DISCUSSION
cancer, precancerous lesions
CERVICAL DISEASE, PRECANCEROUS LESIONS, CANCER, DISEASE, RECURRENT DISEASE, SCARRING
VIA in the follow-up of patients treated by TA should reliably identify women having a persistent or residual cervical disease that has not been entirely destroyed during treatment or a recurrent disease. This issue may be challenging as residual post-treatment lesions might have characteristics that make them difficult to detect. In our experience, we noticed a great variability of cervical tissue after TA, such as focal thickening, sometimes scarring that may mimic or hide CIN2+ lesions, and a change in the position and visibility of the SCJ and TZ.In our series, we observed a significant shift of 36% (95% CI, 22.9 to 50.8) from TZ1-2 to TZ3, 6-12 months after TA, with more than half of patients having a TZ3 after treatment (56%, Diagnostic performance of VIA to detect precancerous lesions and cancer is likely to be even lower in women having a TZ3.We observed that TZ classification was not uniformly used by all observers, with a high heterogeneity of agreement between observers, ranging from substantial (K > 0.61) to slight or fair (K = 0.01-0.20, K = 0.21-0.40). We also observed an intraobserver discordance between the original TZ classification and the reported SCJ visibility, which led us to introduce a corrected TZ, on the basis of SCJ visibility. This has important implications for eligibility for TA, which appears to be highly subjective.To date, there are no uniform follow-up protocols after TA and the available literature is scarce and frequently overlooks the reliability of VIA after treatment. Traditionally, the same methods that are used for pretreatment diagnosis are also used at a follow-up of 6-12 months after treatment although there is no clear evidence that it increases the detection of persistent or recurrent disease.Alternative methods addressing the limitation of assessment of patients with a non–fully visible TZ are currently being evaluated, such as Artificial Intelligence–based VIA, Artificial Intelligence–based cytology, and HPV rapid testing, which might be promising approaches in the future.Finally, as TA is associated with a significant change in cervical anatomy, which makes interpretation of VIA more complex, clinicians should avoid overtreatment and optimize their decision strategy to treat only women having a true disease.The major strength of this study is that patients were their own controls, as VIA findings were compared between pre- and post-thermal ablation images. This minimizes selection bias and other confounding factors. Second, the series are consecutive cases corresponding to a real routine practice, without selection other than for image quality. The main limitation is that we used static images in which the SCJ and TZ may be more difficult to assess, considering that during in-person examination, the provider can improve visualization by manipulating the cervix with a swab or repositioning the speculum. Another limitation is that the SCJ and TZ can change with age, body hormone levels, and menstrual cycle. In this study, we only report the variable of age. Data on menopause status and menstrual cycle were not collected. Nevertheless, heterogeneity of the study sample is limited by an inclusion age of 30-49 years and participants acting as their own controls.In conclusion, a high number of post-thermal ablation examinations are documented as TZ3, supporting that VIA might have limited value as a primary follow-up examination of patients treated with TA. Further studies need to be conducted to determine the value of VIA after TA to provide better guidance for health care providers.