Reference Manual - IARC Screening Group

Treatment and Followup• offers excellent cure rates with a good cost-benefit ratio for treatmentof lesions that have a low likelihood of being cancerous.For most countries with limited resources, cryotherapy, either alone or incombination with LEEP (provided at a referral center), is the bestoutpatient option.OUTPATIENT TREATMENT PROCEDURESUntil recently, which of these outpatient treatment options is mosteffective has been disputed. A randomized clinical trial conducted byMitchell and colleagues (1998) provides strong evidence thatcryotherapy, laser vaporization and LEEP are not significantly differentin effectiveness (success rates ranging from 74 to 83%). In order toreduce bias in this study, all patients were classified according to the size(area) and type (histologic grade) of the lesion.As shown in Table 7-2, differences in effectiveness, persistence,recurrence and complications were not statistically significant. Inaddition, to more accurately determine the recurrence rate, women werefollowed up for a longer time than in any previous study of this type.The main factor that was associated with treatment failure was lesionsize, and it was clear that when large lesions (for example, lesions thatmight be too large for the cryoprobe to reach) were present, all threetreatment methods (cryotherapy, LEEP and laser) were more likely to failthan when smaller lesions were present.Table 7-2. Comparison of Treatment OptionsEffectiveness(at 1 year)• Persistence• RecurrenceCryotherapy(n = 139)76%7%19%Laser Vaporization(n = 121)83%4%13%LEEP(n = 130)84%4%13%Complications 2% 4% 8%Bleeding(peri- andpostoperative)0% 1% 3%Source: Mitchell et al. 1998.In fact, when the size, type and location of the lesion were taken intoaccount, only the association between lesion size and the rates ofpersistence was statistically significant. Women with lesions coveringmore than two-thirds of the surface of the cervix were 19 times morelikely to have persistent disease than those with smaller lesions,7-2 Cervical Cancer Prevention Guidelines for Low-Resource Settings