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Rapid response to:


Clinical course of untreated cervical intraepithelial neoplasia grade 2 under active surveillance: systematic review and meta-analysis

BMJ 2018; 360 doi: (Published 27 February 2018) Cite this as: BMJ 2018;360:k499

Rapid Response:

Re: Clinical course of untreated cervical intraepithelial neoplasia grade 2 under active surveillance: systematic review and meta-analysis

Rapid Response to Treatment or Surveillance for CIN2? – 3rd March 2018. 360-337-378 No8143
We have read with interest the original research by Tainio et al about treatment or surveillance for CIN2? ( BMJ, 3rd March)
The diagnosis of CIN2 must be based on a cervical biopsy rather than a smear test result of colposcopic finding, although evidence suggests that high grade cytological abnormality have a likelihood of being CIN2 or 3 as suggested by Hellberg et al, 1994.1 The positive predictive value of colposcopy for distinguishing high grade from low grade is 57%. Mitchel et al, 1998. 2
Firstly, though we agree that there is no clear definition for active surveillance in the context of CIN2, we advise that conservative management of CIN2 needs to be discussed at the colposcopy multidisciplinary team meeting before offering the patient this option.
Secondly the age of the patient needs to be taken into consideration. The older the patient, the more risk of the squamo-columnar junction regressing to a higher level within the endocervical canal and increased risk of recurrence. CIN 2 in older women would require treatment rather than surveillance.3
Thirdly, the women should be given informed choice which is very important. As such surveillance should be offered in young nulliparous women without a family or who desire a family.
Lastly clinical care must be taken in women who presented with associated symptoms of post coital bleeding or intermenstrual bleeding as studies have shown that there is high probability of co-existing CIN equivalent to CIN2 or higher.4
1. Hellberg D et al. Positive cervical smear with subsequent normal colposcopy an dhistology – frequency of CIN In the long term follow up. Gynecol Oncol 1994, 63(2) ;148-151.
2. Mitchel et al. Colposcopy for the diagnosis of squamous intraepithelial lesions: a meta-analysis. Obstet Gynecol 1998, 91(4);626-631.
3. Flannelly G, Bolger B, Fawzi H et al. Follow up after LLETZ: could schedules be modified according to risk of recurrence . BJOG 2001,108(10):1025-1030.
4. Rosenthal AN, Panoskaltsis T, Smith T et al. The frequency of significant pathology in women attending a general gynaecological service for post coital bleeding. BJOG 2001, 108:103-106.

Competing interests: No competing interests

29 March 2018
Stewart Disu
Consultant Gynaecologist
Ade Sanusi -
London North West Healthcare NHS Trust
Watford Rd, Harrow HA1 3UJ