Factors Related to Overtreatment in the See-and-Treat Approach: A Retrospective Multicentric Observational Study

Overtreatment rate after immediate local excision of suspected cervical intraepithelial neoplasia: A prospective cohort study

OBJECTIVE

The gold standard of cervical intraepithelial neoplasia (CIN) treatment is large loop excision of the transformation zone (LLETZ) after histopathological diagnosis from punch biopsies. In addition, treatment may be appropriate at initial colposcopy. Our objective was to study the applicability of immediate treatment strategy according to clinical parameters.

METHODS

We conducted a prospective cohort study among patients referred to colposcopy at Helsinki University Hospital, Finland, between January 2014, and September 2018 (ISRCTN10933736). Patients treated with LLETZ, either after biopsies or immediately at initial colposcopy, were included. The main outcome measure was overtreatment (OT) rate defined as normal or low-grade histopathological findings in LLETZ specimen within both treatment groups.

RESULTS

A total of 572 patients treated with LLETZ were included: 360 treated after biopsies and 212 treated immediately at initial colposcopy. When LLETZ was performed immediately after high-grade referral cytology and with colposcopic impression of high-grade disease, the overtreatment (OT) rate was 10.0% (95% CI 9.10 to 17.2), whereas when LLETZ was done after biopsy-confirmed high-grade lesions, the OT rate was 18.9% (95% CI 14.7 to 23.7), resulting in risk difference (RD) -8.91% (95% CI -16.0 to -1.82). Among HPV16/18 positive patients the OT rate was 8.22% (95% CI 3.08 to 17.0) for immediate treatment, resulting in RD of -10.7% (95% CI -18.3 to -3.04) compared to LLETZ after biopsies.

CONCLUSIONS

Immediate LLETZ does not result in overtreatment when applied on selected cases, especially after high-grade referral cytology and when high-grade lesion is also colposcopically suspected.

Assessing Barriers Encountered by Women in Cervical Cancer Screening and Follow-Up Care in Urban Bolivia, Cochabamba

Background: Timely detection of cervical cells infected with high-risk human papillomavirus (HPV) improves cervical cancer prevention. In Bolivia, actual screening coverage only reaches 33.3% of the target population aged between 25 and 64 years despite free cytology screening. Furthermore, 50% to 80% screened women are lost during follow-up. This study aimed at identifying factors explaining this lack of follow-up care. Method: During the first phase, face-to-face semi-structured interviews were conducted with HPV-positive women. Secondly, we explored the reasons for the non-adherence to the follow-up care: knowledge, perceptions and beliefs about HPV, as well as barriers to healthcare access, using a structured survey on Cochabamba women and healthcare professionals. Results: Barriers to effective follow-up of the targeted populations were associated with health system shortcomings, including poor service delivery at the front- and second-line, health providers shortage, inadequate training, waiting time, high direct and indirect costs of care seeking and care, complex procedures to obtain HPV screening results and poor patient–provider communication. The follow-up was perceived as extremely stressful by the participants. Conclusion: Improved communication on HPV and HPV-related cancers in terms of representation in the general population and among the health professional’s population is vital to improve access for HPV infection follow-up care.