To treat or not to treat; the clinical dilemma of atypical squamous cells of undetermined significance (ASC-US)

Objective: Management of patients diagnosed on cervical smears with twice consecutively atypical squamous cells of undetermined significance (ASC-US) remains a clinical dilemma. We describe a follow-up of aggressive vs. less aggressive colposcopic treatment in order to determine which treatment is preferable.

Design: Retrospective cohort study with a follow-up of 10 years.

Setting: Two hospitals in The Netherlands.

Population: Women referred for primary colposcopy with two consecutive ASC-US smears (n=230) to either one of the two hospitals.

Methods: In one hospital, patients underwent direct loop excision of all colposcopically detected abnormalities, even if not suspected for cervical intraepithelial neoplasia (CIN; aggressive strategy; n=118). In the other hospital, a less aggressive policy was followed when low-grade CIN lesions were suspected at colposcopy (less aggressive strategy; n=112).

Main outcome measures: The number of loop excisions, detection of CIN lesions and cytological follow-up of both groups.

Results: Less aggressive management resulted in less loop excisions (p<0.001). At initial colposcopy, the aggressive group showed a 10-fold incidence of histologically detected CIN lesions compared with the less aggressive group (1.8 vs. 19.5%). During 10 years of follow-up, both groups showed the same percentages of CIN lesions (8.1 vs. 8.4%). Aggressive management resulted in faster normalization of cervical smears (p<0.001). However, at final follow-up, there was no statistical difference in the percentage of normalization of cervical smears between both groups.

Conclusions: Aggressive and less aggressive colposcopic strategies are equally safe and show good clinical outcomes. Treatment decisions, however, must be adjusted to women's individual demands.