GENERAL GYNECOLOGY

Topical 5-uorouracil for treatment of cervical intraepithelial

neoplasia 2: a randomized controlled trial
Q7
Lisa Rahangdale, MD, MPH; Quinn K. Lippmann, MD, MPH; Katelyn Garcia, MS; Debra Budwit, MD;
Jennifer S. Smith, PhD; Linda van Le, MD
OBJECTIVE: The objective of the study was to evaluate the efcacy of
intravaginal application of 5% 5-uorouracil (5-FU) for the treatment of
cervical intraepithelial neoplasia (CIN) 2 in women.
STUDY DESIGN: Women aged 18-29 years with CIN 2 were recruited
for this randomized controlled trial of observation vs treatment with
intravaginal 5-FU. Women in the observation group returned in
6 months for a Papanicolaou smear, colposcopy, and a human
papillomavirus (HPV) deoxyribonucleic acid test. Women in the 5-FU
group were treated with intravaginal 5-FU once every 2 weeks for a
total of 16 weeks and were similarly evaluated at 6 months. All women
who had a baseline visit were included in the intention-to-treat
analysis. Values of P < .05 were considered statistically signicant.
RESULTS: Between August 2010 and June 2013, 60 women were
randomized and had a baseline visit for intervention (n 31) vs
observation (n 29). Of women who had cervical biopsy results at
6 months, regression of disease was demonstrated in 93% of women
in the 5-FU group (26 of 28) and 56% of women in the observation
group (15 of 27). Under the intention-to-treat analysis, a relative risk
for cervical disease regression of 1.62 (95% condence interval [CI],
1.10e2.56) was found between the 5-FU and observation arms
(P .01). When the cervical biopsy, Papanicolaou smear, and HPV
results were combined for the 6 month follow-up visit, 50% of the 5-FU
group (14 of 28) had a documented normal biopsy, normal Papani-
colaou smear, and negative HPV test compared with 22% in the
observation group (6 of 27) (relative risk, 2.25; 95% condence
interval, 1.05e5.09; P < .05). There were no moderate or severe
side effects in the intervention group.
CONCLUSION: Topical 5-FU appears to be an effective medical therapy
for CIN 2 in young women. 5-FU is readily available and may be
considered as an off-label treatment option for young women with CIN
2 who are interested in the treatment of disease but want to avoid
excisional procedures.
Key words: cervical intraepithelial neoplasia, 5-uorouracil, medical
therapy
Cite this article as: Rahangdale L, Lippmann QK, Garcia K, et al. Topical 5-uorouracil for treatment of cervical intraepithelial neoplasia 2: a randomized controlled trial.
Am J Obstet Gynecol 2014;210:xx-xx.
H
istorically, most women with
cervical intraepithelial neoplasia
(CIN) 2 and 3 underwent excisional
therapy or ablation of the cervical trans-
formation zone.
1-3
However, 5-26% of
women have disease recurrence, even
with negative surgical margins.
4
Addi-
tionally, excisional treatment procedures
have been associated with increased
risk of premature delivery
5-8
as well as
anxiety, pain, bleeding, and health care
expenditure.
8-11
Because nearly half
of CIN 2 lesions regress in young
women, current guidelines endorse
close observation of young women as
a preferable management strategy for
CIN 2 and acceptable management
strategy for CIN 3.
1,2,12-14
Although
expectant management is appealing,
approximately one third of CIN 2 cases
will persist and the remaining may
progress to CIN 3 on follow-up.
12-14
There are no medical therapies recom-
mended to promote the clearance of
From the Departments of Obstetrics and Gynecology (Drs Rahangdale, Lippmann, and van Le), Biostatistics (Ms Garcia), Pathology (Dr Budwit), and
Epidemiology (Dr Smith), University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, Q1 NC.
Received Oct. 17, 2013; revised Dec. 5, 2013; accepted Dec. 28, 2013.
Q.K.L. is currently with the Department of Reproductive Medicine, University of California, San Diego, School of Medicine, San Diego, CA. K.G. is currently
with the Department of Biostatistics, Wake Forest Baptist Medical Center, Winston-Salem, NC.
This study was supported by an American College of Obstetricians and Gynecologists Hologic Research Award for the Prevention of Cervical Cancer and
by a James W. Woods Junior Faculty Award from the University of North Carolina School of Medicine. QIAGEN supplied human papillomavirus testing.
The authors report no conict of interest.
Presented at the 40th annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology, Albuquerque, NM, Aug. 8-10, 2013, and at the
28th Annual Scientic Meeting of the International Papillomavirus Society (International Papillomavirus Conference), San Juan, Puerto Rico, Nov. 30
through Dec. 6, 2012.
Reprints: Lisa Rahangdale, MD, MPH, Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill School of Medicine, 3031 Old
Clinic Bldg, CB#7570, Chapel Hill, NC 27599. lisa_rahangdale@med.unc.edu.
0002-9378/$36.00 2014 Mosby, Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajog.2013.12.042
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human papillomavirus (HPV) or cer-
vical dysplasia.
Topical 5-uorouracil (5-FU) is used
for the treatment of skin cancers and le-
sions caused by HPV, including genital
warts, vulvar intraepithelial neoplasia
and vaginal intraepithelial neoplasia.
15-17
The 5-FU treatment of genital disease
is an off-label use of the medication
because it has not been approved by the
Food and Drug Administration or rec-
ommended by the American College of
Obstetricians and Gynecologists for this
use.
Initial treatment regimens were asso-
ciated with severe side effects such as
pain and chronic ulceration.
18
These
side effects were likely a dose-related
response because standard treatments
require multiple daily applications;
studies limiting topical 5-FU to less
frequent application or diluted doses
have reported favorable side effect pro-
les.
19-21
The objective of this study was to
assess the efcacy, safety, and accept-
ability of intravaginal 5-FU as a primary
treatment for CIN 2 in young women.
MATERIALS AND METHODS
This was a prospective nonblinded,
randomized trial of intravaginal 5%
5-FU vs standard-of-care observation in
young women with CIN 2 (no placebo).
The primary outcome was regression of
disease 6 months after the diagnosis of
CIN 2. Secondary outcomes included
high-risk HPV status at 6 months,
12 month pathological ndings, and
safety and acceptability data.
This study was approved by the Uni-
versity of North Carolina (UNC) Insti-
tutional Review Board. All participants
underwent written informed consent
procedures.
Women (aged 18-29 years) presenting
to the UNCs Womens Hospital Clinics
with satisfactory colposcopic examina-
tions, a biopsy-conrmed diagnosis
of CIN 2, and in whom follow-up
observation with cytology and colpos-
copy every 6 months was planned were
approached for study enrollment. Women
who were non-English speaking, human
immunodeciency virus (HIV) infected,
immunosuppressed, pregnant, planning
pregnancy, or breast-feeding during the
study time period or were unwilling to
use condoms and another form of
birth control during the treatment time
period were excluded from the study.
Dual contraception (condoms plus 1
of the following: oral, intravaginal,
injectable, implantable, or intrauterine
conception) was required for the 5-FU
group because of its potential terato-
genic effects demonstrated in intravenous
administration.
22
Women were coun-
seled regarding teratogenic risk during
the consent process.
Order of randomization was gener-
ated based on a simple randomization
table with a 1:1 allocation ratio, and as-
signments were placed into sequentially
numbered opaque envelopes. After ver-
bal interest was reported by a potential
participant on the phone, women were
randomized to an observation or treat-
ment group (5-FU) by study staff. Par-
ticipants in the observation group were
given the option to have their written
consent forms mailed and completion
of a background survey by phone. They
were scheduled for appointments in
6 months from biopsy date and received
standard phone and written appoint-
ment reminders from the health care fa-
cility in addition to reminders fromstudy
staff. Reminders consisted of phone calls,
texting, or e-mailing, depending on the
preference of the participant.
The 5-FUgroup presented to the study
site for written consent procedures and
received written and verbal instructions
for insertion of 2 g of 5-FU via vaginal
applicators every 2 weeks for a total of
8 doses. This dosing schedule was based
on its reported safety, tolerability, and
efcacy in a prior trial of intravaginal
5-FU for the prevention of recurrence of
CIN after excisional procedure in HIV-
infected women.
21
However, because
our studys patient population was not
potentially immunocompromised, we
chose a shorter course of 16 weeks as
per other treatment studies for HPV-
related diseases.
7,8,23,24
The 5-FUparticipants were instructed
to insert 2 g of topical 5% 5-FU cream
(Efudex; Valeant Pharmaceuticals Inter-
national, Quebec, Canada) at night with
a vaginal applicator, which could be
twisted onto the study tube for the
removal of 5-FU cream. After the
medication was inserted into the vagina
proximal to the cervix, participants
placed a tampon per vagina overnight to
keep the creamat the cervix. Participants
were instructed to remove the tampon in
the morning, shower, and frequently
hand wash and change panty liners over
the next 2 days to avoid irritation from
the cream.
Women were supplied home preg-
nancy tests for use prior to each appli-
cation of cream. Condoms or abstinence
from sexual activity 48 hours after use of
the cream was also recommended to
diminish any potential irritation to the
participants sexual partner. All supplies
were provided to the participants. Use of
study drug was delayed if a participant
was having her menstrual cycle.
Participants in the 5-FU group re-
turned for a safety and acceptability
visit at the study site after 8-16 weeks
of use of intravaginal 5-FU to complete
a survey and pelvic examination. A
single unblinded coinvestigator assessed
adherence and genital symptoms and
performed a colposcopic examination of
vaginal and cervical tissue as per the
National Institutes of Health Division of
AIDS Table for Grading the Severity of
Adult and Pediatric Adverse Events: Fe-
male Genital Grading Table for Use in
Microbicide Studies (Table 3 for a listing
of criterion.).
25
The interview included an accept-
ability questionnaire in which partici-
pants were surveyed regarding emotions
felt while using the creamand side effects
to their sexual partner; logistical con-
cerns surrounding use of the cream were
scored on a 5 point Likert scale. Prior
to the 6 month visit, all participants
received hospital-based and study-based
reminders similar to the observation
group described above.
At the 6 month visit, colposcopically
guided cervical biopsies were performed
at the site previously biopsied and diag-
nosed with CIN 2 on original histology
6 months prior for both intervention
and control arms. In all participants,
additional biopsies were obtained if
there was clinical concern for other areas
of dysplasia. We completed similar
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procedures at the 12 month visit. If the
participant had normal results at the
6 month visit and had a normal colpos-
copy, no biopsies were taken at the
12 month visit unless abnormal colpo-
scopic ndings were noted. Women who
had treatment procedures (because of a
CIN diagnosis or personal preference
because of persistent CIN 2) during the
study were withdrawn from the study.
The colposcopist, a board-certied
obstetrician-gynecologist and the direc-
tor of the colposcopy clinic, was not
blinded to the study group of the
participants.
HPV testing was performed at the 6
and 12 month visits using the Digene
Hybrid Capture 2 high risk HPV DNA
test at the Department of Pathology, Yale
University (New Haven, CT). A single
pathologist coinvestigator, board-certied
in cytopathology with a focused subspe-
cialty practice in gynecological surgical
and cytopathology, was blinded to our
randomization scheme and reviewed all
cytology and pathologic specimens for
entry criteria and for follow-up cytology
and histology. Additional p16 immuno-
histochemistry staining was conducted
if clinically indicated.
Sample size and statistical analysis
Sample size calculations were based on
the primary outcome of the regression of
disease. Based on published literature, we
assumed that 50%of CIN2 lesions would
regress with observation alone,
13,14
and a
clinically signicant difference was esti-
mated at 30%. The total sample size
required for the study was 89 women
(45 in each arm, a 0.05, b 0.80 and
2-sided Student t test).
The differences between the treatment
and observation groups were assessed for
all categorical baseline variables and
outcomes using 2-sided Fisher exact tests
of association. Continuous baseline var-
iables were assessed using exact Wilcoxon
rank sum tests. Histological biopsy re-
sults at the 6 month visit were separated
into a dichotomous variable indicating
regression of disease vs persistence or
progression of disease.
The association between the regres-
sion of disease (regression or persistence/
progression) and group status (5-FUand
observation) was determined using a
2-sided Fisher exact test of association.
Additionally, relative risk (RR) with exact
condence interval (CI) was calculated to
aid in understanding the direction of the
association. The analyses were completed
using intention-to-treat (ITT) method-
ology and by imputing histological bi-
opsy results for the women with missing
6 month measurements. Imputed values
were found using the last observation
carried forward method (ie, women
without results were designated to still
have their baseline result [CIN 2,
CIN 3]). Furthermore, a sensitivity
analysis was conducted by removing the
women with missing 6 month measure-
ments and repeating the analysis to
ensure the imputation method was con-
servative. Values of P < .05 were
considered statistically signicant. Other
variables assessed were histological
results at 12 months after diagnosis,
cervical cytology, HPV presence, and
genotype. All analyses were completed
using SAS 9.3 (SAS Institute, Cary, NC)
or StatXact version 9.
Q2
RESULTS
Between Aug. 1, 2010, and June 1, 2012,
93 women who met inclusion criteria
were approached for enrollment (Figure F1 ).
Twenty-six women declined and another
7 were subsequently excluded because of
protocol violations prior to the baseline
visit. Sixty women were randomized and
underwent a baseline enrollment survey.
Baseline characteristics of both groups are
described in Table 1 T1 .
There were no statistically signicant
differences between the 5-FU and obser-
vation groups. The median age of par-
ticipants was 24 and 23 years in the 5-FU
and observation groups, respectively
(P .32). There were no differences
between the groups in regard to the
w
e
b
4
C
=
F
P
O
FIGURE
Flow
Q5
of participants
Flow of participants in randomized-controlled trial of intravaginal 5-FU vs observation in young
women with CIN 2.
CIN, cervical intraepithelial neoplasia; 5-FU, 5-uoruracil.
Rahangdale. 5-uorouracil for treatment of cervical intraepithelial neoplasia. Am J Obstet Gynecol 2014.
www.AJOG.org General Gynecology Research
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FLA 5.2.0 DTD YMOB9615_proof 30 January 2014 4:18 pm ce
following CIN- or HPV-related parame-
ters: tobacco use, rst abnormal Papani-
colaou smear, a prior history of CIN 2 or
3, or a prior history of cryotherapy or
loop electrosurgical excision procedure.
Two women in the 5-FU group and
1 woman in the observation group also
were noted to have ndings consistent
with both CIN 2 and 3. All histological,
cytological, and HPV results at each
measured time point are described in
Table 2 T2
T3
.
Six month outcomes
Of the 60 women who underwent
randomization and baseline procedures,
56 women, 28 women in each group,
were analyzed at the 6 month visit.
Cervical biopsy results are available on
55 of the 60 women (Figure). One
woman in the observation group was not
biopsied because she was pregnant at the
6 month visit; therefore, her 6 month
cervical biopsy result was considered
missing and was imputed using the last
observation carried forward method,
which is the same method used for the
other 4 women missing 6 month visits. A
range of 1e4 quadrant biopsies (mean,
2.7) was assessed for diagnosis in each
participant.
With the ITT analysis, regression of
disease was demonstrated in 84% of
women in the 5-FUgroup (26 of 31) and
52% of women in the observation group
(15 of 29). An RR of 1.62 (95% CI,
1.10e2.56) was observed, revealing that
signicantly more women in the 5-FU
group had regression of disease (P
.01). Under the sensitivity analysis,
regression of disease was demonstrated
in 93% of women in the 5-FU group
(26 of 28); 56% of women in the 5-FU
group (15 of 27) were HPV negative
compared with 26% of women in the
observation group (7 of 27), a RR of 2.14
(95% CI, 1.07e5.37; P .05).
Given the possibility we could miss an
abnormality by basing our results solely
on colposcopically directed biopsies, we
repeated the ITT analysis, adjusting for
the women with discrepant Papanico-
laou and biopsy results (ie, women
with regression of disease on biopsy
results) but also with either a high-grade
squamous epithelial lesion (HSIL) or
TABLE 1
Self-reported characteristics of participants
Demographics
5-FU Observation
P values n % n %
Race
White 24 77.4 18 62.1 .26
African American 6 19.4 7 24.1
Other
a
1 3.2 4 13.8
Ethnicity
Hispanic 3 9.7 4 13.8 .70
Non-Hispanic 28 90.3 25 86.2
Age, y
19-20 2 6.5 1 3.5 .28
21-25 17 54.8 22 75.9
26-30 12 38.7 6 20.7
Median age, y
b
24 (19e29) 23 (20e29) .32
Marital status
Married 6 19.4 5 17.2 .65
Divorced/separated 2 6.5 4 13.8
Never married 23 74.2 20 69.0
Education
High school or less 8 25.8 8 27.6 1.00
More than high school 23 74.2 21 72.4
Health insurance (public or private) 18 58.1 10 34.5 .08
Sexual history
Current contraception use 28 90.3 24 82.8 .47
Ever condom use 18 58.1 13 44.8 .44
Age at rst intercourse, y
12-15 10 32.3 12 41.4 .79
16-20 20 64.5 16 55.2
21-25 1 3.2 1 3.5
Number of sexual partners over lifetime
1-5 10 32.3 15 51.7 .31
6-10 12 38.7 9 31.0
>10 9 29.0 5 17.2
Number of sexual partners in last year
1 23 74.2 19 65.5 .58
2 8 25.1 10 34.5
Medical history
Current tobacco use 7 22.6 8 27.6 .77
Past tobacco use 14 45.2 10 34.5 .44
HPV vaccine (1-3 doses) 10 32.3 6 20.7 .39
Rahangdale. 5-uorouracil for treatment of cervical intraepithelial neoplasia. Am J Obstet Gynecol 2014.(continued)
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atypical squamous cells of undetermined
signicance-favor high grade (ASCH)
Papanicolaou result. Two women from
the 5-FU group with normal biopsies
and an ASCH and HSIL Papanicolaou
result and 1 woman in the observation
group with a normal biopsy and ASCH
Papanicolaou were attributed to the
persistent disease group.
Under ITT analysis, regression of dis-
ease was demonstrated in 77% of the
5-FU group (24 of 31) and 48% of the
observation group (14 of 29). An RR of
1.60 (95% CI, 1.06e2.61) was found
between the 5-FUand observation arms,
respectively (P .03). Under the sensi-
tivity analysis, these 3 women were
additionally removed from the analysis,
and regression of disease was demon-
strated in 92% of women in the 5-FU
group (24 of 26) and 54% of women in
the observation group (14 of 26), an RR
of 1.71 (95% CI, 1.20e2.71, P <.01).
Lastly, we combined the biopsy,
Papanicolaou smear, and HPV data into
1 variable of normal, normal, and
negative results, respectively. When cer-
vical biopsy, Papanicolaou smear and
HPV results were combined for the
6 month follow-up visit, 50% of the
5-FUgroup (14 of 28) had a documented
normal biopsy, normal Papanicolaou
smear, and negative HPV test compared
with 22% in the observation group
(6 of 27) (RR, 2.25; 95% CI, 1.05e5.09;
P < .05). Atypical squamous cells of
uncertain signicance Papanicolaou re-
sults with negative HPV testing were
considered in the normal Papanicolaou
smear category as per current clinical
standards.
1
Twelve month outcomes
As a secondary outcome, we assessed the
36 women (20 in the 5-FUgroup and 16
in the observation group) who returned
for follow-up procedures at 12 months.
Five of the women who completed the
6 month visit were no longer enrolled
because they had loop electrosurgical
excision procedure procedures at the
6 month time point, and 15 of the
women who completed the 6 month visit
had withdrawn or were lost to follow-up.
In the observation group, 55% of the
women (16 of 29) had 12 month visits.
Of these women, 31.3% (5 of 16) had
normal biopsies, 12.5% (2 of 16) had
CIN 1, 18.8% (3 of 16) had CIN 2,
12.5% (2 of 16) had CIN 3, and 25.0%
(4 of 16) were not biopsied because
of normal colposcopic ndings. The
TABLE 1
Self-reported characteristics of participants (continued)
Demographics
5-FU Observation
P values n % n %
Ever had an STD 5 16.1 6 20.7 .74
Nulliparous 23 74.2 15 51.7 .11
First abnormal Papanicolaou smear 13 41.9 13 44.8 1.00
Prior history CIN 2 or CIN 3
c
6 19.4 1 3.5 .10
Prior history cryotherapy or excision 4 12.9 1 3.5 .35
CIN, cervical intraepithelial neoplasia; 5-FU, 5-uoruracil; HPV, human papillomavirus; STD, sexually transmitted disease.
a
Asian (n 1), American Indian or Alaskan Native (n 1), unknown (n 3);
b
Age in years is represented by the median in the
n column and the range in the % column;
c
One participant in the observation group unsure of a prior history of CIN 2 or 3.
Rahangdale. 5-uorouracil for treatment of cervical intraepithelial neoplasia. Am J Obstet Gynecol 2014.
TABLE 2
Pathology, cytology, and HPV results of participants enrolled in trial
of intravaginal 5-FU compared with observation at baseline and 6 month
follow-up
Variable
Baseline (n [60) 6 months (n [56)
5-FU Control 5-FU Control
n % n % n % n %
Pathology
No biopsy 0 0.0 0 0.0 0 0.0 1 3.6
Normal 0 0.0 0 0.0 24 85.7 12 42.9
CIN 1 0 0.0 0 0.0 2 7.1 3 10.7
CIN 2 29 93.6 28 96.6 1 3.6 8 28.6
CIN 3 2 6.5 1 3.5 1 3.6 4 14.3
Papanicolaou smear
Normal 0 0.0 0 0.0 16 57.1 7 25.0
ASCUS 9 29.0 4 13.8 7 25.0 4 14.3
ASCH 8 25.8 2 6.9 1 3.6 2 7.1
LSIL 8 25.8 16 55.2 2 7.1 6 21.4
HSIL 6 19.4 7 24.1 2 7.1 8 28.6
Unknown 0 0.0 0 0.0 0 0.0 1 3.6
HPV result
Yes NT NT 12 42.9 20 71.4
No NT NT 15 53.6 7 25.0
Unknown NT NT 1 3.6 1 3.6
ASCH, atypical squamous cells of undetermined signicance-favor high grade; ASCUS, or atypical squamous cells of
undetermined signicance; CIN, cervical intraepithelial neoplasia; 5-FU, 5-uoruracil; HPV, human papillomavirus; HSIL,
high-grade squamous epithelial lesion; LSIL, low-grade squamous intraepithelial lesion; NT, not tested.
Rahangdale. 5-Fluorouracil for treatment of cervical intraepithelial neoplasia. Am J Obstet Gynecol 2014.
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4 womenwho were not biopsied also had
negative Papanicolaou smears and HPV
results.
In the 5-FUgroup, data were collected
at the 12 month visit for 65% of the
women (20 of 31). Of these women,
50.0% (10 of 20) had normal biopsies,
no women had CIN1, 5.0%(1 of 20) had
CIN 2, no women had CIN 3, and 45.0%
(9 of 20) were not biopsied because
of normal colposcopic ndings. Of
the women with normal colposcopic
ndings, 6 had normal Papanicolaou
and negative HPVresults, 1 had a normal
Papanicolaou and positive HPV result,
and 2 had atypical squamous cells
of uncertain signicance Papanicolaou
smears and positive HPV results.
5-FU safety and acceptability
Ninety-four percent of 5-FU partici-
pants (29 of 31) completed an accept-
ability questionnaire and colposcopic
examination after using a median of
4 doses (range, 4e8 doses) of the study
drug. Findings on colposcopic exami-
nation during the use of the cream
demonstrated that most women had
grossly normal examinations. Abnormal
examination ndings were classied
as minimal based the adverse events
grading scale described in Materials and
Methods
7
(Table 3). Overall, 48% of
women reported a side effect such as
pain, bleeding, discharge, burning/itch-
ing/irritation, urinary concerns, or other
concerns. The majority of women
reported discharge and burning/itching/
irritation as their chief concern.
Participants were asked whether any
of the reported symptoms (Table 3)
caused interference with any usual ac-
tivities. The specic question was as
follows: Do any of the symptoms you
described cause you interference with
your usual activities? In other words,
do they interfere with you working,
shopping, cooking, going out, or doing
things that you enjoy? No participant
reported interference. Participants were
then asked, On a scale of 1-10, describe
how much interference you have? (1 is
minimal, 10 is severe). The range of
reported interference was 1e4. Of note,
2 women experienced vulvar irritation,
which resolved within 2 weeks of stop-
ping the cream. One of these women
had a single ulceration and another had
erythema on her vulva. Given the rare
occurrence of such symptoms, in-
vestigators withdrew both women from
further use of the cream. However, both
women reported that the symptoms did
not interfere with daily activities. A third
woman discontinued the use of the
cream prior to completion because of
anxiety.
At the 6 month follow-up, partici-
pants in the 5-FU group self-reported a
mean of 7.5 (range, 2.0e8.0) applica-
tions of the study drug; 86% of women
(24 of 28) reported using all 8 doses.
No women became pregnant while using
the 5-FU cream.
Women were asked additional ques-
tions regarding their experience using
intravaginal 5-FU. Despite 48% of pa-
tients reporting at least 1 side effect,
83% of participants (24 of 29) reported
feeling overall satised with the use of
the 5-FU cream. Ninety-seven percent
women (28 of 29) believed the creamwas
safe, and all were condent they had used
the cream correctly. Ten percent women
(3 of 29) agreed that they were con-
cerned that they may hurt themselves
while using the cream. No women re-
ported any adverse events experienced
by their sexual partner. When asked
regarding emotions felt surrounding use
of the cream, women reported feeling
the following: anxious (14%), afraid
(3%), embarrassed (0%), empowered
TABLE 3
Side
Q6
effects of biweekly 5-FU assessed during treatment based
on the National Institutes of Health Division of AIDS table for grading
the severity of adult and pediatric adverse events: female genital grading
table for use in microbicide Studies
7
(n [29)
Variable Frequency (%)
Erythema, mucopurulent discharge, friability
a
Normal 22 (76)
Minimal (<50% of cervix involved) 7 (24)
Moderate or more severe 0 (0)
Epithelial disruption (%)
a
0 23 (79)
<25 6 (21)
>25 0 (0)
Intermenstual bleeding
None 25 (86)
Symptoms or on examination 4 (14)
Like menses or heavier 0 (0)
Side effects
b
Pain 4 (14)
Bleeding other than when having menses 5 (17)
Discharge 7 (24)
Itching/burning/irritation 9 (31)
Urinary concerns 0 (0)
Other concerns
c
3 (10)
5-FU, 5-uoruracil.
a
Based on colposcopic examination;
b
Based on interview; participants may have listed more than 1 side effect;
c
Anxiety,
insertion of tampon/applicator uncomfortable, swelling.
Rahangdale. 5-uorouracil for treatment of cervical intraepithelial neoplasia. Am J Obstet Gynecol 2014.
Research General Gynecology www.AJOG.org
1.e6 American Journal of Obstetrics &Gynecology MONTH 2014
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(10%), overwhelmed (0%), or intimi-
dated (0%). Sixty-two percent reported
no emotion at all.
COMMENT
In this randomized trial of clinical out-
comes after the use of intravaginal 5-FU,
we report that there was a signicantly
increased likelihood of histopathological
regression of disease. Regression of CIN
2 was demonstrated in 93% of women in
the 5-FU group (26 of 28) and 56% of
women in the observation group (15 of
27). By the 6 month visit, women in the
5-FU group were twice as likely to be
HPVnegative thanwomen in the control
group. When all outcomes were com-
bined, women in the 5-FU group were
twice as likely to have negative cervical
biopsies, Papanicolaou smears, and HPV
tests at 6 months. Lastly, we demon-
strated that topical 5-FU dosed every
2 weeks was well tolerated by healthy
women. The efcacy and acceptability of
5-FU in this dosing format has not pre-
viously been studied in this population
and explores the possibility of a patient-
controlled management option for CIN.
This study provides additional evi-
dence to support the pursuit of a feasible
topical treatment of CIN. 5-FU is an off-
label therapeutic option for the treat-
ment of vaginal intraepithelial neoplasia
and has previously been shown to have
an impact on the recurrence of CIN.
21,26
In a trial of intravaginal 5-FU use for
the treatment of cervical dysplasia in
HIV-infected women after excisional
procedures for CIN 2-3, treatment with
5-FU was signicantly associated with
prolonged time to CIN development
(P .04).
21
Participants in the observa-
tion arm of this trial were more likely to
have CIN 2-3 recurrence (P .01).
21
Toxicity has always been a concern with
5-FU therapy; however, this study, from
which we based our clinical trial design,
reported no high-grade toxicities after
18 months of follow-up. Approximately
one third of participants reported local
reproductive tract side effects.
21
Studies of intravaginal cidofovir and
imiquimod have shown efcacy in clin-
ical regression of disease and clearance of
HPVin women with CIN 2 and 3.
27,28
In
the imiquimod study, 73% of women
underwent histological regression of
CIN 2 and 3 compared with 39% of
women using placebo (P .009).
27
In
the cidofovir study, histological clearance
was demonstrated in 61% compared
with 20% in the treatment and pla-
cebo groups, respectively (P < .01).
28
Although comparable efcacy to our
study, boththerapies required application
multiple times per week (3 times per
week for cidofovir, 1-3 times for imiqui-
mod) and also reported local and sys-
temic side effects. Those studies carried
the advantage of placebo-control; how-
ever, in all studies, including our own, the
pathologist was blinded to treatment
results.
We purposely did not choose a
placebo-control because we did not want
to introduce any intervention that would
interfere with the natural regression of
disease (eg, increased condom use, pla-
cebo altering the vaginal milieu), which
is the current standard of care. Our
sample size is comparable with these
other studies (59 and 48 participants in
the imiquimod and cidofovir studies,
respectively). Although larger sample
sizes will be required for further inves-
tigation and validation of our results, we
demonstrated regression of disease in
women in the 5-FUgroup. None of these
therapies, including 5-FU, are Food and
Drug Administration approved or rec-
ommended by American College of
Obstetricians and Gynecologists for the
management of cervical dysplasia.
One limitation of our study is that
biopsy outcomes were, for the most
part, not based on conization biopsies
or 4 quadrant biopsies with p16 immu-
nohistochemical staining but clinically
oriented, colposcopically directed bi-
opsies (mean, 2.7). We do not have data
on the size of the lesion at baseline.
Although we had a single pathologist
evaluate all specimens, this method in-
troduces the concern for bias on the part
of the investigator conducting biopsies,
which may have led to erroneous di-
agnoses if nondiseased areas were bio-
psied. We attempted to address this issue
by adjusting for women with discrepant
Papanicolaou smears (HSIL and ASCH
Papanicolaou smear result associated
with CIN 1 or normal biopsies) and still
found a resultant risk difference that was
statistically signicant in favor of the
5-FU group using 2 different analyses.
Additionally, we compiled the biopsy,
Papanicolaou smear, and HPV data, and
found that women in the 5-FU group
were twice as likely to have a normal
biopsy, normal Papanicolaou smear, and
negative HPV test than the women in the
observation group. Although some of
the rigor of clinical trial design was lost
in retrieving data from a clinical setting,
this limitation was also an advantage of
this study in that we were able to conduct
a trial on a hard-to-reach young popu-
lation who may not usually participate
in clinical trials. More than half of the
participants did not have private or
government-sponsored health insurance.
We had only an 8% dropout rate at the
6 month follow up.
In this prospective randomized trial,
we demonstrated that intravaginal 5-FU
was effective in promoting the regression
of CIN 2 and was safe and acceptable to
healthy women aged 18-29 years of age.
However, it is important to note that
despite the apparent efcacy of topical
5-FU in this study, we must caution that
counseling for the prevention of preg-
nancy is needed when using this medi-
cation in women of child-bearing age
because of its potential for teratogenic
effects in its intravenous form.
22
Addi-
tionally, because of the potential for
mucosal disruption, we do not know
whether this therapy could put a woman
at higher risk of sexually transmitted
infections. Nonetheless, these ndings
provide young women with a potential
medical option for intervention after
diagnosis of CIN 2 rather than having to
choose between doing nothing (observa-
tion) or surgical treatment. The avail-
ability of such an option may reduce both
patient and provider anxiety over a CIN 2
diagnosis because these fears may propel
both parties toward more conservative
surgical interventions with the potential
for consequences in future pregnancies.
Future research aimed at under-
standing whether topical 5-FUdecreases
the time toward the inevitable regres-
sion of CIN 2, its effects on HPV infec-
tion itself, its use in CIN 3 or older
women, or whether it is a comparable
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therapy with an excision or ablation
procedure is needed. However, this
study and prior research using this drug
regimen demonstrate that topical 5-FU
is a readily available, well-tolerated,
patient-controlled medical treatment
for cervical dysplasia in young women.
Although excision and ablation are
well-established, standard-of-care pro-
cedures, the time has come for our eld
to consider and study medical manage-
ment options as alternatives for women
who decline or cannot access surgical
treatments. -
ACKNOWLEDGMENTS
We would like to thank nursing and support staff
of the UNC Womens Hospital outpatient clinics
for their assistance with completion of this study.
We would also like to thank Jennifer Cayless
(UNC Department of Pathology) and the UNC
Center for Womens Health Research for study
coordination.
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