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期刊来源：JAMA

文献发表时间：2023-08-08

原文链接：https://jamanetwork.com/journals/jama/article-abstract/2807981

摘要内容如下：

重要性

在美国，每年约有10万人接受宫颈癌前病变治疗，1.4万人被诊断为宫颈癌，4000人死于宫颈癌。

观察结果

基本上，全世界所有的宫颈癌都是由13种致癌人乳头瘤病毒（HPV）基因型之一的持续感染引起的:16、18、31、33、35、39、45、51、52、56、58、59和68。在9至12岁时接种HPV疫苗可能会预防90%以上的宫颈癌前病变和癌症。在21岁至65岁的子宫颈患者中，通过筛查和治疗子宫颈癌前病变（定义为子宫颈高度鳞状上皮内病变）来预防宫颈癌。如果不治疗，高级别病变可发展为宫颈癌。宫颈阴道HPV检测对检测癌前病变的敏感性为90%。在普通人群中，HPV检测结果阴性后5年内发生癌前病变的风险低于0.15%。在HPV检测结果阳性的人群中，HPV基因分型和宫颈细胞学检查（巴氏检测）相结合可以确定癌前病变的风险。对于目前癌前风险低于4%的人，建议根据5年癌前风险在1年、3年或5年内重复进行HPV检测。对于目前癌前风险为4%至24%的人群，如低度细胞学检查结果（意义未明的非典型鳞状细胞[ASC-US]或低度鳞状上皮内病变[LSIL]）和HPV检测阳性持续时间未知的人群，建议进行阴道镜检查。对于癌前风险低于25%的患者（如宫颈上皮内瘤变1级[CIN1]或组织学LSIL），通过重复阴道镜检查监测癌前病变并避免切除治疗，可以减少治疗相关的不良反应，包括可能与早产有关。对于目前癌前风险为25%至59%的患者（例如，ASC的高级别细胞学结果不能排除高级别病变[ASC-H]或HPV检测结果阳性的高级别鳞状上皮内病变[HSIL]），治疗包括阴道镜检查和活检或切除治疗。对于那些目前癌前风险为60%或更高的患者，如HPV-16阳性HSIL患者，首选直接进行切除治疗，但首先进行阴道镜检查以确认是否需要切除治疗是可以接受的。临床决策支持工具可以促进正确的管理。

结论和相关性

在美国，每年大约有10万人接受宫颈癌前病变的治疗，以预防宫颈癌。有宫颈的人群应进行HPV检测筛查，如果HPV阳性，应进行基因分型和细胞学检测，以评估宫颈癌前病变的风险，并确定是否需要进行阴道镜检查或治疗。在青春期接种HPV疫苗可能会预防90%以上的宫颈癌前病变和癌症。

英文原文如下：

Abstract

Importance  Each year in the US, approximately 100 000 people are treated for cervical precancer, 14 000 people are diagnosed with cervical cancer, and 4000 die of cervical cancer.

Observations  Essentially all cervical cancers worldwide are caused by persistent infections with one of 13 carcinogenic human papillomavirus (HPV) genotypes: 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, and 68. HPV vaccination at ages 9 through 12 years will likely prevent more than 90% of cervical precancers and cancers. In people with a cervix aged 21 through 65 years, cervical cancer is prevented by screening for and treating cervical precancer, defined as high-grade squamous intraepithelial lesions of the cervix. High-grade lesions can progress to cervical cancer if not treated. Cervicovaginal HPV testing is 90% sensitive for detecting precancer. In the general population, the risk of precancer is less than 0.15% over 5 years following a negative HPV test result. Among people with a positive HPV test result, a combination of HPV genotyping and cervical cytology (Papanicolaou testing) can identify the risk of precancer. For people with current precancer risks of less than 4%, repeat HPV testing is recommended in 1, 3, or 5 years depending on 5-year precancer risk. For people with current precancer risks of 4% through 24%, such as those with low-grade cytology test results (atypical squamous cells of undetermined significance [ASC-US] or low-grade squamous intraepithelial lesion [LSIL]) and a positive HPV test of unknown duration, colposcopy is recommended. For patients with precancer risks of less than 25% (eg, cervical intraepithelial neoplasia grade 1 [CIN1] or histologic LSIL), treatment-related adverse effects, including possible association with preterm labor, can be reduced by repeating colposcopy to monitor for precancer and avoiding excisional treatment. For patients with current precancer risks of 25% through 59% (eg, high-grade cytology results of ASC cannot exclude high-grade lesion [ASC-H] or high-grade squamous intraepithelial lesion [HSIL] with positive HPV test results), management consists of colposcopy with biopsy or excisional treatment. For those with current precancer risks of 60% or more, such as patients with HPV-16–positive HSIL, proceeding directly to excisional treatment is preferred, but performing a colposcopy first to confirm the need for excisional treatment is acceptable. Clinical decision support tools can facilitate correct management.

Conclusions and Relevance  Approximately 100 000 people are treated for cervical precancer each year in the US to prevent cervical cancer. People with a cervix should be screened with HPV testing, and if HPV-positive, genotyping and cytology testing should be performed to assess the risk of cervical precancer and determine the need for colposcopy or treatment. HPV vaccination in adolescence will likely prevent more than 90% of cervical precancers and cancers.