CHAPTER 4: SCREENING FOR CERVICAL CANCER

Chapter 5: Diagnosis and Management of Precancer 129MANAGEMENT OPTIONS FOR PRECANCERStandard practice for diagnosis: colposcopy and biopsyBiopsy performed with the aid of a colposcope is the standard method for diagnosis ofcervical precancer and preclinical invasive cancer. For satisfactory biopsy, the entiretransformation zone must be visible to allow the degree of abnormality to be assessedand to identify areas for biopsy. If the SCJ or the transformation zone is partially orentirely inside the cervical canal, an endocervical speculum examination should bedone to visualize any lesions in their entirety, and an endocervical curettage (ECC)done to obtain a sample for histopathological examination. If precancer is diagnosed, itshould be treated using cryotherapy, LEEP or cold knife conization.Barriers to colposcopy and biopsy servicesIdeally, colposcopy and biopsy should be used to manage women with a positivescreening test, but there are frequently barriers to the establishment of these services:• Colposcopes are sophisticated, relatively expensive instruments.• Specialized training and experience are required to maintain proficiency.• Biopsy samples need to be transported to a histopathology service, which may bedifficult in low-resource settings.5Chapter 5: Diagnosis and Management of PrecancerAlternative approaches to diagnosis and treatment“Screen-and-treat” approachAnnexIn this approach, treatment decisions are based on the results of the 4bscreening test, without a prior diagnostic test. Most screen-positivewomen can be treated with cryotherapy at primary health care level Screen and treatat the time of screening; this could reduce loss to follow-up and havean impact on cervical cancer control. However, tissue will not be available for laterexamination. This approach is discussed in more detail in Annex 4b.Colposcopy-based “see-and-treat” approachTo address the issue of potential overtreatment with the screen-and-treat approach, anintermediate approach can be used. Patients with a positive screen (on Pap smear, VIA,VILI, or HPV) can be examined with a colposcope. If a precancerous lesion is detected,it can be treated immediately. If cryotherapy is the chosen treatment, colposcopicallydirectedbiopsies can be taken before treatment to confirm the diagnosis following theprocedure. If LEEP is used, tissue will be available as a result of the procedure. Thisapproach is contingent on the availability of equipment and trained and experiencedproviders.