Cervical dysplasia treatment: key issues for developing countries

Abstract

Many developing countries face serious obstacles that have hindered establishment of successful cervical cancer control programs. Various countries are now seeking to strengthen cytology services and identify simple low-cost screening strategies; but any real gains in reducing cervical cancer incidence and mortality will also require effective treatment of women with preinvasive disease. Despite a trend toward conservative outpatient approaches for treating cervical dysplasia in industrialized countries, clinicians in many developing countries still rely primarily on invasive inpatient methods such as cone biopsy and hysterectomy. For women who could be treated with less invasive methods, these procedures tend to pose unnecessary risks and entail high costs that put them beyond the reach of many patients. Outpatient therapy, employing methods such as cryotherapy and the loop electrosurgical excision procedure (LEEP), combined with proper follow-up, is appropriate for dealing with visible lesions on the ectocervix when invasive cancer and endocervical involvement have been ruled out. Cryotherapy and LEEP hold out particular promise for developing countries because of their effectiveness, lack of side-effects, simplicity, and low cost. Cure rates range from 80% to 95%, depending on the method used and the severity of the lesions. However, each method has advantages and disadvantages that demand consideration. Various ways of reducing the number of follow-up visits, including the two-visit "see and treat" approach, are also available for use in areas where women's access to health services may be limited. A recent survey by the Program for Appropriate Technology in Health (PATH) affirmed the tendency to rely on cone biopsy and hysterectomy. It also found that in many places all degrees of preinvasive disease were treated, rather than only high-grade or severe conditions; that respondents in Latin America, the Caribbean, and Asia tended to use cryotherapy and LEEP more widely than other low-cost methods; that LEEP was preferred over cryotherapy in Latin America; and that colposcopes and other basic equipment needed to provide treatment were not consistently or widely available in some settings.

PIP: Financial, technical, and logistical factors have impeded the establishment of effective cervical cancer control programs in many developing countries. Efforts are now underway to strengthen cytology services and identify simple, inexpensive, alternative screening strategies that will improve early detection of cervical intraepithelial neoplasia (CIN). As part of this effort, the Program for Appropriate Technology in Health (PATH) surveyed the CIN treatment practices and preferences of 110 health practitioners from 33 developing countries. The survey revealed widespread reliance on invasive inpatient procedures such as cone biopsy and hysterectomy and a tendency to treat all preinvasive CIN, rather than only high-grade or severe CIN. Simple, low-cost, effective (80-95%) outpatient procedures such as cryotherapy and the loop electrosurgical excision procedure (LEEP) were selected more widely in Asia, the Caribbean, and Latin America than in Africa, but remained underutilized relative to inpatient treatments. In many settings, colposcopes and other basic equipment were not available. Respondents identified hysterectomy, cone biopsy, and LEEP as the most effective treatments of severe dysplasia. Overall, these findings suggest a need for more efficient use of scarce medical resources. Cryotherapy and LEEP, combined with proper follow-up, are particularly appropriate for developing countries in cases where invasive cancer and endocervical involvement have been ruled out.