Ablative Therapies for Cervical Intraepithelial Neoplasia in Low-Resource Settings: Findings and Key Questions

Cremer, Miriam; Conzuelo-Rodriguez, Gabriel; Cherniak, William; Randall, Thomas C.

doi:10.1200/jgo.18.00093

Cited by 9 publications

(13 citation statements)

References 44 publications

(37 reference statements)

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“…A good number of observational studies and only one RCT by Singh et al, (1988) have demonstrated the high efficacy of TA to treat histopathology proved cervical neoplasias in various settings and even in the HIV infected women (Hussein and Galloway, 1985;Smart et al, 1987;Gordon and Duncan, 1991;Joshi et al, 2013;Campbell et al, 2016;Naud et al, 2016). However, several meta-analysis and systematic reviews of such studies underscored the paucity of information related to the adverse events during and after the procedure (Dolman et al, 2014;Cremer et al, 2018;Randall et al, 2019). Concerns have been expressed by some authors regarding the possibility of the women feeling more pain during TA (Maza et al, 2016).…”

Section: Discussionmentioning

confidence: 99%

A Prospective Randomized Trial to Compare Safety, Acceptability and Efficacy of Thermal Ablation and Cryotherapy in a Screen and Treat Setting

Banerjee

Mandal

et al. 2020

Asian Pac J Cancer Prev

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Background: The prospective randomized study aimed to compare the safety, acceptability and efficacy of thermal ablation (TA) to that of cryotherapy in screen and treat setting. Methods: The participants were recruited prospectively in a community-based screening clinic in India. Women positive on visual inspection with acetic acid (VIA) test and/ or Human Papillomavirus (HPV) test were assessed for eligibility for ablative treatment. Total 286 eligible women were randomized to receive either cryotherapy (N=150) or TA (N=136) performed by health workers. Colposcopy and cervical biopsy were performed on all, prior to treatment. Post-treatment follow-up was after one year with colposcopy and biopsy. Results: Both the treatment methods had high acceptability. Significantly higher proportion of women treated by cryotherapy reported pain compared to women treated by TA, though intensity was mild in vast majority of them. Approximately 30% of women in both arms had histologic abnormalities, mainly CIN 1, and among those who attended follow-up 74.1% and 81.0% didn't have any CIN after cryotherapy and TA respectively. Conclusion: TA is as acceptable and safe as cryotherapy in screen and treat setting. TA has the logistic advantages for the low-resourced settings as the machines are more portable, do not require costly refrigerant gas and battery-driven models are available. The cure rates for CIN 1+ lesions in our study were comparable between cryotherapy and TA.

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Section: Discussionmentioning

confidence: 99%

A Prospective Randomized Trial to Compare Safety, Acceptability and Efficacy of Thermal Ablation and Cryotherapy in a Screen and Treat Setting

Banerjee

Mandal

et al. 2020

Asian Pac J Cancer Prev

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“…39,45,46 Thermal ablation has now been widely adopted within Malawi both within government and non-governmental organization (NGO)-supported screening services and its use is reported in other contexts. 49,47,48 Critically, in 2019, the WHO 43 issued revised guidance for treatment of cervical precancer lesions, for the first time supporting the use of thermal ablation. This guidance recognized the challenges relating to the cost and availability of a refrigerant gas for cryotherapy (as mentioned above), and the need for an evidence-based recommendation for use of thermal ablation in LICs.…”

Section: Thermal Ablationmentioning

confidence: 99%

“…Machines – both the traditional (WISAP) and newer hand-held models – are lightweight compared to cryotherapy equipment, and the hand-held models are also battery-operated or solar-powered (a WISAP C3 thermo-coagulator (https://www.wisap.de/Gynecology.html) and Liger thermo-coagulator (http://www.curemedicalglobal.com/)), respectively. Treatment time is short – WHO guidance recommends thermal ablation be provided at a minimum of 100°C for 20–30 s. 49 There is an initial cost outlay for the machine and probes, but ongoing maintenance costs are low. 11,34 In our experience in Malawi, cost savings compared with cryotherapy were realized after 50 treatments.…”

Section: Treatment Of Early Lesionsmentioning

confidence: 99%

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Cervical cancer screening – The challenges of complete pathways of care in low-income countries: Focus on Malawi

Cubie

Campbell

2020

Womens Health (Lond Engl)

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Cervical cancer is the fourth most common cancer among women globally, with approximately 580,000 new diagnoses in 2018. Approximately, 90% of deaths from this disease occur in low- and middle-income countries, especially in areas of high HIV prevalence, and largely due to limited prevention and screening opportunities and scarce treatment options. In this overview, we describe the opportunities and challenges faced in many low- and middle-income countries in delivery of cervical cancer detection, treatment and complete pathways of care. In particular, drawing on our experience and that of colleagues, we describe cervical screening and pathways of care provision in Malawi, as a case study of a low-resource country with high incidence and mortality rates of cervical cancer. Screening methods such as cytology – although widely used in high-income countries – have limited relevance in many low-resource settings. The World Health Organization recommends screening using human papillomavirus testing wherever possible; however, although human papillomavirus primary testing is more sensitive and detects precancers and cancers earlier than cytology, there are currently costs, infrastructure considerations and specificity issues that limit its use in low- and middle-income countries. The World Health Organization accepts the alternative screening approach of visual inspection with acetic acid as part of ‘screen and treat’ programmes as a simple and inexpensive test that can be undertaken by trained health workers and hence give wider screening coverage; however, subjectivity and variability in interpretation of findings between providers raise issues of false positives and overtreatment. Cryotherapy using either nitrous oxide or carbon dioxide is an established treatment for precancerous lesions within ‘screen and treat’ programmes; more recently, thermal ablation has been recognized as suitable to low-resource settings due to lightweight equipment, short treatment times, and hand-held battery-operated and solar-powered models. For larger lesions and cancers, complete clinical pathways (including loop excision, surgery, radiotherapy, chemotherapy and palliative care) are required for optimal care of women. However, provision of each of these components of cancer control is often limited due to limited infrastructure and lack of trained personnel. Hence, global initiatives to reduce cervical mortality need to adopt a holistic approach to health systems strengthening.

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“…As in other studies, thermal ablation did not cause any significant side effects, and the most common side effects were abnormal vaginal discharge and light vaginal bleeding. 20,[30][31][32] These reported side effects are comparable and less common than those reported for cryotherapy, the most widely used ablative therapy for CIN in sub-Saharan Africa. 33 False VIA-positive results were high among our study population; 20 (69%) of 29 VIA-positive women with histologic results did not have CIN.…”

Section: Discussionmentioning

confidence: 72%

Uptake and safety of community‐based “screen‐and‐treat” with thermal ablation preventive therapy for cervical cancer prevention in rural Lilongwe, Malawi

Chinula

Topazian

Mapanje³

et al. 2021

Intl Journal of Cancer

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Malawi has the highest invasive cervical cancer (ICC) mortality rate worldwide, and ICC is the leading cause of cancer death among women. In 2004, Malawi adopted visual inspection with acetic acid (VIA) and ablative treatment with cryotherapy.However, screening coverage has remained low (<30%) and few women (<50%) who require ablative treatment receive it. Additional barriers include long distances to health facilities and challenges with maintaining gas supplies. Thermal ablation is a safe and effective alternative to cryotherapy. We assessed the safety and uptake of community-based ICC screening with VIA and same-day treatment using a handheld thermocoagulator (HTU) in rural Malawi. We held educational talks alongside community leaders and conducted VIA screening in nonclinic community settings to nonpregnant women aged 25 to 49 years without history of hysterectomy or genital cancer/precancer. Eligible women received same-day thermal ablation and HIV testing/counseling. We collected cervical biopsies before treatment and followed up women at Weeks 6 and 12, with repeat biopsy at Week 12. Between July and August 2017, 408 (88%) of 463 eligible women underwent VIA. Overall, 7% (n = 30) of women had a positive VIA, of whom 93% (n = 28) underwent same-day thermal ablation. Among the 30 VIA-positive women, 5 had cervical intraepithelial neoplasia (CIN) 1, 4 had CIN 2/3 and 21 had benign histologic findings. Abnormal vaginal discharge (60%) and light vaginal bleeding (52%) were the most reported adverse events. There was high uptake of the community-based ICC screening in the study population and treatment was safe in this setting. Similar strategies that minimize false-positive results are urgently needed in Malawi. K E Y W O R D S community-based screening, invasive cervical cancer, screen-and-treat, thermal ablation, VIA 1 | INTRODUCTION Cervical cancer is the fourth most common cancer among women worldwide. In 2018, invasive cervical cancer (ICC) caused 311 000 deaths with Abbreviations: CAB, Community Advisory Board; CIN, cervical intraepithelial neoplasia; HPV, human papillomavirus; HTU, handheld thermocoagulation; ICC, invasive cervical cancer;

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Ablative Therapies for Cervical Intraepithelial Neoplasia in Low-Resource Settings: Findings and Key Questions

Cited by 9 publications

References 44 publications

A Prospective Randomized Trial to Compare Safety, Acceptability and Efficacy of Thermal Ablation and Cryotherapy in a Screen and Treat Setting

A Prospective Randomized Trial to Compare Safety, Acceptability and Efficacy of Thermal Ablation and Cryotherapy in a Screen and Treat Setting

Cervical cancer screening – The challenges of complete pathways of care in low-income countries: Focus on Malawi

Uptake and safety of community‐based “screen‐and‐treat” with thermal ablation preventive therapy for cervical cancer prevention in rural Lilongwe, Malawi

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