The treatment of cervical intra-epithelial neoplasia: when could we 'see and loop'

Treatment methods for cervical intraepithelial neoplasia in England: A cost-effectiveness analysis

OBJECTIVE

To compare the cost-effectiveness of different treatments for cervical intraepithelial neoplasia (CIN).

DESIGN

A cost-effectiveness analysis based on data available in the literature and expert opinion.

SETTING

England.

POPULATION

Women treated for CIN.

METHODS

We developed a decision-analytic model to simulate the clinical course of 1000 women who received local treatment for CIN and were followed up for 10 years after treatment. In the model we considered surgical complications as well as oncological and reproductive outcomes over the 10-year period. The costs calculated were those incurred by the National Health Service (NHS) of England.

MAIN OUTCOME MEASURES

Cost per one CIN2+ recurrence averted (oncological outcome); cost per one preterm birth averted (reproductive outcome); overall cost per one adverse oncological or reproductive outcome averted.

RESULTS

For young women of reproductive age, large loop excision of the transformation zone (LLETZ) was the most cost-effective treatment overall at all willingness-to-pay thresholds. For postmenopausal women, LLETZ remained the most cost-effective treatment up to a threshold of £31,500, but laser conisation became the most cost-effective treatment above that threshold.

CONCLUSIONS

LLETZ is the most cost-effective treatment for both younger and older women. However, for older women, more radical excision with laser conisation could also be considered if the NHS is willing to spend more than £31,500 to avert one CIN2+ recurrence.

The diagnostic accuracy of colposcopy - A review of research methodology and impact on the outcomes of quality assurance

OBJECTIVE

To review the published diagnostic accuracy figures for the performance of colposcopy and to assess how the various forms of bias might explain the very wide range of reported values and the impact they have on quality assurance of cervical screening.

METHODS

Publications were only selected where they contained sufficient raw data to enable diagnostic accuracy statistics to be calculated for the detection of cervical intraepithelial neoplasia grade 2+ (CIN2+), as determined by punch biopsy. In addition, both the colposcopic impression at the time of examination and the disease threshold used to determine the need for biopsy must have been reported.

RESULTS

Large differences in diagnostic accuracy figures were found when the output of colposcopy was defined either, on the basis that the colposcopist thought there was CIN2+ present or, that the colposcopist considered there to be some disease present and so took a biopsy to confirm this. Weighted mean sensitivity was 68.5% (95% CI 59.9-77.1) for the first method but 95.7% (95% CI 93.4-98.0) for the second method. Weighted mean specificity was 75.9% (95% CI 69.3-82.5) for the first method but 34.2% (95% CI 27.0-41.4) for the second method. Weighted mean PPV was 68.9% (95% CI 64.2-73.6) for the first method but 54.3% (95% CI 46.5-62.1) for the second method.

CONCLUSION

The main reason for the wide range of published diagnostic accuracy figures, arises from the use of two different methods of assessing the output of colposcopy. Colposcopic Impression is appropriate when assessing the performance of a colposcopist at the time of examination, but the taking of a biopsy to confirm that Disease is Present should be used when assessing patient management. Accurate assessment of both outcomes is fundamental to any quality assurance programme.

Overtreatment and Cost-Effectiveness of the See-and-Treat Strategy for Managing Cervical Precancer

BACKGROUND

See-and-treat using loop electrosurgical excision procedure (LEEP) has been recommended as an alternative in managing high-grade cervical squamous intraepithelial lesions, but existing literature lacks evidence of the strategy's cost-effectiveness. We evaluated the overtreatment and cost-effectiveness of the see-and-treat strategy compared with usual care.

METHODS

We modeled a hypothetical cohort of 40-year-old females who had not been screened for cervical cancer and followed them through their lifetimes using a Markov model. From a U.S. health-system perspective, the analysis was conducted in 2012 dollars and measured effectiveness in quality-adjusted life-years (QALY). We estimated incremental cost-effectiveness ratios (ICER) using a willingness-to-pay threshold of $50,000/QALY. The robustness of the see-and-treat strategy's cost-effectiveness and its overtreatment rates were further examined in various sensitivity analyses.

RESULTS

In the base-case, the see-and-treat strategy yielded an ICER of $70,774/QALY compared with usual care. For most scenarios in the deterministic sensitivity analysis, this strategy had ICERs larger than $50,000/QALY, and its cost-effectiveness was sensitive to the disutility of LEEP treatment and biopsy-directed treatment adherence under usual care. Probabilistic sensitivity analysis showed that the see-and-treat strategy had a 50.1% chance to be cost-effective. It had an average overtreatment rate of 7.1% and a 78.8% chance to have its overtreatment rate lower than the 10% threshold.

CONCLUSION

The see-and-treat strategy induced an acceptable overtreatment rate. Its cost-effectiveness, compared with usual care, was indiscriminating at the chosen willingness-to-pay threshold but much improved when the threshold increased.

IMPACT

The see-and-treat strategy was reasonable for particular settings, that is, those with low treatment adherence. Cancer Epidemiol Biomarkers Prev; 25(5); 807-14. ©2016 AACR.

Options for managing low grade cervical abnormalities detected at screening: cost effectiveness study

OBJECTIVE

To estimate the cost effectiveness of alternative methods of managing low grade cervical cytological abnormalities detected at routine screening. Design Cost analysis within multicentre individually randomised controlled trial.

SETTING

Grampian, Tayside, and Nottingham.

PARTICIPANTS

4201 women with low grade abnormalities.

INTERVENTIONS

Cytological surveillance or referral to colposcopy for biopsy and recall if necessary or referral to colposcopy with immediate treatment based on colposcopic appearance.

MAIN OUTCOME MEASURES

Data on resource use collected from participants throughout the duration of the trial (36 months), enabling the estimation of both the direct (health care) and indirect (time and travel) costs of management. Quality of life assessed at recruitment and at 12, 18, 24, and 30 months, using the EQ-5D instrument. Economic outcomes expressed as costs per case of cervical intraepithelial neoplasia (grade II or worse) detected, by trial arm, as confirmed at exit, and cost utility ratios (cost per quality adjusted life year (QALY) gained) for the three pairwise comparisons of trial arms.

RESULTS

The mean three year discounted costs of surveillance, immediate treatment, and biopsy and recall were pound150.20 (euro177, $249), pound240.30 (euro283, $415), and pound241.10 (euro284, $4000), respectively, viewed from the health service perspective. From the social perspective, mean discounted costs were pound204.40 (euro241, $339), pound339.90 (euro440, $563), and pound327.50 (euro386, $543), respectively. Estimated at the means, the incremental cost effectiveness ratios indicated that immediate treatment was dominated by the other two management methods, although it did offer the lowest cost per case of cervical intraepithelial neoplasia detected and treated. The pronounced skews in the distributions indicated that probabilistic uncertainty analysis would offer more meaningful estimates of cost effectiveness. The observed differences in the cost effectiveness ratios between trial arms were not significant.

CONCLUSION

Judged within the time frame of the TOMBOLA evaluation, there is no compelling economic reason to favour any one follow-up method over either of the others.

TRIAL REGISTRATION

ISRCTN 34841617.

A comparative study of the assessment of cervical intraepithelial neoplasia in women having large loop excision of the transformation zone

Findings on Papanicolaou (Pap) smear and colposcopically directed punch biopsy show discrepancies when compared with findings on loop excision specimens and this situation creates management problems. We performed a comparative assessment of cervical intraepithelial neoplasia (CIN) in 100 consecutive women who had large loop excision of the transformation zone (LLETZ) with a view to developing a local protocol that would be safe, avoid delay and minimise over-treatment. Agreement between Pap smear and LLETZ was 62% with 21% overcall and 17% undercall at Pap smear; there was no significant correlation (Spearman's rank correlation coefficient 0.17 P > 0.05). The agreement between punch biopsy and LLETZ was 61% with 25% overcall and 15% undercall at punch biopsy; there was a slight agreement over chance (kappa=0.20) and there was a weak but significant correlation (Spearman's rank correlation coefficient=0.26; P = 0.047). Colposcopic impression of 'highly abnormal'lesions agreed with high grade lesions on LLETZ in 83% of cases. The problem of undercall suggests that defaulters with apparent low grade dyskaryosis need to be pursued to colposcopy as vigorously as defaulters with high grade dyskaryosis. The lack of significant correlation between cervical cytology and LLETZ finding suggests that the smear-to-colposcopy waiting interval should not be strictly based on the degree of dyskaryosis.

Treatment of high-grade squamous intraepithelial lesions: A “see and treat” versus a three-step approach

OBJECTIVE

The study's subject was to examine the correlation between histologic findings in patients with high-grade squamous intraepithelial lesion (HGSIL) who have undergone loop electrosurgical excisional procedure (LEEP) with and without prior colposcopically directed biopsy.

STUDY DESIGN

This retrospective study included 144 patients with cytologic HGSIL, of which 62 were treated by a three-step protocol, in which LEEP was performed only if the colposcopically directed cervical biopsies were positive (CIN II-III), and 82 women who were treated by "see and treat" protocol, in which LEEP was immediately performed if colposcopy was suggestive of CIN II or III lesions.

RESULTS

There were no differences in the final histological findings between the groups.

CONCLUSIONS

The colposcopically directed LEEP after a HGSIL on PAP-smear may reduce the time interval between diagnosis and treatment with a similar accuracy of diagnosis compared to the standard three-step protocol.

Do women with high-grade cervical intraepithelial neoplasia prefer a see and treat option in colposcopy?

OBJECTIVE

To compare women's experiences of either see and treat (ST) or defer and treat (DT) at first visit to colposcopy following abnormal cytology.

DESIGN

A prospective postal questionnaire survey.

SETTING

Colposcopy clinics of a University Hospital.

SAMPLE

A total of 272 women with high-grade cervical intraepithelial neoplasia (CIN) referred to colposcopy.

METHODS

A total of 136 women receiving ST and a matched sample of women receiving DT (N = 136) were sent a postal questionnaire 7 days after first appointment at colposcopy to assess evaluations of their experience, psychological distress and relief. Subsequent appointment keeping was extracted from medical records.

MAIN OUTCOME MEASURES

Anxiety and subsequent behaviour.

RESULTS

Women undergoing ST were significantly less anxious and more relieved than those undergoing DT. They also evaluated their first appointment as more motivationally congruent. While women undergoing ST were less likely than DTs to keep their second appointment, there was no overall difference in did not attend (DNA) rates at 15-month follow up.

CONCLUSIONS

ST is psychologically beneficial and may be preferred by women with CIN2/3.

See-and-treat strategy for diagnosis and management of cervical squamous intraepithelial lesions

In a see-and-treat protocol, patients referred for colposcopy because of an abnormal Pap smear in cervical-cancer screening can be treated by loop excision, without biopsy, during one visit to the clinic. However, overtreatment in the see-and-treat strategy has been reported to be 1.2-83.3% for low-grade squamous intraepithelial lesions (SIL) and to be 13.3-83.3% for high-grade SIL. Range of overtreatment narrowed to 4.0-23.5% for those with normal pathology and to 18.0-29.4% for those with normal or low-grade pathology when calculation of overtreatment was restricted to patients diagnosed with high-grade SIL on colposcopy and referral Pap smear. Most common treatment complications are bleeding and infection. Nonetheless, the strategy has become accepted internationally: low costs, decreased patient anxiety, and increased compliance make it appealing, especially in settings with limited health resources, and for patients at risk of not being treated in a timely manner or of not returning for a second appointment. Mathematical modelling may give information about the appropriateness and usefulness of this treatment while the results of long-term clinical trials are awaited.

Treatment of high-grade squamous intraepithelial lesions: a 2- versus 3-step approach

OBJECTIVE

The purpose of this study was to determine whether colposcopically directed biopsy is a necessary step in the evaluation of patients with high-grade squamous intraepithelial lesions.

STUDY DESIGN

A retrospective analysis was conducted of the correlation between the high-grade squamous intraepithelial lesion Papanicolaou test and the colposcopically directed biopsy and the correlation between the high-grade squamous intraepithelial lesion Papanicolaou test and the loop electrosurgical excisional procedure.

RESULTS

Of 72 patients with high-grade squamous intraepithelial lesions on Papanicolaou test, 48 patients had a pathologic diagnosis on cervical biopsy of CIN II or greater, which provides a 67% correlation between the Papanicolaou test and the colposcopically directed biopsy. Fifty-six patients had a pathologic diagnosis on loop electrosurgical excisional procedure of CIN II or greater, which provides a 78% correlation between the Papanicolaou test and the loop electrosurgical excisional procedure. The median interval between the Papanicolaou test and the definitive treatment was significantly longer (P <.001) when colposcopically directed biopsy was performed before the loop electrosurgical excisional procedure.

CONCLUSION

The colposcopically directed loop electrosurgical excisional procedure after a high-grade squamous intraepithelial lesion Papanicolaou test may reduce the time interval between diagnosis and treatment; furthermore, it offers equal correlation when compared with traditional treatment.

How should we grade CIN?

How should we grade CIN? The grading of cervical intraepithelial neoplasia (CIN) is problematic. CIN represents a morphological continuum, but biopsies displaying this lesion are classified into two (e.g. Bethesda) or three grade categories, sometimes with poor reproducibility. There are also difficulties in reliably distinguishing low-grade CIN from its reactive simulants. Because of problems with inter- and intra-observer disagreement in the grading of CIN and the diagnosis of low-grade lesions, three expert contributions were commissioned to address the question 'how should we grade CIN?'.

Cervical intraepithelial neoplasia is associated with increased polyamine oxidase and diamine oxidase concentrations in cervical mucus

OBJECTIVE

The aim of this study was to establish whether reactive oxygen species, generated during oxidation of amines, catalyzed by polyamine oxidase (PAO) and diamine oxidase (DAO) in cervical secretions may play a role in the etiology of cervical cancer.

METHODS

Cervical mucus was obtained from women attending the gynecological outpatient department: 139 with and 154 without cytological evidence of cervical intraepithelial neoplasia were recruited. The mucus was freeze dried in liquid nitrogen, weighed, and later resuspended for assay of PAO and DAO concentrations using a chemiluminescence method. The two groups were compared by group sequential analysis using PEST3 software.

RESULTS

Patients with a colposcopic diagnosis of a high-grade squamous intraepithelial lesion (SIL) had significantly higher enzyme activities than control cases (L(N)PAO 1.37 (0.37) versus 1.18 (0.35): Student t test: P < 0.001; L(N)DAO 1.37 (0.36) versus 1.15 (0.37): Student t test: P < 0.001).

CONCLUSION

It is probable that this rise in enzyme activity precedes cytological changes and plays some part in the etiology of cervical cancer, as the cells that undergo premalignant change are normally squamous in origin, whereas mucus is a product of columnar epithelium. Higher enzyme activity in patients with SIL than in controls may be a reflection of higher risk of exposure to amine substrates in semen through multiple sexual partners.

Psychosocial and economic aspects of a trial of management of mild and borderline cervical abnormalities (TOMBOLA)

TOMBOLA is a randomized controlled trial to determine (a) the most effective and efficient management strategy for women with borderline or mildly dyskaryotic cervical smear results, and (b) the most appropriate treatment for women with abnormalities detected following colposcopy. This paper outlines the trial's psychosocial and economic protocol, and explains how TOMBOLA can provide detailed evidence on the psychosocial and economic impact of alternative management options and follow-up. This protocol has been developed in parallel with the clinical protocol, thereby offering the opportunity for the development of a type-specific outcome measure and detailed piloting of all instruments. The multi-disciplinary approach to TOMBOLA allows the combination of clinical outcomes with both generic and specific psychosocial and health-related quality of life measures. The convergent validity between these measures will be assessed, with a view to developing a specific utility index for the future assessment of cervical screening modalities.

The feasibility of a one-stop colposcopy clinic in the management of women with low grade smear abnormalities: a prospective study

OBJECTIVES

To assess the feasibility of a one-stop colposcopy clinic for the management of women with low-grade smear abnormalities. Secondly, to determine whether the approach of immediate information of biopsy results combined with treatment if indicated helps to reduce patient anxiety and improve overall patient satisfaction with the colposcopy process.

DESIGN

Prospective study following the introduction of a "one-stop" process for the management of women with low grade smear abnormalities.

SUBJECTS

First 118 women managed in a "one-stop" clinic during an 8-month period.

METHODS

Assessment of patient anxiety via self-completed questionnaires and comparison of anxiety scores with a control group managed via a standard clinic.

RESULTS

The median waiting time for results in the one-stop clinic was 120 min (range: 100-165). All women in both groups felt anxious at the time of the clinic visit. However, after 1 week the majority of patients managed via the one-stop process felt slight anxiety only (P=0.0001) as opposed to those patients in the control group who remained anxious (P=NS). In addition, all women said they would prefer the one-stop approach for further smear abnormalities if a further colposcopic examination was warranted.

CONCLUSION

A one-stop colposcopy clinic is feasible for the management of women with low-grade smear abnormalities. In addition, it delivers a quality service, optimises patient management, reduces anxiety and is the patient's choice.