Sawaya George F, Smith-McCune Karen
Department of Obstetrics, Gynecology and Reproductive Sciences, the UCSF Center for Healthcare Value, and the UCSF Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, San Francisco, California.
Obstet Gynecol. 2016 Mar;127(3):459-467. doi: 10.1097/AOG.0000000000001136.
Recent changes in cervical cancer screening and management guidelines reflect our evolving knowledge about cervical carcinogenesis. In the pursuit of precision, however, decision-making has become complicated. We provide an overview of cervical cancer screening with a focus on what clinicians can do to maximize screening benefits while minimizing screening harms. The approach relies on categorizing women at each step in the screening process by their estimated risk of high-grade precancerous lesions and cervical cancer. Current screening guidelines are designed to find a reasonable balance between benefits and harms by recommending less screening in most women. Current management guidelines are designed to assure consistent decisions regarding referral to colposcopy. After initial colposcopy, we outline three major management options based on risk assessment. For treatment, we recommend ablational procedures when appropriate because they are similarly effective, less costly, and potentially safer than excisional procedures. We advise caution in adopting new screening strategies until they demonstrate cost-effective patient-centered improvements compared with current strategies. Clinicians can maximize their effect on cervical cancer prevention by being attentive to guidelines, assuring that women have access to appropriate human papillomavirus vaccination and providing low-cost, high-quality screening and treatment.
宫颈癌筛查与管理指南的近期变化反映了我们对宫颈癌发生发展的不断演变的认识。然而,在追求精准的过程中,决策变得复杂起来。我们概述了宫颈癌筛查,重点关注临床医生如何在将筛查危害降至最低的同时,最大化筛查益处。该方法依赖于在筛查过程的每个步骤中,根据女性患高级别癌前病变和宫颈癌的估计风险对其进行分类。当前的筛查指南旨在通过建议大多数女性减少筛查,在益处和危害之间找到合理的平衡。当前的管理指南旨在确保在转诊至阴道镜检查方面做出一致的决策。在初次阴道镜检查后,我们根据风险评估概述了三种主要的管理选择。对于治疗,我们建议在适当的时候采用消融手术,因为它们同样有效,成本更低,而且可能比切除手术更安全。在新的筛查策略证明与当前策略相比具有以患者为中心的成本效益改进之前,我们建议谨慎采用。临床医生可以通过关注指南、确保女性能够接种适当的人乳头瘤病毒疫苗以及提供低成本、高质量的筛查和治疗,最大化他们对宫颈癌预防的影响。