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

Abstract

BackgroundSince 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.MethodsWe 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.ResultsThe 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.ConclusionsWhen 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.

The comparative and cost-effectiveness of HPV-based cervical cancer screening algorithms in El Salvador

“…A review of available evidence suggests that cryotherapy is not associated with excess harm in resource-limited settings when performed by qualified providers, but data are insufficient for women of reproductive age. 28 Also, speculatively, the ablation of the squamocolumnar junction may reduce future risk of acquiring a new HPV infection that could progress to cancer. 29 We note that, due to the low specificity of local pathology diagnoses, most women in the CM cohort who received colposcopy were referred to treatment; thus, the potential for overtreatment exists with both management strategies.…”

Influencing Women's Actions on Cervical Cancer Screening and Treatment in Karawang District, Indonesia

“…This inexpensive and technically simple technique destroys abnormal tissue by freezing it with a probe cooled by liquid carbon dioxide (CO 2 ). A systematic review of 32 studies found that the procedure is safe and has an overall cure rate of almost 90% (Castro et al, 2003), and more recent studies have confirmed its effectiveness Luciani et al, 2008;Chamot et al, 2010).…”

Cervical Cancer Screening and Prevention for HIV-Infected Women in the Developing World

“…Adverse effects after cryotherapy are relatively uncommon and generally minor, reported in 1-2% of women (Cirisano 1999;Nene 2008). Discomfort usually resolves within a week after treatment (Chamot 2010;). Significant bleeding after cryotherapy is uncommon.…”