The overtreatment risk of see-and-treat strategy in management of abnormal cervical cytology

Overtreatment in the see-and-treat approach for high-grade squamous cervical cytology

Objectives

To evaluate overtreatment with the 'see-and-treat' approach in patients with high-grade squamous cervical cytology, and identify the clinical factors associated with overtreatment.

Study design

Patients with high-grade squamous intra-epithelial lesion (HSIL) cytology undergoing colposcopy and loop electrosurgical excision procedure (LEEP) in a single visit or the 'see-and-treat' approach from January 2005 to December 2019 were reviewed retrospectively. The overtreatment rate and complications following LEEP were explored.

Results

In total, 220 cases were identified. The overtreatment rate was 11.4%, and surgical complications were haemorrhage (n = 3, 1.36%) and infection (n = 9, 4.09%). On univariable analysis, factors associated with overtreatment were current cytological result and colposcopic impression. On multi-variable analysis, current cytological result of non-HSIL compared with HSIL/cancer, and colposcopic diagnosis of low-grade lesion or normal compared with high-grade lesion or cancer had adjusted odds ratios of 13.81 [95% confidence interval (CI) 1.23-155.20; p = 0.033] and 3.58 (95% CI 1.32-9.74; p = 0.013), respectively.

Conclusions

The overtreatment rate with the 'see-and-treat' approach was 11.4%. Independent factors associated with overtreatment were current cervical cytological result of non-HSIL, and low-grade or normal colposcopic diagnosis.

Clinical practice variation and overtreatment risk in women with abnormal cervical cytology in the Netherlands: two-step versus see-and-treat approach

BACKGROUND

Only a few small studies have compared the 2-step method (biopsy followed by treatment) with a see-and-treat (immediate treatment) approach in women both low-grade or high-grade referral cytology. The clinical practice variation in the Netherlands has not been reviewed before.

OBJECTIVES

To determine overtreatment rates in the 2-step versus see-and-treat approach in women referred for colposcopy because of abnormal cytology results, and to evaluate clinical practice variation in the Netherlands.

MATERIALS AND METHODS

This was a population-based retrospective cohort study including 36,581 women with a histologic result of the cervix identified from the Dutch Pathology Registry (PALGA) between 2016 and 2017. Odds ratios for overtreatment, defined primarily as cervical intraepithelial neoplasia grade 1 or less, were determined for the 2-step and see-and-treat approach in relation to age, high-risk human papillomavirus status, and referral cytology.

RESULTS

Of the included women 10,713 women (29.3%) received the 2-step method; 6,851 women (18.7%) underwent see-and-treat; and 19,017 women (52.0%) received conservative management after colposcopy with histologic assessment with cytologic follow-up or another type of treatment. Despite the existence of a national guideline advising see-and-treat only in case of suspected high-grade disease in women who have completed their childbearing, there is a wide practice variation between the 2 strategies in the Netherlands, with 7.0-88.3% of the women receiving see-and-treat per laboratory. The median time between cytology and treatment was 1-2 months (range, 0-12 months) in women receiving see-and-treat and the 2-step method, respectively. A total of 4119 women (23.5%) were overtreated, with older women, high-risk human papillomavirus-negative women, and women with low-grade cytology results being more likely to be overtreated. Women with low-grade cytology results and see-and-treat were associated with a higher overtreatment rate than women receiving the 2-step method (65.0% [1414 of 2174] versus 32.1% [1161 of 3613], respectively; odds ratio, 3.34; 95% confidence interval, 2.92-3.82). However, in women with high-grade cytology results, see-and-treat was inversely associated with overtreatment (11.3% [529 of 4677] versus 14.3% [1015 of 7100], respectively; odds ratio, 0.68; 95% confidence interval, 0.58-0.81).

CONCLUSION

A see-and-treat approach is justified only in women with high-grade cytology results who have completed their childbearing. There is a wide practice variation between the 2 strategies in the Netherlands, and gynecologists should adhere to the guideline to prevent overtreatment.