Selecting Patients for Endocervical Curettage.

E ndocervical curettage (ECC) is a minor but painful procedure. It increases the cost of colposcopy but may identify occult cervical lesions whose detection may allow treatment that aborts oncogenesis, saving lives. The yield of ECC rises with age, as the squamocolumnar junction recedes into the endocervix, where lesions may arise and progress undetected. Targeting ECC to highest risk women increases yield among sampled women but reduces sensitivity. Whether this trade-off is worthwhile has been debated for decades, and as two articles in this issue of the Journal of Lower Genital Tract Disease make clear, the debate continues. These interesting but flawed studies illustrate why clinicians remain confused about whether to target women for ECC at colposcopy. Traditionally, ECCwas used to assess the endocervix, allowing superficial ablative procedures such as cryotherapy when negative and triaging women to excisional treatments such as conization when positive. Because ablation only destroys tissue within millimeters of the cryoprobe, cryotherapy might fail to treat occult endocervical disease that could progress to cancer. Failure to obtain or act on ECC was found to predict posttreatment cancer. However, ECC samples more than just the endocervix, often picking up ectocervical tissue. Positive ECCs that did not reflect endocervical lesions nevertheless led to cone biopsy, with general anesthesia, increased bleeding, and a higher risk for subsequent pregnancy complications. The shift away from cryotherapy to loop electrosurgical excision procedures (LEEPs) as the mainstay of therapy for CIN reduced the need for pretreatment endocervical tissue sampling, as assessment of the LEEP specimen identifies disease at the endocervical margin requiring re-excision, close follow-up, or even hysterectomy. In this context, ECC is now employed as a blind endocervical biopsy to detect occult high-grade CIN, regardless of location. Several authors have explored how targeting ECC to women with risk factors affects yield. Applying these studies to clinical practice is problematic, as the 2 papers published in this issue illustrate. Most ECCs are negative; however, a nonzero proportion will show CIN2+, and there is no consensus about the yield threshold that justifies ECC. Absolute yield is less important than the proportion of cases for which positive ECC changes management, only 1% to 2% of colposcopies. For example, older women with unsatisfactory colposcopy and high-grade cytology grade often have a positive ECC, but all need a diagnostic excisional procedure: because ECC will not alter management, it can be avoided in these cases. Most studies are retrospective interpretations of colposcopy databases, with conclusions drawnwithout a validation dataset. Selection criteria are often obscure, limiting generalizability. Continuous variables, such as age or the extent of endocervical disease, are converted to categorical variables for statistical analysis. This obscures the very different risks of a 25-year-old with mucus obscuring a nulliparous cervix and a 38-year-old with endocervical acetowhite epithelium to the limit of visualization: both are younger than 40 years of age with unsatisfactory colposcopy. Finally, the reproducibility of an ECC diagnosis is at best moderate. The 2 papers on ECC in this issue allow clinicians to draw some conclusions relevant to practice but illustrate the problems in our knowledge base on ECC. Pretorius and colleagues retrospectively reviewed almost 2 decades of prospectively recorded colposcopy results from the Southern California Permanente Medical Group. There was no standard for when to perform ECC. Although the authors noted that 4.5% of 18,537 colposcopies had an ECC showing CIN2+ and presented the proportion of women with positive ECC in a variety of clinical scenarios, they do not present the overall rate of ECC or the number needed to identify 1 case of CIN2+. Statistical analysis was limited to chi-square testing, a crude technique in an age when researchers carry tremendous computing power in their pockets. The authors’ unsurprising conclusion was that targeting ECC to highest risk women results in a substantial decline in sensitivity, although sensitivity with and without ECC was not reported for the 18,537 cases in their series. In the second paper on ECC in this issue, van der Marel reviewed 126 cases of ECC done in a larger prospective study of colposcopy conducted in Europe. This analysis apparently was not prespecified. Subjects’ median age was 41 years, and most women had high-grade cytology resulting in limited generalizability to young women with atypical or low-grade cytology. Overall, 44% of these high-risk women had CIN2+. ECC was performed at colposcopy for a variety of indications but was not