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EDITORIALS: Guglielmo Ronco, Mario Giovanni Sideri, and Stefano Ciatto Cervical intraepithelial neoplasia and higher long term risk of cancer BMJ 2007; 335: 1053-1054 [Full text]

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Routine screening programme

Victoria M. Pickles   (25 November 2007)

After treatment of CIN, 66% of post-treatment disease is detected more than 2 years after treatment and is 6 times more common if the margins were involved.

William P Soutter, Sadaf Ghaem-Maghami   (27 November 2007)

Author's reply

Guglielmo Ronco, Mario Giovanni Sideri, Stefano Ciatto   (7 December 2007)

Routine screening programme 25 November 2007
Victoria M. Pickles, Surgeon London WC1 Send response to journal: Re: Routine screening programme	This article is indeed very topical. The United Kingdom already spends a large sum of money on the prevention of cervical cancer, which has been demonstrated to have significantly reduced since the current routine screening programme was initiated in the UK. It is an example of medical success in the identification of a precursor state in the form of CIN and the prevention of cervical cancer. This study may well add to our knowledge of the natural progression of CIN and provide some guidance on the improvement of an already successful programme. Competing interests: None declared
After treatment of CIN, 66% of post-treatment disease is detected more than 2 years after treatment and is 6 times more common if the margins were involved. 27 November 2007
William P Soutter, Honorary Reader in Gynaecological Oncology Hammersmith Hospital, London W12 0HS, Sadaf Ghaem-Maghami Send response to journal: Re: After treatment of CIN, 66% of post-treatment disease is detected more than 2 years after treatment and is 6 times more common if the margins were involved.	We agree completely with Ronco and colleagues that long term follow up is essential after treatment of CIN and have argued for that since 1997.(1) However, they have slightly misquoted our 2006 paper. In fact, those data showed that a significant number of women with post-treatment disease were detected only after 3 years. Our data from a long-term follow up of women treated at Hammersmith Hospital shows that 66% were detected more than 2 years after treatment (manuscript in preparation). We are examining the data to see if late detection of post-treatment disease was due to failure to comply with follow up. Unlike Lopes et al, we have found that colposcopy does increase the detection rate of post-treatment CIN.(3) We have also recently published the results of a meta-analysis showing that the risk of high-grade post- treatment disease in women with involved margins in the excision specimen was 18% compared with 3% in those who with free margins.(4) (1) Soutter WP, de Barros LA, Fletcher A, Monaghan JM, Duncan ID, Paraskevaidis E et al. Invasive cervical cancer after conservative therapy for cervical intraepithelial neoplasia. Lancet 1997; 349(9057):978-980. (2) Soutter WP, Sasieni P, Panoskaltsis T. Long-term risk of invasive cervical cancer after treatment of squamous cervical intraepithelial neoplasia. International Journal of Cancer 2006; 118[8], 2048-2055. (3) Soutter WP, Butler JS, Tipples M. The role of colposcopy in the follow up of women treated for cervical intraepithelial neoplasia. BJOG 2006; 113(5):511-514. (4) Ghaem-Maghami S, Sagi S, Majeed G, Soutter WP. Incomplete excision of cervical intraepithelial neoplasia and risk of treatment failure: a meta-analysis. Lancet Oncol 2007; 8(11):985-993. Competing interests: None declared
Author's reply 7 December 2007
Guglielmo Ronco, see Editorial see Editorial, Mario Giovanni Sideri, Stefano Ciatto Send response to journal: Re: Author's reply	The association between incompleteness of excision and post-treatment risk of high-grade cervical intraepithelial neoplasia (CIN) found by Ghaem -Maghami’s review (1) is surely relevant. In Strander’s data (2) the excess risk of cervical cancer is larger for women treated in recent years. Increased frequency of incomplete excision, more than the use of conservative treatments in itself, could be a reason. Studies directly investigating the association between margin condition and long-term invasive cancer risk would be very useful. Similarly, our main point was that studies investigating the association between invasive cancer risk and different follow-up protocols would be highly desirable, as preventing cancer is the relevant target. Therefore we agree that trends in invasive cancer incidence are more relevant in suggesting follow-up protocols then those in CIN detection (data in Soutter’s 2006 meta analysis (3), where the proportion of CIN detected after more than 3 years is not directly reported, are consistent with some 60% of the CIN found within 10 years having been identified during the first three, although with heterogeneity between studies). However we think that there is a need for direct evidence of the cost-effectiveness of different follow-up protocols in preventing invasive cancer. REFERENCES 1 Ghaem-Maghami S, Sagi S, Majeed G, Sotter WP. Incomplete excision of cervical intraepithelial neoplasia and risk of treatment failure: a meta analysis. Lancet Oncol 2007;8:985-993. 2 Strander B, Andersson-Ellstrom A, Milsom I, Sparen P. Despite treatment of severe dysplasia (carcinoma in situ) women face a long-term increased risk of invasive cancer. A population based cohort study. BMJ 2007;335:1077-80. 3 Soutter WP, Sasieni P , Panoskaltsis T. Long term risk of invasive cervical cancer after treatment of squamous cervical intraepithelial neoplasia. Int J Cancer 2006;118:2048-55. Competing interests: see Editorial