The “See and Treat” Strategy for Identifying Cytologic High-Grade Precancerous Cervical Lesions Among Low-Income Brazilian Women

Abstract

After cytologic identification of high-grade cervical squamous intraepithelial lesions (HSILs), the most common management procedure is colposcopy-guided biopsy and endocervical curettage. The “see and treat” approach using the loop electrosurgical excision procedure (LEEP) is an alternative strategy that provides immediate and concomitant diagnosis and treatment without a previous biopsy. The see-and-treat approach may result in overtreatment in women with cervical lesions who do not require treatment or adverse effects. However, this strategy circumvents the failure to diagnose or treat HSILs and is an important strategy in low-resource and low-income settings. The see-and-treat strategy has been adopted in some states and regions in Brazil, but the possible benefits of this strategy have not been fully investigated. This retrospective study assessed the strategy of see-and-treat by LEEP for HSIL precancerous cervical lesions and evaluated post-LEEP recurrence among low-income women in Brazil. A retrospective survey of data from medical records of the Department of Gynecology, Hospital of Public Health, in União da Vitória, Paraná, Brazil, identified women who underwent LEEP for cytologic HSILs without prior biopsy between 2004 and 2008. Follow-up of patients for LEEP sample histology was performed with Papanicolaou (Pap) smear. A total of 117 women underwent LEEP for cytologic HSILs during the study period. In these women, histologic examination of tissue excised by LEEP showed that 26.7% had no lesions, and 72.6% had either histologically proven cervical intraepithelial neoplasia 2/3 (67.5%) or microinvasive/invasive carcinomas (5.2%). At follow-up, there was no significant difference in the recurrence rate between women with histologic findings of cervical intraepithelial neoplasia 2/3 and those with no lesions (16.7% and in 25%, respectively; P > 0.05). The most frequent type of recurrence (78%) was HSILs (P < 0.001). The surgical margin status among patients with cytologic HSILs was as follows: ectopositive and endopositive margins (6.3%), ectopositive margins (3.8%), and endopositive margins (33.0%). No significant difference was found in recurrence rates for women with endopositive (26.3%), no margin (17.4%), and cautery artifact margin (25.0%) involvement (P > 0.05). These findings suggest that the benefits of the see-and-treat strategy for patients with cytologic HSILs outweigh the risk of overtreatment. The data demonstrate that margin involvement should not be the only prognostic indicator. All women with both positive and negative margins on LEEP should be carefully followed.