For the management guidelines, we chose CIN 3+ as the best surrogate for cancer risk. The definition of CIN 3+ as used in these guidelines includes CIN 3, AIS, and the rare cases of invasive cervical cancer that are found in screening programs. These management guidelines consider CIN 3+ risk at the time point relevant for the clinical action being considered—Clinical Action Thresholds for colposcopy and treatment consider immediate risks of CIN 3+, whereas longer-term surveillance recommendations use 5-year risks.
CIN3+ was chosen as an endpoint instead of cancer because cancer is uncommon in the United States, and risk is profoundly decreased by precursor treatment. Cancers that are found in robust screening programs may represent cancers already prevalent at first screening, rare instances of aggressive or HPV-negative tumors not detectable by screening, or false negative results.24 (link) CIN 3+ was chosen instead of CIN 2+ because it is a more pathologically reproducible diagnosis,25 (link) the HPV type distribution in CIN 3+ lesions more closely approximates that of invasive cervical cancers than the larger range of types found in CIN 2,15 (link)–18 (link),26 (link) and CIN 2 has appreciable regression rates in the absence of treatment.27 (link)–29 (link) The choice of CIN 3+ does have some limitations, as even among CIN 3/AIS lesions, risks of progression to cancer differ. Glandular lesions including AIS, lesions with HPV 16 and 18 infections, and those occurring in older patients have higher cancer risks than HPV-negative lesions and those occurring in younger patients.30 (link)Different nomenclatures for cervical histopathology are in use in the United States. The LAST Project and the WHO recommend a 2-tiered terminology (histologic LSIL/HSIL) for reporting histopathology of HPV-associated squamous lesions, similar to the Bethesda system used for reporting cervical cytology.31 (link),32 However, the CIN nomenclature is still commonly used, and data used to generate this set of guidelines relied on CIN nomenclature. Although no direct correlation is possible without use of the p16 biomarker, histologic HSIL is similar but not identical to CIN 2/3.33 (link)
CIN3+ was chosen as an endpoint instead of cancer because cancer is uncommon in the United States, and risk is profoundly decreased by precursor treatment. Cancers that are found in robust screening programs may represent cancers already prevalent at first screening, rare instances of aggressive or HPV-negative tumors not detectable by screening, or false negative results.24 (link) CIN 3+ was chosen instead of CIN 2+ because it is a more pathologically reproducible diagnosis,25 (link) the HPV type distribution in CIN 3+ lesions more closely approximates that of invasive cervical cancers than the larger range of types found in CIN 2,15 (link)–18 (link),26 (link) and CIN 2 has appreciable regression rates in the absence of treatment.27 (link)–29 (link) The choice of CIN 3+ does have some limitations, as even among CIN 3/AIS lesions, risks of progression to cancer differ. Glandular lesions including AIS, lesions with HPV 16 and 18 infections, and those occurring in older patients have higher cancer risks than HPV-negative lesions and those occurring in younger patients.30 (link)Different nomenclatures for cervical histopathology are in use in the United States. The LAST Project and the WHO recommend a 2-tiered terminology (histologic LSIL/HSIL) for reporting histopathology of HPV-associated squamous lesions, similar to the Bethesda system used for reporting cervical cytology.31 (link),32 However, the CIN nomenclature is still commonly used, and data used to generate this set of guidelines relied on CIN nomenclature. Although no direct correlation is possible without use of the p16 biomarker, histologic HSIL is similar but not identical to CIN 2/3.33 (link)