The optimal management of patients with low-grade squamous intraepithelial lesions (LSIL), many of whom have transient human papillomavirus (HPV) infections, is controversial. We applaud Susie Lau and Eduardo Franco for tackling this difficult issue.1 However, we are concerned that Canadian practitioners will interpret their commentary and its algorithm as an endorsed guideline. Clinical practice guidelines should be based on thorough review of the evidence, expert review by a wide variety of stakeholders and practitioner feedback. Furthermore, recommendations should be clear, straightforward and clinically applicable. We believe their algorithm is unlikely to be accepted into clinical practice because of its complexity and its reliance on obtaining an accurate date of sexual debut.
The authors quote US guidelines2 for cervical abnormalities but fail to recognize other consensus guidelines in Canada and abroad. The report of the Pan-Canadian Forum on Cervical Cancer Prevention and Control3 was based on a consensus process that included a wide variety of stakeholders. That report did not provide specific guidelines for the management of LSIL, but recommended that a national consensus management algorithm be developed. Currently, the Cervical Cancer Prevention and Control Network, supported by the Public Health Agency of Canada, is developing strategies to achieve those recommendations.
A revised set of Ontario-based guidelines was recently released;4 optimal management of women with LSIL was one of the most contentious issues. In the end, the review panel concluded that for the present there is insufficient evidence to recommend different management strategies for LSIL based on a specific patient age.