Title: Long-term Follow-up of Young Women with High Grade Squamous Intraepithelial Lesions

Objective: Our primary objective was to compare the difference in number of cervical excisional procedures in women <25 years with high grade cytology or histology who were managed expectantly versus those who underwent immediate excision. We hypothesized that women <25 years with high-grade cytology (HSIL, ASC-H, LSIL-H, AIS and AGC) or histology (CIN2 or greater) managed expectantly would have fewer excisions over the study period. Secondary objectives were 1) to compare the number of women, managed expectantly versus managed with immediate excision with CIN2+ two years after initial diagnosis and 2) to determine the rates of regression, progression and persistence among young women with high-grade histology. Methods: This was a retrospective cohort study of all women < 25 years who presented to the WPCC with high-grade cytology or histology between 1999 and 2012. Women were grouped by management category (expectant versus immediate excision). Results: Between 1999-2012, 493 women meeting eligibility criteria were seen at the WPCC, 417 are included in the primary analysis: 145 in the immediate excision group and 272 in the expectant management group. Throughout the study period, women in the expectant management group underwent a mean of 0.2 excisional procedures compared to a mean of 1.1 excisional procedures in the immediate excision group (p = <0.0001). 22% of the women in the expectant group eventually underwent an excisional procedure. Two years after initial presentation, 27.4% of women in the expectant group and 3.5% of women in the immediate excision group had CIN2+ on biopsy. Of the 129 women with CIN2+ on initial biopsy who were expectantly managed, 79 (61.2%) showed regression, and only 10 (7.8%) showed progression from CIN2 to CIN3. All regressions took place by year 5, with the majority (72/79, 91%) by year 2. There were no cancer diagnoses at baseline or at end of study period. Conclusion: In young women with high-grade dysplasia managed expectantly, 61% showed regression. If all women in this study had been expectantly managed, 88 excisions may have been avoided. No cases of cancer were identified, further supporting the safety of expectant management for young women with high-grade cervical lesions.