Treatability by Cryotherapy in a Screen-and-Treat Strategy

Abstract

We estimated the percentage of women infected with human papillomavirus (HPV+) who cannot be immediately treated with cryotherapy. In a 10,000-woman Costa Rican cohort, we analyzed the 559 HPV+ women aged 25 to 55 years and estimated the proportion for whom immediate cryotherapy was not indicated (i.e., invasive cancer, large precancerous lesions, or benign abnormalities that risk failure such as large ectopy, squamocolumnar junction not visualized, polyps, ulcers, or distorted or atrophied cervix). To determine whether cryotherapy at time of baseline HPV screening would effectively treat HPV+ women, 2 expert gynecologists independently judged entire clinical histories (5-7 years of cytology, histology, and HPV tests) and a full longitudinal series of digitized cervical images. Reviewers judged 144 (25.8%) of 559 HPV+ women as not treatable by immediate cryotherapy. Among 72 women with cervical intraepithelial neoplasia grade 3 who would benefit most from a screening program, 35 (48.6%) were not treatable. In particular, 29 women (40.3%) were determined not treatable for reasons most likely associated with cryotherapy's inadequacy (lesion was large, suspected cancerous or in the endocervical canal or fornix). "Screen-and-treat" programs in low-resource settings will soon use a rapid HPV test to screen older women once or twice in their lifetime, identifying women at higher risk for precancer. Our findings suggest that cryotherapy might not effectively treat many precancers, and other safe, low-technology treatment options could be required, in a scenario where all HPV+ women in this targeted group would receive cryotherapy at the same visit.