1
|
Reuschenbach M, Valente S, Takyar J, Dhawan A, Hall A, Agrawal N, Ghelardi A, Del Pino M, Nowakowski A, Sabale U. Treatment characteristics, HPV genotype distribution and risk of subsequent disease among women with high-grade cervical intraepithelial neoplasia in Europe: A systematic literature review. Eur J Obstet Gynecol Reprod Biol 2024; 300:129-140. [PMID: 39002399 DOI: 10.1016/j.ejogrb.2024.06.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Revised: 06/05/2024] [Accepted: 06/20/2024] [Indexed: 07/15/2024]
Abstract
INTRODUCTION High-grade cervical intraepithelial neoplasia (CIN), a premalignant lesion of the uterine cervix, is caused by persistent Human Papillomavirus (HPV) infection. CIN can be identified through screening programs and high-grade CIN is usually treated by ablation or excision. This study aimed to summarize the clinical management and outcomes among women with high-grade CIN in Europe. METHODS A systematic literature review was conducted to identify treatment methods and their frequency of use, report HPV genotype prevalence and distribution and summarize patterns for subsequent lesions after primary treatment, among women with high-grade CIN in Europe. Embase®, MEDLINE® and Cochrane databases were searched (1st January 2012 to 30th August 2022), along with relevant conference proceedings (2018-2022), inclusive. Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) compliant methodology was adopted. Eligibility criteria included non-immunosuppressed female patients with CIN2+ from Europe (published in English). RESULTS In total, n = 55 studies were included. CIN excisional therapy was the most received treatment approach (15.8-100 %, loop electrosurgical excision procedure/large loop excision of the transformation zone most common), followed by ablative therapies (1-43.3 %, cold coagulation most common). Other approaches included 'wait and watch' (4.8-52.6 %) and hysterectomy (4.8-16.2 %). HPV positivity rates ranged from 67.8-100 % pre-conization and 4.7-32.8 % post-conization. The most prevalent HPV genotypes reported (both pre- and post-treatment) were HPV16 and HPV18. In patients who received excisional or ablative procedures subsequent CIN was most frequently diagnosed ≤6 months after treatment. The overall rate of subsequent CIN reported was 0.5-20.9 %. CONCLUSION Conization and ablation were the most common techniques, however, these procedures were associated with sub-optimal outcomes. Close clinical follow-up is important due to the risk of subsequent CIN or invasive cancer. This review serves as a reference point for the comparison of future treatment patterns as they evolve across Europe, following improved implementation of prophylactic HPV vaccination and screening.
Collapse
Affiliation(s)
- Miriam Reuschenbach
- Global Medical and Scientific Affairs, MSD Sharp & Dohme GmbH, Munich, Germany
| | | | | | | | | | | | - Alessandro Ghelardi
- Azienda Usl Toscana Nord-Ovest, UOC Ostetriciae Ginecologia, Ospedale Apuane, Massa, Italy
| | - Marta Del Pino
- Institute Clinic of Gynecology, Obstetrics, and Neonatology, Hospital Clínic, Universitat de Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain
| | - Andrzej Nowakowski
- Department of Cancer Prevention, The Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Ugne Sabale
- Value & Implementation Outcomes Research, MSD, Vilnius, Lithuania.
| |
Collapse
|
2
|
Zhang L, Sauvaget C, Mosquera I, Basu P. Efficacy, acceptability and safety of ablative versus excisional procedure in the treatment of histologically confirmed CIN2/3: A systematic review. BJOG 2023; 130:153-161. [PMID: 35689493 DOI: 10.1111/1471-0528.17251] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 05/03/2022] [Accepted: 05/14/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Outcomes of earlier systematic reviews of the efficacy of ablative and excisional techniques to treat cervical intraepithelial neoplasia grade 2 or 3 (CIN2/3) were biased, as most of the included studies did not compare the techniques head-to-head. OBJECTIVE To systematically review the outcomes of studies comparing ablative and excisional techniques to treat CIN2/3 head-to-head. SEARCH STRATEGY Medline, Embase and Global Index Medicus were searched from inception until May 2021. SELECTION CRITERIA Studies directly comparing the efficacy and safety of excisional and ablative treatments on histologically confirmed CIN2/3. Eligibility criteria for the women treated with ablation had to be same as those treated with excision. DATA COLLECTION AND ANALYSIS A total of 323 articles were archived. Data on the risk of persistence/recurrence and safety were extracted from the original trials. Comparison between the two procedures was reported by forest plots, stratified by follow-up intervals and by HIV status. MAIN RESULTS Six publications were included. The risk of persistence/recurrence following ablation was significantly higher than that following excision (overall, RR 1.65, 95% CI 1.25-2.19; at 6-month follow-up, RR 1.94, 95% CI 1.29-2.91; at 12-month follow-up, RR 1.78, 95% CI 1.27-2.51; at 24-month follow-up, RR 1.57, 95% CI 1.11-2.23). The findings remained similar among women living with HIV (WLHIV). Both procedures were equally safe. CONCLUSIONS Excisional treatment was more effective than ablative treatment, with both procedures having similar safety profiles. Other programmatic considerations will guide the selection of technique, especially in resource-limited settings.
Collapse
Affiliation(s)
- Li Zhang
- Early Detection, Prevention & Infections Branch, International Agency for Research on Cancer, Lyon, France
| | - Catherine Sauvaget
- Early Detection, Prevention & Infections Branch, International Agency for Research on Cancer, Lyon, France
| | - Isabel Mosquera
- Early Detection, Prevention & Infections Branch, International Agency for Research on Cancer, Lyon, France
| | - Partha Basu
- Early Detection, Prevention & Infections Branch, International Agency for Research on Cancer, Lyon, France
| |
Collapse
|
3
|
Papoutsis D, Williams J, Underwood M, Parry-Smith W. Healing pattern of the cervical stroma following cold coagulation treatment for cervical intraepithelial neoplasia: A case report. Oncol Lett 2022; 23:81. [PMID: 35126723 DOI: 10.3892/ol.2022.13201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 11/05/2021] [Indexed: 11/06/2022] Open
Abstract
Cold coagulation of the cervix for cervical intraepithelial neoplasia (CIN), when compared with cervical excision, has previously demonstrated comparable cure rates and a reduction in the rate of spontaneous preterm birth. In the present report the healing pattern in the cervices of two women after cold coagulation is described. Both women underwent cold coagulation due to CIN3, which was found on pre-treatment cervical punch biopsies. They were followed up after cold coagulation and at 7 and 18 months, respectively, they underwent cervical excision. The histopathological slides from the excised specimen were reviewed, which represents the healed cervix after cold coagulation. A clear boundary of collagenisation was noted in the superficial stroma, which appeared to stop at the junction with the healthy muscular stroma. The collagenised superficial stroma depth, which represents the area that was thermally ablated and has now healed, measured 1.6 and 1.5 mm for the two women, respectively, which is less compared with that typically removed by cervical excision. Observations from these two cases indicate that cold coagulation does not appear to disrupt the deep tissue architecture of the cervix and could therefore explain the reduced levels of adverse obstetric morbidity in patients who underwent cold coagulation ablative treatment of the cervix, which has been previously reported.
Collapse
Affiliation(s)
- Dimitrios Papoutsis
- Department of Obstetrics and Gynaecology, Shrewsbury and Telford Hospitals NHS Trust, Telford TF16TF, UK.,Midwifery Department, School of Health Sciences, University of Western Macedonia, 50200 Kozani, Greece
| | - Joanna Williams
- Department of Histopathology, Shrewsbury and Telford Hospitals NHS Trust, Telford TF16TF, UK
| | - Martyn Underwood
- Department of Obstetrics and Gynaecology, Shrewsbury and Telford Hospitals NHS Trust, Telford TF16TF, UK
| | - William Parry-Smith
- Department of Obstetrics and Gynaecology, Shrewsbury and Telford Hospitals NHS Trust, Telford TF16TF, UK
| |
Collapse
|
4
|
Armstrong GM, Ragupathy K. Test of cure and beyond: superiority of thermal ablation over LLETZ in the treatment of high-grade CIN. Arch Gynecol Obstet 2022; 306:1815-1820. [PMID: 35107616 PMCID: PMC9519675 DOI: 10.1007/s00404-022-06409-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 01/12/2022] [Indexed: 11/26/2022]
Abstract
Purpose Among the treatment modalities for high-grade cervical intraepithelial neoplasia (CIN), large-loop excision of the transformation zone (LLETZ) is the commonest offered in the UK, whereas thermal ablation (TA) has not been common in several decades, despite several notable advantages. TA and LLETZ are both routinely undertaken in our colposcopy unit, and extensive follow-up data have been used to interrogate outcomes between the two modalities and determine whether one modality may be preferred over the other. Methods Up to 8 years of follow-up data (cytology and histology) were collected for patients who have undergone LLETZ or TA and failed post-treatment test of cure (ToC). These data were analysed and used to plot Kaplan–Meier survival curves, in order to compare outcomes: negative cytology, dyskaryosis, low- and high-grade CIN and invasive squamous cell carcinoma. Results i) Very few women treated with TA developed recurrent high-grade CIN in the follow-up period; (ii) LLETZ-treated women had a significantly higher rate of recurrence than those treated by TA; (iii) women who failed both virology and cytology components of post-treatment ToC had higher recurrence than those who failed only one, and the rate of recurrence was highest in those treated by LLETZ (> 65%). Conclusion TA is an effective treatment of high-grade CIN, with a high chance of achieving double-negative ToC and low recurrence relative to LLETZ. We recommend the wider adoption of TA, so that young women of reproductive age have a choice of treatment with no reported adverse effects on pregnancy outcomes.
Collapse
Affiliation(s)
| | - K Ragupathy
- Obstetrics and Gynaecology Department, NHS Tayside, Ninewells Hospital, Dundee, UK
| |
Collapse
|
5
|
Soler M, Masch R, Saidu R, Cremer M. Thermal Ablation Treatment for Cervical Precancer (Cervical Intraepithelial Neoplasia Grade 2 or Higher [CIN2+]). Methods Mol Biol 2022; 2394:867-882. [PMID: 35094363 DOI: 10.1007/978-1-0716-1811-0_46] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Cervical cancer is a leading cause of mortality for women in low- and middle-income countries (LMICs). Invasive disease can be prevented through the treatment of high-grade cervical precancer lesions. Types of treatment for cervical precancer include excisional procedures that surgically remove the affected tissue and ablation treatments which utilize extreme temperatures to destroy precancerous cells. Excision is the first-line treatment in higher income countries, but requires specialized training and equipment that make it unsuitable for low-income settings. The most common treatment globally is cryotherapy, which utilizes cryogenic gas to freeze the area. However, the need for gas presents significant procurement and logistical challenges. The World Health Organization (WHO) has recently endorsed the use of thermal ablation, a method that utilizes heat to destroy precancerous tissue. This review describes three existing thermal ablation devices and protocols for their use, including step-by-step instruction guides to perform a successful treatment with each device and observations specific to each machine.
Collapse
Affiliation(s)
- Montserrat Soler
- Ob/Gyn and Women's Health Institute, Cleveland Clinic, Cleveland, OH, USA.
- Basic Health International, Pittsburgh, PA, USA.
| | | | - Rakiya Saidu
- Department of Obstetrics and Gynaecology, University of Cape Town, Cape Town, South Africa
| | - Miriam Cremer
- Ob/Gyn and Women's Health Institute, Cleveland Clinic, Cleveland, OH, USA
- Basic Health International, Pittsburgh, PA, USA
| |
Collapse
|
6
|
Ragupathy K, Jayasinghe T, McMullen W. Thermal Ablation of High-Grade Premalignant Disease of the Cervix-Standing the Test of Time: A Retrospective Study. J Low Genit Tract Dis 2022; 26:27-31. [PMID: 34928251 DOI: 10.1097/lgt.0000000000000638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Analyze long-term (20 years) cytology and histology outcomes after treatment of high-grade cervical intraepithelial neoplasia (HGCIN) with thermal ablation (TA). METHODS All women having TA for HGCIN between January 1996 and December 1998 (36 months; N = 885) were identified; data were collected on age of patients, symptoms, colposcopy findings, and biopsy reports. Local and national (cytology and colposcopy) databases and colposcopy records were used to collect long-term follow-up data. Probability of CIN recurrence was assessed using Kaplan-Meier "survival" curve. RESULTS Follow-up data (available for 796) was collected in 2018 capturing 20 years of follow-up data. Two hundred eighty-one women were treated for CIN 2 and 515 women for CIN 3. Seven hundred ninety-one of 796 (>99%) were treated at first visit. Two hundred sixty two of 796 (33%) had evidence of crypt involvement on pretreatment biopsy. Probability of having consistently normal cytological follow-up was 92%, 89%, 86%, and 83% at 5, 10, 15, and 20 years, respectively. Cumulative probability of having recurrent HGCIN was 0.5% at 5 years, 1% at 10 years, 1.9% at 15 years, and 3% at 18 years. There was 1 invasive squamous cell cancer at 11 years after treatment. CONCLUSIONS Thermal ablation is a safe and effective treatment for HGCIN, which is now shown to have stood the test of time. We advise more widespread adoption in the United Kingdom and globally so long as agreed criteria are met.
Collapse
Affiliation(s)
- Kalpana Ragupathy
- Gynaecology Department, NHS Tayside, Ninewells Hospital, Dundee, United Kingdom
| | | | | |
Collapse
|
7
|
Papoutsis D, Underwood M, Williams J, Parry-Smith W, Panikkar J. Expansile Endocervical Crypt Involvement by CIN2 - 3 as a Risk Factor for High Grade Cytology Recurrence After Cold Coagulation Cervical Treatment. Geburtshilfe Frauenheilkd 2020; 80:941-948. [PMID: 32905285 PMCID: PMC7467802 DOI: 10.1055/a-1202-2157] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2019] [Accepted: 06/17/2020] [Indexed: 12/03/2022] Open
Abstract
Introduction
To determine whether expansile endocervical crypt involvement (ECI) on pretreatment cervical punch biopsies is a risk factor for high grade cytology recurrence in women following cold coagulation for cervical intraepithelial neoplasia (CIN).
Materials and Methods
This was a secondary analysis on the results of an observational study of women who had a single cold coagulation cervical treatment between 2001 – 2011 and who were followed up for cytology recurrence. Women with a previous cervical treatment were excluded.
Results
559 women were identified with a mean age of 28.7 ± 6.2 years. Expansile and non-expansile ECI were identified in 5.4 and 4.3% of women, respectively. The proportion of women with high grade cytology recurrence was 10% for those with expansile ECI and 2.3% for those without. Multivariate analysis showed that women with expansile ECI when compared to those without, had a four-fold greater risk for high grade cytology recurrence (HR = 4.22; 95% CI: 1.10 – 16.29, p = 0.036). There was no significant association found between non-expansile ECI and overall or high grade cytology recurrence. The increased biopsy depth and the CIN3 grade of pretreatment cervical punch biopsies were significantly associated with greater odds for the detection of expansile ECI. We calculated that the optimal-cut off of pretreatment cervical punch biopsy depth for the detection of expansile ECI was 4 mm (sensitivity: 73.3%; specificity: 55.1%).
Conclusions
Expansile ECI is a risk factor that increases the likelihood of high grade cytology recurrence following cold coagulation. Deeper pretreatment cervical punch biopsies need to be taken so as not to miss expansile ECI prior to ablative treatment.
Collapse
Affiliation(s)
- Dimitrios Papoutsis
- Department of Obstetrics and Gynaecology, Shrewsbury and Telford Hospitals NHS Trust, Telford, United Kingdom.,Department of Health Sciences, University of Western Macedonia, Koila, Kozani, Greece
| | - Martyn Underwood
- Department of Obstetrics and Gynaecology, Shrewsbury and Telford Hospitals NHS Trust, Telford, United Kingdom
| | - Joanna Williams
- Department of Histopathology, Shrewsbury and Telford Hospitals NHS Trust, Telford, United Kingdom
| | - William Parry-Smith
- Department of Obstetrics and Gynaecology, Shrewsbury and Telford Hospitals NHS Trust, Telford, United Kingdom
| | - Jane Panikkar
- Department of Obstetrics and Gynaecology, Shrewsbury and Telford Hospitals NHS Trust, Telford, United Kingdom
| |
Collapse
|
8
|
Papalia N, Rohla A, Tang S, Nation J, Nelson G. Defining the short-term disease recurrence after loop electrosurgical excision procedure (LEEP). BMC WOMENS HEALTH 2020; 20:34. [PMID: 32102650 PMCID: PMC7045470 DOI: 10.1186/s12905-020-00901-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/17/2019] [Accepted: 02/11/2020] [Indexed: 11/10/2022]
Abstract
BACKGROUND The goal of cervical cancer screening is to identify dysplastic lesions for subsequent excision in order to prevent invasive disease. There is clinical equipoise, on how to best follow women for disease surveillance after treatment with some Canadian provinces exclusively performing colposcopy and some utilizing Human Papilloma Virus (HPV) testing in addition to cervical cytology. Loop Electrosurgical Excision Procedure (LEEP) is used to treat pre-invasive HPV-mediated disease and patients are typically followed for 12 months after disease excision. This study aims to quantify the prevalence of high-grade disease at the time of the second follow-up colposcopy visit, in a practice setting that utilizes laser ablation in addition to LEEP. METHODS In a retrospective cohort study, consecutive patient charts were accessed through the electronic medical record system, ARIA, at the Tom Baker Cancer Centre, in Calgary, Alberta, from January 2010 to December 2015. Data was extracted and a REDCap database was used to compile pertinent information from charts meeting inclusion criteria. Descriptive and analytic statistics were performed. RESULTS Of the 303 patients identified, 221 patients met inclusion criteria. 86% of these patients met discharge criteria from colposcopy after the second follow up visit. 31 (14%) were seen in a subsequent visit for abnormal findings. Of these, 7 (3.2%) underwent further treatment for high-grade disease/Cervical Intraepithelial Neoplasia (CIN 2/3). Of the 31, 23 (10.6%) had a third - negative - visit, resulting in discharge from colposcopy. One patient had a repeat LEEP for persistent Low-Grade Squamous Intraepithelial Lesion (LSIL). CONCLUSION In summary, our data demonstrates a prevalence of 3.2% of high-grade disease at the time of a second colposcopic follow up visit after treatment, in a setting which frequently utilizes laser ablation in combination with LEEP, for large lesions. This recurrence rate is consistent with most published literature on recurrence rates of CIN2/3.
Collapse
Affiliation(s)
- Nicholas Papalia
- Department of Obstetrics and Gynaecology, University of Calgary, 1108-1500 7th Street SW, Calgary, AB, T2R 1A7, Canada.
| | - Amanda Rohla
- Department of Obstetrics and Gynaecology, University of Calgary, 1108-1500 7th Street SW, Calgary, AB, T2R 1A7, Canada
| | - Selphee Tang
- Department of Obstetrics and Gynaecology, Alberta Health Services, Calgary, Canada
| | - Jill Nation
- Department of Obstetrics and Gynaecology, University of Calgary, 1108-1500 7th Street SW, Calgary, AB, T2R 1A7, Canada
| | - Gregg Nelson
- Department of Obstetrics and Gynaecology, University of Calgary, 1108-1500 7th Street SW, Calgary, AB, T2R 1A7, Canada
| |
Collapse
|
9
|
Papoutsis D. An appraisal of the meta-analysis on the feasibility, acceptability, safety and efficacy of thermal ablation in the treatment of cervical cancer precursor lesions. Prev Med 2019; 123:341-342. [PMID: 31122397 DOI: 10.1016/j.ypmed.2018.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 11/30/2018] [Accepted: 12/09/2018] [Indexed: 10/26/2022]
Affiliation(s)
- Dimitrios Papoutsis
- Department of Obstetrics and Gynaecology, Shrewsbury and Telford Hospital, NHS Trust, Telford, United Kingdom; Department of Health Sciences, Technological Educational Institute of Western Macedonia, Kozani, PC 50100, Greece.
| |
Collapse
|
10
|
Cremer M, Alfaro K, Garai J, Salinas M, Maza M, Zevallos A, Taxa L, Diaz AC, Castle P, Alonzo TA, Masch R, Soler M, Conzuelo-Rodriguez G, Gage JC, Felix JC. Evaluation of two alternative ablation treatments for cervical pre-cancer against standard gas-based cryotherapy: a randomized non-inferiority study. Int J Gynecol Cancer 2019; 29:ijgc-2018-000148. [PMID: 31055452 PMCID: PMC9884482 DOI: 10.1136/ijgc-2018-000148] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Revised: 03/20/2019] [Accepted: 04/08/2019] [Indexed: 01/31/2023] Open
Abstract
INTRODUCTION Gas-based cryotherapy is the conventional ablative treatment for cervical pre-cancer in low-income settings, but the use of gas poses significant challenges. We compared the depth of necrosis induced by gas-based cryotherapy with two gas-free alternatives: cryotherapy using CryoPen,and thermoablation. METHODS We conducted a five-arm randomized non-inferiority trial: double-freeze carbon dioxide (CO2) cryotherapy (referent), single-freeze CO2 cryotherapy, double-freeze CryoPen, single-freeze CryoPen, and thermoablation. Subjects were 130 women scheduled for hysterectomy for indications other than cervical pathology, and thus with healthy cervical tissue available for histological evaluation of depth of necrosis post-surgery. The null hypothesis was rejected (ie, conclude non-inferiority) if the upper bound of the 90% confidence interval (90% CI) for the difference in mean depth of necrosis (referent minus each experimental method) was <1.14 mm. Patient pain during treatment was reported on a scale of 0 (no pain) to 10 (worst pain). RESULTS A total of 133 patients were enrolled in the study. The slides from three women were deemed unreadable. One patient was excluded because her hysterectomy was postponed for reasons unrelated to the study, and two patients were excluded because treatment application did not follow the established protocol. For the remaining 127 women, mean depth of necrosis for double-freeze CO2 (referent) was 6.0±1.6 mm. Differences between this and other methods were: single-freeze CO2 = 0.4 mm (90% CI -0.4 to 1.2 mm), double-freeze CryoPen= 0.7 mm (90% CI 0.04 to 1.4 mm), single-freeze CryoPen= 0.5 mm (90% CI -0.2 to 1.2 mm), and thermoablation = 2.6 mm (90% CI 2.0 to 3.1 mm). Mean pain levels were 2.2±1.0 (double-freeze CO2 cryotherapy), 1.8±0.8 (single-freeze CO2 cryotherapy), 2.5±1.4 (double-freeze CryoPen), 2.6±1.4 (single-freeze CryoPen), and 4.1±2.3 (thermoablation). DISCUSSION Compared with the referent, non-inferiority could not be concluded for other methods. Mean pain scores were low for all treatments. Depth of necrosis is a surrogate for treatment efficacy, but a randomized clinical trial is necessary to establish true cure rates.
Collapse
Affiliation(s)
- Miriam Cremer
- OB/GYN and Women's Health Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Basic Health International, San Salvador, El Salvador
- Basic Health International, New York City, New York, USA
| | - Karla Alfaro
- Basic Health International, San Salvador, El Salvador
| | - Jillian Garai
- Basic Health International, New York City, New York, USA
| | - Manuel Salinas
- Instituto Salvadoreño del Seguro Social, San Salvador, El Salvador
| | - Mauricio Maza
- Basic Health International, San Salvador, El Salvador
| | | | - Luis Taxa
- Instituto Nacional de Enfermedades Neoplásicas, Lima, Peru
| | - Ana C Diaz
- Instituto Salvadoreño del Seguro Social, San Salvador, El Salvador
| | - Philip Castle
- Yeshiva University Albert Einstein College of Medicine, Bronx, New York, USA
| | - Todd A Alonzo
- University of Southern California, Los Angeles, California, USA
| | - Rachel Masch
- Basic Health International, New York City, New York, USA
| | - Montserrat Soler
- OB/GYN and Women's Health Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Basic Health International, New York City, New York, USA
| | | | - Julia C Gage
- National Cancer Institute, Bethesda, Maryland, USA
| | - Juan C Felix
- Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| |
Collapse
|
11
|
Randall TC, Sauvaget C, Muwonge R, Trimble EL, Jeronimo J. Worthy of further consideration: An updated meta-analysis to address the feasibility, acceptability, safety and efficacy of thermal ablation in the treatment of cervical cancer precursor lesions. Prev Med 2019; 118:81-91. [PMID: 30342109 DOI: 10.1016/j.ypmed.2018.10.006] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2018] [Revised: 10/02/2018] [Accepted: 10/08/2018] [Indexed: 11/17/2022]
Abstract
Treatment of preinvasive lesions is critical to the success of secondary prevention of cervical cancer. In many settings, however, excision or ablation of preinvasive lesions can prove challenging. Thermal ablation (TA) is a form of treatment for cervical precancer that may present fewer logistical challenges in resource limited settings. In 2013, Dolman and colleagues wrote a meta-analysis of publications reporting cure rates from TA. This included only one article from a low or middle-income country (LMIC). We updated Dolman's meta-analysis to include more recent articles from LMICs. A formal review of the world literature was performed for the years 2014-2017. Article titles and abstracts were reviewed for relevance; full articles were assessed for quality. The primary endpoint was treatment outcome for cervical intraepithelial neoplasia grade 2 or higher (CIN2+). The I2 statistic was used to assess heterogeneity between studies. Studies were stratified by geographic region, decade that the study was published, World Bank economic classification of the country where the study was performed, and other factors. We reviewed 34 total reports and included 23 in our meta-analysis, including 10,995 and 6371 patients, respectively. A total of 7 studies were performed in LMICs, including 6 studies included in the meta-analysis. The overall response rate for TA treatment of biopsy proven CIN2+ was 93.8%. Consistent with the wide variety of settings and patient populations, there was significant heterogeneity between studies. TA appears to be an effective treatment for CIN2+ across a variety of settings, including in LMICs.
Collapse
Affiliation(s)
- Thomas C Randall
- Gynecologic Oncology, The Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
| | - Catherine Sauvaget
- Screening Group, Early Detection and Prevention Section, International Agency for Research on Cancer, Lyon, France
| | - Richard Muwonge
- Screening Group, Early Detection and Prevention Section, International Agency for Research on Cancer, Lyon, France
| | - Edward L Trimble
- Global HPV and Cervical Cancer Research and Control, National Cancer Institute, Rockville, MD, USA
| | - Jose Jeronimo
- Global Coalition Against Cervical Cancer, Seattle, WA, USA
| |
Collapse
|
12
|
Cremer ML, Conzuelo-Rodriguez G, Cherniak W, Randall T. Ablative Therapies for Cervical Intraepithelial Neoplasia in Low-Resource Settings: Findings and Key Questions. J Glob Oncol 2018; 4:1-10. [PMID: 30372399 PMCID: PMC7010451 DOI: 10.1200/jgo.18.00093] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Barriers to access for cervical precancer care in low-resource settings go beyond cost. Gas-based cryotherapy has emerged as the standard treatment in these areas, but there are barriers to this technology that have necessitated the development and implementation of affordable and portable alternatives. This review identifies knowledge gaps with regard to technologies primarily used in low-resource settings, including standard cryotherapy, nongas-based cryotherapy, and thermoablation. These gaps are addressed using evidence-based guidelines, patient and provider acceptability, long-term obstetric outcomes, and treatment of women with HIV infection. This review highlights the need for prospective studies that compare ablative methods, especially given the increasing use of thermoablation.
Collapse
Affiliation(s)
- Miriam L. Cremer
- Miriam L. Cremer, Cleveland Clinic, Cleveland, OH; Gabriel Conzuelo-Rodriguez, Basic Health International, New York, NY; William Cherniak, Bridge to Health Medical and Dental, Toronto, Ontario, Canada; and Thomas Randall, Massachusetts General Hospital, Boston, MA
| | - Gabriel Conzuelo-Rodriguez
- Miriam L. Cremer, Cleveland Clinic, Cleveland, OH; Gabriel Conzuelo-Rodriguez, Basic Health International, New York, NY; William Cherniak, Bridge to Health Medical and Dental, Toronto, Ontario, Canada; and Thomas Randall, Massachusetts General Hospital, Boston, MA
| | - William Cherniak
- Miriam L. Cremer, Cleveland Clinic, Cleveland, OH; Gabriel Conzuelo-Rodriguez, Basic Health International, New York, NY; William Cherniak, Bridge to Health Medical and Dental, Toronto, Ontario, Canada; and Thomas Randall, Massachusetts General Hospital, Boston, MA
| | - Thomas Randall
- Miriam L. Cremer, Cleveland Clinic, Cleveland, OH; Gabriel Conzuelo-Rodriguez, Basic Health International, New York, NY; William Cherniak, Bridge to Health Medical and Dental, Toronto, Ontario, Canada; and Thomas Randall, Massachusetts General Hospital, Boston, MA
| |
Collapse
|
13
|
Papoutsis D, Underwood M, Parry-Smith W, Panikkar J. Early and late pregnancy outcomes in women treated with cold-coagulation versus LLETZ cervical treatment for cervical intraepithelial neoplasia; a retrospective cohort study. Arch Gynecol Obstet 2018; 297:1015-1025. [PMID: 29404740 DOI: 10.1007/s00404-018-4704-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 01/30/2018] [Indexed: 10/18/2022]
Abstract
PURPOSE To compare the pregnancy outcomes between women who were treated with cold-coagulation versus large loop excision of the transformation zone (LLETZ) for cervical intraepithelial neoplasia. METHODS This was a retrospective cohort study of women who had a single cervical treatment between 2010 and 2011. We identified those women who had a singleton pregnancy subsequent to their cervical treatment until September 2017. Women with previous cervical treatment, previous miscarriage or preterm delivery were excluded. RESULTS We identified 86 women with a pregnancy after LLETZ treatment and 75 women after cold coagulation. Those who had LLETZ when compared to cold coagulation miscarried more often in the first trimester (33.7 vs 17.3%; p = 0.01) than in the second trimester. In women with LLETZ this effect of increased early miscarriage was shown to be prolonged and to persist up to 17 months after excision. Women with LLETZ when compared to cold coagulation had higher spontaneous preterm birth rates (8.9 vs 6.7%) even though the difference was non significant, with the earliest spontaneous preterm birth occurring at 32 weeks and 34 weeks, respectively. CONCLUSION We found that women who received LLETZ treatment when compared to cold coagulation had higher spontaneous preterm birth rates in their subsequent pregnancy and miscarried more frequently in the first trimester, and demonstrated an increased early miscarriage risk that persisted for more than a year after excisional treatment.
Collapse
Affiliation(s)
- Dimitrios Papoutsis
- Department of Obstetrics and Gynaecology, Shrewsbury and Telford Hospital NHS Trust, Princess Royal Hospital, Apley Castle, Grainger Drive, Telford, TF16TF, UK.
| | - Martyn Underwood
- Department of Obstetrics and Gynaecology, Shrewsbury and Telford Hospital NHS Trust, Princess Royal Hospital, Apley Castle, Grainger Drive, Telford, TF16TF, UK
| | - William Parry-Smith
- Department of Obstetrics and Gynaecology, Shrewsbury and Telford Hospital NHS Trust, Princess Royal Hospital, Apley Castle, Grainger Drive, Telford, TF16TF, UK.,Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, Birmingham Women's Hospital, The University of Birmingham, Academic Unit, Mindelsohn Way, Edgbaston, Birmingham, B15 2TG, UK
| | - Jane Panikkar
- Department of Obstetrics and Gynaecology, Shrewsbury and Telford Hospital NHS Trust, Princess Royal Hospital, Apley Castle, Grainger Drive, Telford, TF16TF, UK
| |
Collapse
|
14
|
Haney K, Tandon P, Divi R, Ossandon MR, Baker H, Pearlman PC. The Role of Affordable, Point-of-Care Technologies for Cancer Care in Low- and Middle-Income Countries: A Review and Commentary. IEEE JOURNAL OF TRANSLATIONAL ENGINEERING IN HEALTH AND MEDICINE-JTEHM 2017; 5:2800514. [PMID: 29204328 PMCID: PMC5706528 DOI: 10.1109/jtehm.2017.2761764] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Accepted: 09/06/2017] [Indexed: 12/22/2022]
Abstract
As the burden of non-communicable diseases such as cancer continues to rise in low- and middle-income countries (LMICs), it is essential to identify and invest in promising solutions for cancer control and treatment. Point-of-care technologies (POCTs) have played critical roles in curbing infectious disease epidemics in both high- and low-income settings, and their successes can serve as a model for transforming cancer care in LMICs, where access to traditional clinical resources is often limited. The versatility, cost-effectiveness, and simplicity of POCTs warrant attention for their potential to revolutionize cancer detection, diagnosis, and treatment. This paper reviews the landscape of affordable POCTs for cancer care in LMICs with a focus on imaging tools, in vitro diagnostics, and treatment technologies and aspires to encourage innovation and further investment in this space.
Collapse
Affiliation(s)
- Karen Haney
- Dell Medical SchoolThe University of Texas at Austin
| | | | | | | | | | | |
Collapse
|
15
|
Castle PE, Murokora D, Perez C, Alvarez M, Quek SC, Campbell C. Treatment of cervical intraepithelial lesions. Int J Gynaecol Obstet 2017; 138 Suppl 1:20-25. [PMID: 28691333 DOI: 10.1002/ijgo.12191] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Precancerous cervical lesions precede the development of invasive cervical cancer by 10-20 years, making cervical cancer preventable if these lesions are detected and effectively treated. Treatment has evolved in the last few decades and now includes ablative options that can be performed in lower-resource settings where surgical excision is not feasible or routinely available. Gas-based cryotherapy, which freezes cervical tissue to induce localized necrosis, is the most commonly used ablative treatment. However, its implementation in low-resource settings is difficult because the refrigerant gas can be difficult to procure and transport, and is expensive. New cryotherapy devices that do not require an external supply of gas appear promising. Thermal coagulation, which burns cervical tissue to induce necrosis, has become more widely available in the last few years owing to its portability and the feasibility of using battery-powered devices. These two ablative treatments successfully eradicate 75%-85% of high-grade cervical lesions and have minor adverse effects.
Collapse
Affiliation(s)
| | - Dan Murokora
- Uganda Women's Health Initiative, Kampala, Uganda
| | | | - Manuel Alvarez
- Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru
| | | | | |
Collapse
|