Surgery for cervical intra-epithelial neoplasia
In this review of seven surgical techniques for treating cervical intra-epithelial neoplasia, no single technique emerged as superior to others.
RHL Commentary by Lindeque BG
1. EVIDENCE SUMMARY
Several different techniques are in use for the surgical treatment of cervical intra-epithelial neoplasia (CIN), and this review compares the effects of alternative surgical treatments for CIN. Few trials addressed all or even most of the endpoints of the review. No single surgical technique was identified as superior to treat CIN. Of the commonly used techniques, large loop excision of the transformation zone (LLETZ) appears to yield the best specimen for histopathological assessment. The equipment required for LLETZ is less expensive than that for laser excision and vaporisation, making LLETZ a more favored technique. Outcome as based on detection of residual post-treatment disease is however similar with LLETZ or laser. Cryotherapy appears to be effective treatment for low grade CIN lesions but not for high grade lesions. Cold knife cone biopsy has a place when endocervical glandular disease is suspected, or when early invasive cervical cancer is suspected on cytology but when no visible lesion is noted on the cervix.
The review included all randomized or quasi-randomized trials following a standardized methodology. Many end points were assessed which led to several findings being based on the results from one or two trials only. The major end point, detection of residual post-treatment disease, was addressed in all studies.
2. RELEVANCE TO UNDER-RESOURCED SETTINGS
2.1. Magnitude of the problem
Cancer of the cervix is the most common gynaecologic cancer of women living in the developing world. These patients have a CIN lesion prior to development of invasive carcinoma. With the aid of screening programmes CIN can be detected with relative ease, and then treated effectively. The most applicable surgical technique should be selected. Applicability depends on effectiveness, cost, morbidity and long term side effects. All techniques require colposcopy. Therefore special training is required for health care workers.
In health care settings where no screening for cervical neoplasia is performed, i.e. Pap smear, the detection rate of CIN will be extremely low. Opportunistic screening will also not decrease the incidence of cancer and mortality rate of cervical cancer in a population, as the same people tend to undergo repeated screening or the screening is done in low risk populations.
In several centres work has been done to assess the impact of naked eye visual inspection of the cervix after application of diluted acetic acid as a screening test (1). The sensitivity of this test is high but the specificity is low and although it is a very economical test, it is inferior to cytology.
2.2. Feasibility of the intervention
Surgical treatment for CIN lesions form an important part of gynaecological cancer care throughout the world, and certainly so in developing countries, to be effective at population level, some form of cervical screening is needed. The introduction of LLETZ in 1989 (2), was followed by wide acceptance of this technique using reliable equipment available at a relatively low cost.
2.3. Applicability of the results of the Cochrane Review
The results of the Cochrane Review are applicable to under-resourced health care settings.
2.4. Implementation of the intervention
To properly implement surgical treatment for CIN, a screening programme must first be in place in order to detect those women with CIN in need of treatment. Required equipment for a treatment programme will include a colposcope, the LLETZ electrodiathermy apparatus, and instruments used in the gynaecologic examination. The procedure can be performed under local intracervical or paracervical block. Electricity as well as resuscitation equipment is necessary. As many women in developing countries go through life without ever having cervical screening performed, population awareness should be increased to ensure patient compliance with treatment. Support from government health care departments is required to fund screening campaigns and follow-up of women with pathological findings.
The use of surgical treatment for CIN can unfortunately not be seen in isolation from these other issues, although the review focused on surgical treatment only.
2.5. Research
Following this review, several important aspects recommended for research can be identified. The most important would be to perform a large RCT on one-visit (“see and treat”) LLETZ versus LLETZ following colposcopy and directed biopsy and therefore requiring an extra clinic visit. Furthermore, several of the end points of the review, for example prevalence of post-treatment cervical stenosis, the relevance of possibly involved excisional margins and the associated thermal artifact, and the occurrence of adequate colposcopy at follow-up all need further assessment as the evidence for the current recommendations is limited.
References
- University of Zimbabwe/JHPIEGO Cervical Cancer Project J. Visual inspection with acetic acid for cervical-cancer screening: test qualities in a primary-care setting. The Lancet 1999;353:869-873.
- Prendiville W, Cullimore J, Norman S. Large loop excision of the transformation zone (LLETZ): a new method of management for women with cervical intraepithelial neoplasia. British journal of obstetrics and gynaecology 1989;96:1054-1060.
This document should be cited as: Lindeque BG. Surgery for cervical intra-epithelial neoplasia: RHL commentary (last revised: 3 August 2004). The WHO Reproductive Health Library; Geneva: World Health Organization.