Outcomes of loop electrosurgical excision procedure for cervical neoplasia in human immunodeficiency virus-infected women

Loop electrosurgical excision procedure (LEEP) plus top hat for HIV-infected women with endocervical intraepithelial neoplasia in Kenya

OBJECTIVE

To determine the utility of detecting endocervical cervical intraepithelial neoplasia (CIN) 2+ with endocervical curettage (ECC) and treating with loop electrosurgical excision procedure (LEEP) plus top hat (+TH) among women with HIV.

METHODS

Cytology was followed by coloscopy-directed biopsy if participants had HSIL or ASC-H and biopsy plus ECC if there were glandular cells present. CIN2/3 on ECC and/or inadequate colposcopy (ENL) was treated with LEEP+TH, while CIN2/3 on ectocervix (ECL) received LEEP alone. Recurrent CIN2+ were compared over a 2-year follow-up.

RESULTS

Of 5330 participants, 160 underwent ECC, 98 were CIN2/3 on ECC, and 77 received LEEP+TH. ECC detected 15 (9%) more women with CIN2/3 than biopsy alone. Women were more likely to have ENL if they were older (≥45 vs <35 years) (adjusted relative risk [aRR] 2.14; P = 0.009) and on antiretroviral treatment longer (≥2 vs <2 years) (aRR 3.97; P < 0.001). Over the 2-year follow-up, 35 (29%) ENL had recurrent CIN2+ after TH compared to 19 (24%) ECL after LEEP (hazard ratio 1.32; 95% confidence interval 0.75-2.31; P = 0.338).

CONCLUSION

Among HIV-infected women, adding ECC did not increase detection of pre-cancerous disease significantly and treatment with LEEP+TH for ENL was comparable to treatment with LEEP for ECL.

Treatment of pre- and confirmed cervical cancer in HIV-seropositive women from developing countries: a systematic review

BACKGROUND

Cervical cancer has become a major public health challenge in developing countries with a reported age-standardised incidence rate of about 17.9/100,000/year and lifetime risks approaching 1 in 20 in some settings. Evidence indicates that HIV-seropositive women are 2 to 12 times more likely to develop precancerous lesions that lead to cervical cancer than HIV-negative women. There is a lack of rigorous evidence on which treatment methods are being utilised for HIV-positive women, and this review aims to synthesise available evidence on treatment modalities for both cervical neoplasia and cervical cancer in HIV-seropositive women in developing countries.

METHODS

A systematic review guided by a published protocol was conducted. Online databases including MEDLINE/PubMed, Embase, CINAHL and Emerald (via EBSCOhost), PsycINFO, Cochrane Library, and health databases, which cover developing countries (3ie Systematic Reviews, WHO library and databases, World Bank website), were searched for published articles. Additional articles were found through citation, reference list tracking, and grey literature. Study design, treatment category, geographic country/region, and key outcomes for each included article were documented and summarised.

RESULTS

Thirteen research articles from sub-Saharan Africa, Asia, and South America were included. Eight (61.5%) articles focused on the treatment of cervical cancer with the remaining five (38.5%) assessed cervical neoplasia treatment. The available cervical cancer treatments, radiotherapy, chemotherapy, chemoradiation, and surgery are effective for HIV-seropositive patients, and these are the same treatments for HIV-negative patients. Both cryotherapy and LEEP are effective in reducing CIN2+ among HIV-seropositive women, and a choice between the treatments might be based on available resources and expertise. Radiation, chemotherapy, concurrent treatment using radiotherapy and chemotherapy, and surgery have shown the possibility of effectiveness among HIV-seropositive women. Cervical cancer stage, immunosuppressive level including those on HAART, and multisystem toxicities due to treatment are associated with treatment completion, prognostic, and survival outcomes.

CONCLUSIONS

Treatment of cervical cancer is based on the stage of cancer, and poor outcomes in most developing countries might be due to a lack of optimal treatment regimen. Those infected with HIV were younger and had advanced cervical cancer as compared to those who were HIV-negative. Facilitation and putting HIV-infected people on life-long ART is of importance and has been found to have a positive impact on cervical cancer treatment response. Research on precancerous lesions and cervical cancer management of HIV-seropositive patients focusing on the quality of life of those treated; the effectiveness of the treatment method considering CD4+ count and ART is required.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018095707.

Residual or Recurrent Precancerous Lesions After Treatment of Cervical Lesions in Human Immunodeficiency Virus-infected Women: A Systematic Review and Meta-analysis of Treatment Failure

BACKGROUND

Screening and treating premalignant cervical lesions (cervical intraepithelial neoplasia 2+ [CIN2+]) is an effective way to prevent cervical cancer, and recommendations exist for the monitoring of treatment success. Yet, there is no specific recommendation for human immunodeficiency virus (HIV)-infected women, who are at a known, increased risk of cervical cancer.

METHODS

A systematic review was performed by searching MEDLINE, EMBASE, and Web of Science for studies published from January 1980 through May 2018. Eligible studies described the prevalence of histologically- and/or cytologically-defined lesions in HIV-infected women at least 6 months post-treatment. The primary endpoint was treatment failure, defined as the presence of residual and/or recurrent high-grade CIN2+/high-grade squamous intraepithelial lesions post-treatment. The pooled prevalence in HIV-infected women and the odds ratios (ORs) for HIV-infected compared to HIV-uninfected women were estimated using random-effects models.

RESULTS

Among 40 eligible studies, the pooled prevalence of treatment failure in HIV-infected women was 21.4% (95% confidence interval [CI] 15.8-27.0). There was no significant difference in the treatment failure prevalence for cryotherapy (13.9%, 95% CI 6.1-21.6) versus loop electrosurgical excision procedure (13.8%, 95% CI 8.9-18.7; P = .9), but the treatment failure prevalence was significantly higher in women with positive (47.2%, 95% CI 22.0-74.0) than with negative (19.4%, 95% CI 11.8-30.2) excision margin (OR 3.4, 95% CI 1.5-7.7). Treatment failure was significantly increased in HIV-infected versus HIV-uninfected women, both overall (OR 2.7, 95% CI 2.0-3.5) and in all sub-group analyses.

CONCLUSIONS

There is strong evidence for an increased risk of treatment failure in HIV-infected women, in comparison to their HIV-negative counterparts. The only significant predictor of treatment failure in HIV-infected women was a positive margin status, but further data is needed on long-term outcomes after ablative treatment in HIV-infected women.

Safety of intrauterine devices among women with HIV: a systematic review

BACKGROUND

Use of highly effective contraception among women living with HIV is critical to prevent unintended pregnancy and subsequent risk of maternal complications and perinatal HIV transmission. However, it is not known whether use of intrauterine devices (IUDs) among women with advanced HIV disease poses an increased risk of pelvic infection or HIV progression and transmission.

OBJECTIVES

To identify evidence regarding the risk of pelvic infection, HIV disease progression or HIV transmission among women with HIV using IUDs and whether this risk differs by severity of HIV disease.

METHODS

We searched the PubMed database for all articles published from database inception through January 2016. For the outcome of pelvic infection, we included studies that examined women using IUDs and reported risk of pelvic inflammatory disease (PID) or pelvic infections among women with varying levels of HIV severity or among women with HIV compared with women without HIV. For the outcomes of HIV disease progression and HIV transmission to noninfected male partners, we included studies of women with HIV using IUDs compared with other contraceptive methods or no method.

RESULTS

The review identified eight articles from six study populations which addressed pelvic infections or other IUD-related complications and found mixed results. One study that directly compared women with varying levels of HIV disease severity found no differences in complication rates between those with severe or mild disease after short- and longer-term follow-up. The remaining studies generally found low or no incidence of PID among IUD users. Among eight articles from seven study populations that reported on HIV disease progression, there were generally no differences between women using IUDs compared with other contraceptives, nor were there changes between baseline and follow-up. One article that reported directly on HIV disease transmission to noninfected male partners found no difference in HIV disease transmission, and five articles found no differences in genital viral shedding among women using IUDs. No direct evidence addresses potential differences in HIV disease progression or transmission by HIV disease severity.

CONCLUSION

Limited evidence of fair to poor quality found no differences in infectious complications when comparing IUD complication rates among women with varying levels of HIV disease severity. One study found that IUD use was not associated with HIV transmission, and studies generally found no differences in genital viral shedding or disease progression; however, there was little direct evidence to address potential differences related to HIV severity.

Cervical surgery for cervical intraepithelial neoplasia and prolonged time to conception of a live birth: a case-control study

OBJECTIVE

To determine whether women with a history of surgery for cervical intraepithelial neoplasia (CIN) are at an increased risk of subfertility, measured as a time to pregnancy of more than 12 months.

DESIGN

Case-control study.

SETTING

Iowa Health in Pregnancy Study (IHIPS), a population-based case-control study of preterm and small-for-gestational-age (SGA) live birth outcomes (from May 2002 through June 2005) in the USA.

SAMPLE

Women with an intended pregnancy and a history of either one prior cervical surgery (n = 152), colposcopy only (n = 151), or no prior cervical surgery or colposcopy (n = 1021).

METHODS

Cervical treatment history, pregnancy intention, time to pregnancy, and other variables were self-reported by computer-assisted telephone interviews. Odds ratios were calculated using logistic regression to estimate the risk of prolonged time to pregnancy among women with a history of cervical surgery or colposcopy alone, compared with untreated women (control group).

MAIN OUTCOME MEASURE

Prolonged time to pregnancy (i.e. >1 year).

RESULTS

Prolonged time to pregnancy was most prevalent among treated women (16.4%), compared with untreated women (8.4%) and women with colposcopy only (8.6%) (P = 0.039). After adjusting for covariates, women with prior cervical surgery had a more than two-fold higher risk of prolonged time to pregnancy compared with untreated women (aOR 2.09, 95% CI 1.26-3.46). In contrast, women with a history of colposcopy only had a risk equivalent to that found among untreated women (aOR 1.02, 95% CI 0.56-1.89).

CONCLUSIONS

Women with a history of cervical treatment for CIN are at increased risk of subfertility, measured as a time to pregnancy of more than 12 months.

Bolstering the Evidence Base for Integrating Abortion and HIV Care: A Literature Review

HIV-positive women have abortions at similar rates to their HIV-negative counterparts, yet little is known about clinical outcomes of abortion for HIV-positive women or the best practices for abortion provision. To fill that gap, we conducted a literature review of clinical outcomes of surgical and medication abortion among HIV-positive women. We identified three studies on clinical outcomes of surgical abortion among HIV-positive women; none showed significant differences in infectious complications by HIV status. A review of seven articles on similar gynecological procedures found no differences in complications by HIV status. No studies evaluated medication abortion among HIV-positive women. However, we did find that previously expressed concerns regarding blood loss and vomiting related to medication abortion for HIV-positive women are unwarranted based on our review of data showing that significant blood loss and vomiting are rare and short lived among women. We conclude that although there is limited research that addresses clinical outcomes of abortion for HIV-positive women, existing data suggest that medication and surgical abortion are safe and appropriate. Sexual and reproductive health and HIV integration efforts must include both options to prevent maternal mortality and morbidity and to ensure that HIV-positive women and women at risk of HIV can make informed reproductive decisions.

Loop electrosurgical excision procedure: safety and tolerability among human immunodeficiency virus-positive Kenyan women

OBJECTIVES

To estimate the safety, tolerability, and acceptability of loop electrosurgical excision procedure (LEEP) for cervical intraepithelial neoplasia (CIN 2 or 3) in human immunodeficiency virus (HIV)-positive women performed by nonphysician health care providers in an HIV care and treatment clinic.

METHODS

We performed a prospective cohort study among women undergoing LEEP for biopsy-confirmed CIN 2 or 3 at the Family Acquired Immunodeficiency Syndrome Care and Education Services Clinic in Kisumu, Kenya. Women were followed-up 4 weeks after the procedure and questioned for abstinence as well as presence and severity of side effects after the procedure. The results were analyzed using descriptive statistics and univariable and multivariable analysis.

RESULTS

Among the 180 (91%) women who returned for a 4-week follow up after LEEP, 52% reported at least one postprocedure symptom, including bleeding, discharge, or pain. Using a Likert scale for severity of symptoms, 179 (99%) reported very mild to mild symptoms, whereas one (1%) participant described the symptoms as moderate. No participants reported severe symptoms. Mean CD4 count was significantly higher among women who reported any symptoms compared with women who reported no symptoms after LEEP (419 cells/mm compared with 349 cells/mm, P<.05), an association that remained significant after adjustment for antiretroviral treatment. The presence or severity of postprocedure symptoms did not differ among women who reported sexual activity (16%) less than 4 weeks after the procedure.

CONCLUSION

LEEP performed by clinical officers was well-accepted by HIV-positive women and appears safe, resulting in minimal side effects, even among women with early resumption of intercourse.

LEVEL OF EVIDENCE

II.

Are treatments for cervical precancerous lesions in less-developed countries safe enough to promote scaling-up of cervical screening programs? A systematic review

Background

Since the mid-1990s, there have been growing efforts to prevent cervical cancer in less-developed countries through the development of innovative screening approaches such as visual inspection of the cervix associated with same day management of cervical lesions with cryotherapy or loop electrosurgical excision procedure (LEEP). In the past, promising cancer screening interventions have been widely promoted despite incomplete evidence, only to become the subject of intense controversies about ensuing net health benefit. Because the efficacy and effectiveness of the new protocols for global cervical cancer screening have not been well characterized yet, and as a contribution to the evaluation of the balance between the benefits and risks of these protocols, we reviewed the literature on the safety of cryotherapy and LEEP for cervical intraepithelial neoplasia (CIN) in low- and middle-income countries.

Methods

We searched 12 databases (Medline, Google Scholar, Scopus, Cochrane Library, Web of Science, OCLC, PAIS International Database, WHO Global Health Library, CINAHL, Science.gov, NYAM Grey Literature Report, and POPLINE) for original research published between January 1995 and April 2009. Both peer-reviewed publications and items of "grey" literature were retrieved; no language restriction was applied. We calculated the median (minimum, maximum) reported rate for each harm considered. Because of limitations and heterogeneity in the data, no formal meta-analysis was performed.

Results

The search identified 32 articles that reported safety data from 24 cryotherapy and LEEP studies. The combined sample consisted of 6,902 women treated by cryotherapy and 4,524 women treated by LEEP. Most studies were conducted in reference or research settings in Asia and Africa. Short-term harms of cryotherapy and LEEP appeared to be similar to those described in the literature from high-income countries. Information was sparse on HIV-related harms and long-term reproductive outcomes of treatment.

Conclusions

When performed in resource-limited settings by qualified providers, cryotherapy and LEEP are not associated with excess harm. However, available data are insufficient to propose fully evidence-based protocols for routine screening of HIV-infected women and women of reproductive age.

Outcome of loop electrosurgical excision for HIV-positive women in a low-resource outpatient setting

OBJECTIVE

To assess outcome in HIV-positive women undergoing the loop electrosurgical excision procedure (LEEP).

METHOD

A prospective study was conducted with 789 outpatients undergoing LEEP at Chiang Mai University Hospital between October 2004 and June 2008.

RESULTS

The 70 HIV-positive women (8.9%) were younger (P<0.001) and had a lower parity (P<0.001) than the remaining women. The proportion of women undergoing LEEP for persistent low-grade lesions was higher (8.6% vs 1.9%) and the prevalence of margin involvement was higher (60.0% vs 49.4%) among the HIV-positive women. After adjusting for age, parity, menopausal status, size of excised lesion, and histopathologic result, HIV infection was not significantly associated with LEEP complications (adjusted odds ratio, 0.41; 95% confidence interval, 0.15-1.15).

CONCLUSION

The higher risk of resection margin involvement in HIV-infected women was not associated with LEEP complications.

Management of cryotherapy-ineligible women in a "screen-and-treat" cervical cancer prevention program targeting HIV-infected women in Zambia: lessons from the field

OBJECTIVE

We demonstrate the feasibility of implementing a referral and management system for cryotherapy-ineligible women in a "screen-and-treat" cervical cancer prevention program targeting HIV-infected women in Zambia.

METHODS

We established criteria for patient referral, developed a training program for loop electrosurgical excision procedure (LEEP) providers, and adapted LEEP to a resource-constrained setting.

RESULTS

We successfully trained 15 nurses to perform visual inspection with acetic acid (VIA) followed by immediate cryotherapy. Women with positive tests but ineligible for cryotherapy were referred for further evaluation. We trained four Zambian physicians to evaluate referrals, perform punch biopsy, LEEP, and manage intra-operative and post-operative complications. From January 2006 through October 2007, a total of 8823 women (41.5% HIV seropositive) were evaluated by nurses in outlying prevention clinics; of these, 1477 (16.7%) were referred for physician evaluation based on established criteria. Of the 875 (59.2% of 1147 referred) that presented for evaluation, 748 (8.4% of total screened) underwent histologic evaluation in the form of punch biopsy or LEEP. Complications associated with LEEP included anesthesia reaction (n=2) which spontaneously resolved, intra-operative (n=12) and post-operative (n=2) bleeding managed by local measures, and post-operative infection (n=12) managed with antibiotics.

CONCLUSION

With adaptations for a resource-constrained environment, we have demonstrated that performing LEEP is feasible and safe, with low rates of complications that can be managed locally. It is important to establish referral and management systems using LEEP-based excisional evaluation for women with cryotherapy-ineligible lesions in VIA-based "screen-and-treat" protocols nested within HIV-care programs in resource-constrained settings.