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BACKGROUND: High-risk human papillomavirus-based screening demonstrates higher sensitivity but lower specificity than cytology for detecting high-grade squamous intraepithelial lesions. This has increased colposcopy referrals and introduced a new group of patients with persistent high-risk human papillomavirus infections and normal cytology. OBJECTIVE: In this population, we aimed to describe colposcopic findings, evaluate the diagnostic performance of systematic colposcopy using Swedescore, and assess the prevalence of high-grade squamous intraepithelial lesions. STUDY DESIGN: In this retrospective cohort study, we included 493 patients referred to colposcopy through the Finnish national cervical cancer screening program in 2021 following high-risk human papillomavirus infection persistence with negative for intraepithelial lesion or malignancy or atypical squamous cells of undetermined significance triage cytology. We described and compared colposcopic findings and histological outcomes across the cohort, stratified by referral cytology, age, and other subgroups. Statistical analyses included descriptive statistics and hypotheses testing with appropriate parametric and nonparametric tests. RESULTS: Altogether, 17.8% (88/493) of patients had a histologically confirmed high-grade squamous intraepithelial lesion. Prevalence was higher (P<.001) in those with atypical squamous cells of undetermined significance triage cytology (26.9%, 42/156) than negative for intraepithelial lesion or malignancy triage cytology (13.6%, 46/337). High-grade squamous intraepithelial lesion prevalence was also higher (P<.001) among those aged less than 50 years (22.3%, 78/345) than among those aged more than 50 years (6.8%, 10/148). Most high-grade squamous intraepithelial lesion cases lacked classic high-grade colposcopic features. Sensitivity and specificity of colposcopic impression for detecting a high-grade squamous intraepithelial lesion were 0.34 (95% confidence interval, 0.26-0.47) and 0.91 (95% confidence interval, 0.88-0.94). Swedescore showed moderate discriminative ability (area under the curve, 0.75) for high-grade squamous intraepithelial lesion detection, with high specificity but poor sensitivity. CONCLUSION: A considerable proportion of individuals with persistent high-risk human papillomavirus infections and normal or low-grade cytology-who would not typically be referred under cytology-based screening-had a high-grade squamous intraepithelial lesion. Younger age and atypical squamous cells of undetermined significance cytology correlated with elevated risk. Colposcopists should adjust their interpretation and maintain a low threshold for biopsy in this population. The clinical significance of detected high-grade squamous intraepithelial lesions remains an open question.
Hulmi et al. (Sun,) studied this question.