Sometimes Active Surveillance Makes No Sense

As a medical student I was introduced to the idea that if we spend too much time and money trying to be too conservative, we are paradoxically spending more time, money, and worry than if we had just been more aggressive in the first place. Today we hear more and more about active surveillance (sometimes called watchful waiting). From my experience, active surveillance may at times be overrated.

For example, if a PAP smear is normal, then that’s the end of the process for another three years. However, if the PAP smear is abnormal, possibly indicating cancer or pre-cancer, there is the possibility of a colposcopy examination. The PAP smear is not diagnostic. In other words, it does not tell you what the “abnormal” result means. Searching for a cause of the “abnormal” results requires further examination. A colposcope is a magnification system with a light that can detect cancer or pre-cancer in the vagina and cervix after a slightly acidic solution of acetic acid is applied. Often a small area of what is called cervical intraepithelial neoplasma (CIN) can be identified with the colposcopic examination. Epithelial means in the skin and not below skin level. This term separates the abnormal tissue from cancer, which would extend below the surface level of the skin.

One of the possible results of a colposcopy exam of the “abnormal” cervical tissue can be a diagnosis of some level of CIN. A recently published 20-year study from Denmark on CIN recommends active surveillance. CIN is rated in three forms: CIN1, CIN2, and CIN3, These three stages have to do with grading premalignant and early cervical cancer. The levels stand for (1) mild, (2) moderate, and (3) cancer.

In order to actively survey the stages of CIN, physicians have to do a series of PAP smears, colposcopies, and biopsies, all costing time, money, and anxiety for the patient over the years of watching the CIN. Instead, women with CIN1 or CIN2 could undergo a LEEP (loop electro surgical excision procedure) at the time of the colposcopy and biopsy.

The researchers in this study looked at three possibilities: (1) that the disease would regress (return to normal) immediately, and there was no abnormality on follow up; (2) that the cancer would regress over time; and (3) that cancer would develop over time.

I found one statement in the article rather curious: “However, LEEP has been associated with significant rates of CIN2 regression, (resolution), indicating immediate LEEP of CIN2 may lead to over-treatment. Overtreatment? Who would complain that a treatment is too successful?  

One of the real shortcomings of this article is that we are not told the actual size of the CIN2s. I’ve done thousands of colposcopy examinations and cervical biopsies, and I can tell you that more than 50 percent of CIN2 occurrences are very small, a few millimeters in diameter. They can easily be removed during the colposcopy examination in 5 minutes with a small 3 mm LEEP procedure under local anesthesia.

LEEP procedures should not be confused with the cervical cones we did 40 years ago. Cone biopsies could cause considerable damage. We were supposed to get a “generous” cone to please the pathologists. Generous cones meant that we were removing a significant portion of the cervix. This could cause several problems with pregnancy. The cone could remove enough of the cervix to reduce cervical mucous, which could cause infertility.

A second problem with cones were that they could cause the cervix to become incompetent, dilate too soon, and cause pregnancy loss. The cone could even cause a cervix to become scarred and tight (stenotic) so the cervix couldn’t dilate even with labor at term.

Whether active surveillance makes sense or not depends upon what the alternatives are. In other words, active surveillance makes a lot of sense if the alternative is a cervical cone. On the other hand, if treatment means doing a 3 mm LEEP biopsy that removes all of the CIN2, then why not just go ahead and treat the CIN2 with a LEEP procedure and totally remove the CIN2?

Active surveillance makes no sense when there are minimally invasive procedures which put a stop to the expensive, time-consuming task of continually testing to see if the CIN2 has progressed. And then there’s the bizarre notion that an immediate LEEP procedure for CIN2, a procedure that will prevent any progression of the disease, is somehow over-treatment. While a third of the CIN2 subjects had their CIN2 resolve without any treatment and a second third of the subjects had the CIN2 resolve over time, one third of the subjects had the CIN2 become CIN3. When a LEEP procedure works so well on resolving CIN2, why let one third of the subjects progress to CIN3 when their CIN2 could be removed before reaching the CIN3 stage. How does this make active surveillance preferable to removing the CIN2 with a LEEP procedure?

The notion of watch and wait in medicine has become a popular jargon that looks nice on paper but can, at times, make no sense in practice. We shouldn’t become so enamored of popular medical notions that we miss that the emperor has no clothes.