Long-term impact of cervical ablation in visual assessment of the squamocolumnar junction: implications for subsequent screening and follow-up
Cervical cancer screen-and-treat programs, which combine human papillomavirus (HPV)-based screening with immediate ablation of lesions, are a key strategy for reducing cervical cancer burden in low-resource settings. Although ablation is known to impair squamocolumnar junction (SCJ) visibility in the short-term, its long-term effects remain unclear, with potential implications for subsequent screening and follow-up. This study evaluated whether prior ablation is associated with incomplete SCJ visualization approximately 5 years post-treatment. We analyzed data from the Cervical Cancer Prevention in El Salvador program. Women aged 34 to 55 years who previously participated in Cervical Cancer Prevention in El Salvador were invited for HPV testing approximately 5 years after their initial screening. Those with positive results were further evaluated through visual inspection with acetic acid and colposcopy. We used generalized linear models to assess the association between prior ablation and incomplete SCJ visualization, adjusting for age, parity, and time since the initial HPV screen. Incomplete SCJ visualization was more frequent among women with prior ablation compared to those without previous treatment, both during colposcopy (47% vs 28%; OR 2.34, 95% CI 1.20 to 4.56) and visual inspection with acid (40% vs 25%; OR 2.06, 95% CI 1.05 to 4.01). Older age was also associated with impaired visualization, but the association between prior ablation and incomplete SCJ visibility remained significant after adjustment. Ablative treatment has a sustained impact on SCJ visualization that persists for years after the procedure, limiting the effectiveness of visualization-based surveillance. These findings underscore the need for efficient and affordable triage strategies to minimize unnecessary ablation in screen-and-treat programs and improve long-term follow-up care in low-resource settings.