LAUSR

BACKGROUND Only a few small studies compared the two-step method (biopsy followed by treatment) with see-and-treat (immediate treatment) in women with both low-grade or high-grade referral cytology. The clinical practice variation in the Netherlands has not been reviewed before. OBJECTIVES To determine overtreatment rates in the two-step versus see-and-treat approach in women referred for colposcopy because of abnormal cytology and to evaluate clinical practice variation in the Netherlands. STUDY DESIGN A population-based retrospective cohort study including 36,581 women with a histologic result of the cervix identified from the Dutch Pathology Registry (PALGA) between 2016-2017. Odds ratios of overtreatment primarily defined as cervical intraepithelial neoplasia grade 1 or less were determined for the two-step and see-and-treat approach in relation to age, high risk human papillomavirus status, and referral cytology. RESULTS Of the included women 10,713 women (29.3%) received the two-step method, 6,851 women (18.7%) underwent see-and-treat, and 19,017 women (52.0%) received conservative management after colposcopy with histologic assessment with cytologic follow-up or another type of treatment. Despite the existence of a national guideline, advising see-and-treat only in case of suspecting high-grade disease in women who completed their childbearing, there is a wide practice variation between the two strategies in the Netherlands with 7.0-88.3% of the women receiving see-and-treat per laboratory. The median time between cytology and treatment was one and two months (range 0-12) in women receiving see-and treat and the two-step method, respectively. A total of 4,119 women (23.5%) were overtreated with older women, high risk human papillomavirus negative women, and women with low-grade cytology being more likely to be overtreated. Women with low-grade cytology and see-and-treat were associated with a higher overtreatment rate than women receiving the two-step method (65.0% (1,414/ 2,174) versus 32.1% (1,161/ 3,613), respectively; OR 3.34; 95%CI 2.92 to 3.82). However, in women with high-grade cytology see-and-treat was inversely associated with overtreatment (11.3% (529/ 4,677) versus 14.3% (1,015/ 7,100), respectively; OR 0.68; 95%CI 0.58 to 0.81). CONCLUSIONS See-and-treat is only justified in women with high-grade cytology and who completed their childbearing. There is a wide practice variation between the two strategies in the Netherlands and gynecologists should adhere to the guidelines to prevent overtreatment.