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

Eric Chamot,Jeffrey SA Stringer,Mulindi H Mwanahamuntu,Sibylle Kristensen

doi:10.1186/1472-6874-10-11

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.

Highlights

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)
With evidence suggesting that human papillomavirus (HPV) vaccine will not substitute for secondary prevention [3], attention has been redirected toward the development of novel and simple cervical cancer screening approaches more suitable for use in resource-poor settings
With the support of a medical librarian, we combined more than 20 key search terms (Additional file 1: search algorithm in Medline) to identify all primary studies in which women with cervical intraepithelial neoplasia of any grade were treated with either cryotherapy or LEEP

Summary

Introduction

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). With evidence suggesting that human papillomavirus (HPV) vaccine will not substitute for secondary prevention [3], attention has been redirected toward the development of novel and simple cervical cancer screening approaches more suitable for use in resource-poor settings. These efforts have led to the emergence of screening of middle-aged women by means of visual inspection of the cervix (after application of acetic acid or Lugol’s iodine), or high-risk HPV DNA testing, coupled with immediate or shortly deferred management of abnormalities, as potentially viable and cost-effective strategies to reduce ICC incidence in less-developed countries [4,5,6]

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