Introduction

Cervical cytology screening programs have led to a decrease in the incidence and mortality of cervical cancer in the United States and other developed countries. Following the discovery of Human papillomavirus (HPV) as a potential cause of cervical cancer in the 1970s (1), subsequent epidemiological studies utilized sensitive HPV-DNA detection techniques to assess the prevalence of this virus in populations of all ages. Populations with a high prevalence of HPV infection were the same ones identified in earlier studies as being at high risk of developing cervical cancer. These included women who were young when they initiated sexual intercourse, had multiple sexual partners, and had other sexually transmitted infections (STIs) (2). Several studies in the 1980s also reported that adolescents in the United States had very high rates of unprotected sexual intercourse, STIs, and multiple sexual partners (3). Similarly, women in this age group had high rates of HPV infection (4,5).

In addition to high rates of HPV infection, it was also noted that the cervical cancer precursor, cervical intraepithelial neoplasia (CIN), or recently termed as squamous intraepithelial lesion (SIL), also occurred in high rates in adolescents (5,8). This is not surprising because SIL is the morphological manifestation of HPV replication and protein expression. Moreover, the presence of active squamous metaplasia in adolescents appears to play an important role in the support of viral replication.

From: Current Clinical Oncology: Molecular Pathology of Gynecologic Cancer Edited by: A. Giordano, A. Bovicelli, and R. Kurman © Humana Press Inc., Totowa, NJ

The high rates of SIL found in sexually active adolescents led to the implementation of screening practices in the United States that targeted sexually active adolescents and young women at any age (9-11). Not surprisingly, the new screening practices resulted in an enormous increase in referrals for colposcopy and treatment. Epidemiology studies during the last decade have broadened the understanding of the natural history of HPV, and have shown that young women do not benefit from cervical cancer screening and that watchful observation is often the best management for low-grade SIL (LSIL). The American Cancer Society recently published new guidelines, which support initiating cervical cytology screening after 3 years of the onset of vaginal sexual intercourse, but no later than 21 years of age (12). Follow-up and management of LSIL have also been altered for adolescents to ensure LSIL can be safely followed by cytology or HPV-DNA testing (13). This chapter discusses the prevalence and natural history of HPV and SIL in adolescents as well as the biological factors associated with vulnerability to HPV and its consequences in this age group. Finally, this chapter covers the new guidelines in the United States based on these observations.

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