authors Reply:

   The prevalence of HPV DNA in LSIL and HSIL is known to be very high, and therefore, management decisions are based on the presence of the cytologic abnormality alone. The management of LSIL (referral for colposcopy) and the management of HSIL (loop electrosurgical excision procedure, or LEEP) are similar in that procedural evaluations are needed (with the exception of special populations) and HPV DNA testing would not influence management. The management of ASC-US, however, is dependent upon the results of HPV DNA testing. [1] The ALTS trial demonstrated the utility of HPV DNA testing as a triage strategy in the management of ASC- US for all women (but not for LSIL), and the ASCCP recommended this strategy in their 2001 guidelines. [2,3] The 2006 ASCCP guidelines have been amended to exclude adolescent ASC-US cases (age <_21 years="years" from="from" hpv="hpv" dna="dna" triage="triage" due="due" to="to" the="the" high="high" prevalence="prevalence" of="of" infections="infections" and="and" low="low" risk="risk" cancer="cancer" in="in" this="this" age="age" group.="group." therefore="therefore" our="our" original="original" report="report" we="we" chose="chose" present="present" among="among" persons="persons" with="with" asc-us="asc-us" pap="pap" tests="tests" more="more" detail="detail" by="by" order="order" inform="inform" debate="debate" about="about" optimal="optimal" cutoffs="cutoffs" for="for" triage.="triage." encountered="encountered" relatively="relatively" few="few" lsil="lsil" hsil="hsil" cases="cases" resulting="resulting" combining="combining" categories.="categories." p="p">Although we do not advocate managing LSIL and HSIL on the basis of HPV DNA testing, we report prevalence data for LSIL and HSIL Paps: HR-HPV prevalence (as measured by Hybrid Capture 2 testing) among those with LSIL and aged 14-20 years was 91% (156/171, 95% CI 86-95%) and those aged 21-29 years was 90% (198/219, 95% CI 86-94%). Other 5-year age categories had fewer than 20 cases and we do not report them. Prevalence was 71% (40/56, 95% CI 56-83%) for those aged 30 years and older. There were 54 cases of HSIL, with a HR-HPV prevalence of 93% (43/46, 95% CI 82-97%) among those aged less than 30 years and a prevalence of 75% (6/8, 95% CI 35-97%) among those aged 30 years and older. There was a single case of AIS in our study.

   S. Deblina Datta, MD Hillard Weinstock, MD MPH

   References:

   1. Wright TC Jr, Massad LS, Dunton CJ, Spitzer M, Wilkinson EJ, Solomon D; for the 2006 ASCCP-Sponsored Consensus Conference. 2006 consensus guidelines for the management of women with abnormal cervicalscreening tests. J Low Genit Tract Dis. 2007 Oct;11(4):201-22.

   2. Human papillomavirus testing for triage of women with cytologic evidence of low-grade squamous intraepithelial lesions: baseline data from a randomized trial. The Atypical Squamous Cells of Undetermined Significance/Low-Grade Squamous Intraepithelial Lesions Triage Study (ALTS) Group. J Natl Cancer Inst. 2000 Mar 1;92(5):397-402.

   3. Wright TC Jr, Cox JT, Massad LS, Twiggs LB, Wilkinson EJ; ASCCP- Sponsored Consensus Conference. 2001 Consensus Guidelines for the management of women with cervical cytological abnormalities. JAMA. 2002 Apr 24;287(16):2120-9.

   Conflict of Interest:

   None declared

   Submit response
   Published June 12, 2008
2. Screening Tests for Cervical Cancer

   • Masaharu Tsubokura, M.D.
   • Masahiro Kami M.D. and Tsunehiko Komatsu M.D.

   Teikyo university chiba medical center

   Datta et al. reported that high-risk HPV was widespread among women receiving cervical screening. (1) Surprisingly, the present study showed that the prevalence of cytology results with low-grade squamous intraepithelial lesion (LSIL), high-grade squamous intraepithelial lesion (HSIL) or adenocarcinoma in situ (AIS) was significantly higher among women younger than 30 years compared with those age 30 years or older (P<0.001), while the median age at diagnosis for cervical cancer was 48 years of age in the United States. (2) Although over 50 percent of women with HSIL have cervical intraepithelial neoplasia 2 or greater and 2 percent of women with HSIL have invasive carcinoma, LSIL is associated with a transient HPV infection in adolescents and both the infection and LSIL usually resolve over time. (3) A study involving 187 adolescents aged 13 to 22 years with LSIL showed that 61 percent of the lesions had regressed within one year and 91 percent regressed within three years. (4) Since the risk of CIN 2,3 in women with LSIL is different from that in women with HSIL, management of LSIL is different from that of HSIL. Clinicians will have difficulties in drawing a definite conclusion from this study because the number of women with LSIL, HSIL and AIS was not shown separately. We are grateful if the authors provide us the information on the number of enrollees and the prevalence of high-risk HPV among women with LSIL, HSIL and AIS separately.

   1. Datta et al. Human Papillomavirus Infection and Cervical Cytology in Women Screened for Cervical Cancer in the United States, 2003-2005 Annals of internal medicine 2008;148:493.

   2.http://seer.cancer.gov/csr/1975_2005/results_single/sect_01_table.11_2p gs.pdf

   3. Wright et al. Cervical dysplasia in adolescents. Obstet Gynecol 2005;106:115.

   4. Moscicki et al. Regression of low-grade squamous intra-epithelial lesions in young women Lancet 2004;364:1678

   Conflict of Interest:

   None declared

   Submit response
   Published April 29, 2008