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Managing Precancerous Cervical Disease

The management approach recommended in this manual is based on the principle that testing and treatment can take place during the same visit and that both can take place at the lowest level of the healthcare system where the majority of at-risk women will go at least once in their lives. Given that healthcare providers most often posted to such levels are nurses or nurse-midwives, this approach assumes that both testing and treatment can be performed competently by these or similar cadres of healthcare personnel. A major advantage of the test and immediately treat approach is that it offers a potential solution to the problem of loss-to-followup (generally at least 20%) that occurs as a consequence of delays in receiving laboratory-based screening results (e.g., between Pap smear processing and return of lab results to local clinic) or referrals to a different facility for treatment.

Currently, a test and treat approach to managing precancerous lesions is increasingly being used when women undergo colposcopic examination for a previous positive Pap smear. That is, if colposcopy confirms the results of the Pap smear, many practitioners will proceed to treatment without waiting for histological confirmation. To date, there is no large-scale experience using a test and treat approach in conjunction with VIA. Data from a recent South Africa study using VIA (Megevand et al 1996), however, suggest that a VIA-based test and treat approach could work. In this study, 76 (3.1%) out of 2,426 women screened were positive on VIA. Of these, 61 (80.3%) had SIL on Pap smear, 65 (85.5%) on colposcopy and 55 (72.4%) on biopsy. In other words, 72% of women who tested positive with VIA had a confirmed precancerous lesion on histology.

Treating Women with Unconfirmed Disease 

For many developing countries, determining how best to test and treat women on a large scale remains a problem. While the specificity of VIA is relatively high, the positive predictive value (PPV) even in a high prevalence setting was only about 20%. This means that four of every five women in that population who tested positive on VIA did not have a high-grade (CIN III) lesion and could potentially have been treated (University of Zimbabwe/JHPIEGO Cervical Cancer Project 1999). Because of the low morbidity associated with cryotherapy, however, as well as its other advantages, treatment of all women with an abnormal VIA test (test-positive) could be considered acceptable because of the potential to significantly reduce future cervical cancer risk (see below). Also, if the patient is unlikely to return for followup, some degree of over treatment may be justified.

While this "over treatment" may translate into unnecessary costs to the healthcare system as well as unnecessary discomfort and potential side effects experienced by the women, in a low-resource environment most women are unlikely to ever have the opportunity to have a diagnosis confirming their true disease state. In such an environment, offering treatment for suspicious precancerous lesions, which potentially represent either no disease or only low-grade (CIN I) lesions, could be considered a preventive measure against the later development of cervical cancer. This is because cryotherapy has the potential to significantly reduce the probability of developing cancer or precancerous lesions for at least 5 to 10 years in women determined to be at high risk (Lonky et al 1997). Also, in many settings (especially third world settings) it is standard practice to use cryotherapy or electrocautery for treatment of chronic cervicitis. In such instances, either procedure results in resolution of the cervicitis and reduction of cervical ectopy, which could have a long-term protective effect against acquiring both HPV and HIV. Lastly, recurrences after cryotherapy are more likely to involve one or more types of HPV other than the one present before treatment. By contrast, those seen following excisional treatment (e.g., LEEP) tend to be of the same type (Nuovo, Banbury and Calayag 1991). Thus, if a woman who is VIA test-positive is carrying one of the high-risk HPV types and is treated by cryotherapy, this treatment could eliminate her existing HPV type and possibly prevent her from ever developing a precancerous lesion.

Association Between HIV and Precancer of the Cervix (CIN) 

Data on the association between HIV and CIN are increasingly convincing. Two studies, both from high HIV prevalence areas, demonstrate an association between HIV and CIN (Table 8).

Table 8. Risk of CIN Among Women with HIV Compared to HIV Negative Women 

Author	Country	Date	Odds Ratio  (of having)
Miotti et al	Malawi	1996	2.2 (1.10-4.8)
Maggwa et al	Kenya	1993	2.69 (1.29-5.49)

The implications of these studies on the outpatient treatment for CIN are significant. For example:

• Should women who are known to be HIV positive and who have cervical dysplasia be offered treatment for CIN? If treatment is not offered or accepted, will disease progress more quickly and the chance to prevent development of cancer be lost?
• Will treatment of CIN in HIV-positive women be as effective? Will recurrence rates be greater? Will complication rates be higher?

Clearly, more studies on the role of HIV infection as it relates to increased susceptibility to CIN and the effectiveness of treatment for CIN are needed. In addition, there is preliminary evidence that women who are seropositive for HIV have increased shedding of HIV following treatment (e.g., cryotherapy or LEEP) and during the healing process (Wright 1999). Therefore, because of the increasing prevalence of HIV/AIDS in many countries coupled with the limited availability of HIV testing to reduce risks of HIV transmission before providing treatment, women need to be counseled to either:

• abstain from sexual intercourse for up to 4 weeks (or until the vaginal discharge is gone) following treatment, or
• use condoms if they have intercourse.

Links to Other Reproductive Health Services

Linking cervical cancer screening and treatment services with other reproductive health services is essential and logical, yet these services remain distinctly separate in much of the world. This separation leaves women without access to reproductive healthcare and contributes significantly to women’s poor overall health status. The integration of cervical cancer prevention with existing reproductive health services clearly answers the broad-based call for making it "accessible through the primary healthcare system, to all individuals of appropriate ages as soon as possible" (ICPD 1994). Testing, treatment and the necessary followup care for gynecological cancers is considered an integral part of reproductive health by a range of international organizations and was included in the Cairo Programme of Action (Jones 1999).

Overall, it is quite clear that the way to reduce the incidence of cervical cancer is to:

• screen a large proportion of women at high risk at least once using appropriate techniques, and
• treat women who test positive for possible high-grade dysplasia (VIA positive) by simple outpatient techniques.

Table 9 provides information on the cervical cancer screening and treatment services appropriate to different healthcare facility levels and the need for community involvement to promote awareness of cervical cancer prevention. There is now general agreement that the interventions needed to save the lives and preserve the health of women must form part of a broad strategy to improve reproductive health. This strategy implies that interventions should be applied holistically within a general health context that promotes equity in access to and quality of care. Finally, in order to make the best use of existing resources, these essential services should be integrated into and operate through the existing primary healthcare systems.

As shown in Table 9, the district-level health system is the basic unit for planning and implementing the interventions outlined in this manual in developing countries. The district provides a mechanism for linking families and communities with health centers and hospitals in a functional, cost-effective manner. Through district-based implementation of interventions, it is possible to ensure that health services are available as close as possible to people’s homes. Treatment procedures for precancerous disease of the cervix should be carried out by the healthcare worker closest to the community who is competent to perform them safely and effectively. The person best equipped to provide community-based, appropriate technology, and safe and cost-effective care to women during their reproductive lives is usually the nurse or midwife who works in the community near the women she serves. She can ensure that the healthcare system serves women fairly and effectively and that the health services available respond to the needs of the people.

Table 9. Provision of Cervical Cancer Prevention Services (by Level of Healthcare Facility and Staff) 

Level	Staff May Include	Services	Requirements
Community	Community leadersb  Women’s groups Community health workers (CHWs)	Recognition of importance of cervical cancer  Referral to facilities where screening is available	Community mobilization  IEC (awareness): radio messages, pamphlets and other public information
Primary Level a (Primary Health, Family Planning or Polyclinics)	Nurses, midwives or physician assistants (PAs)	Above activities, plus:  Counseling (sexual and cancer risk)  Visual inspection with acetic acid (VIA)  Treatment with cryotherapy or referral	Pelvic exam  Infection prevention  Basic equipment, CO2 and supplies
First Referral Level (District Hospital)	Above plus:  Medical officers  Nurse midwives  (Ob/Gyn specialists)	Above activities (VIA, cryotherapy) plus:  VIAM or HPV testing  LEEP or cone biopsy  Simple hysterectomy	Limited specialty hospital  General anesthesia  LEEP machine and thin wire loops
Secondary and Tertiary Level (Regional or Referral Hospital)	Above plus:  Ob/Gyn specialists  (Ob/Gyn oncologists)  (Radiotherapist)	Above activities, plus: Full diagnostics (colposcopy, biopsy, HPV)  Radical surgery  Radiotherapy	Full specialty hospital  Radiation therapy services  Chemotherapy

^aLevel where VIA and cryotherapy appropriate 
^bKnowledgeable people, local nongovernmental organizations and private groups  

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