Reference Manual - IARC Screening Group

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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
Treatment and Followupregardless of the procedure used. Other factors that increased the risk ofrecurrence at least two-fold were:• age over 30 years,• positive HPV test (types 16 or 18), and• previous treatment for CIN.CryotherapyCryotherapy involves freezing the cervix, using either compressed carbondioxide or nitrous oxide gas as the coolant. Treatment consists ofapplying the coolant continuously for 3 minutes, allowing the lesion tothaw for 5 minutes, and then applying coolant for another 3- to 5-minutefreeze. This procedure, called the “double freeze” technique, is easilyperformed without anesthesia. Cure rates are 10% better using a doubleversus a single freeze technique (Bryson, Lenehan and Lickrish 1985;Schantz and Thormann 1984). When performed as described, a cure rateof nearly 90% has been reported for lesions as advanced as CIN III.Table 7-3 lists a number of studies reporting the effectiveness ofcryotherapy (overall cure and CIN III cure rates). An extensive literaturereview on cryotherapy published in 2003 confirms its overall utility andsafety (ACCP 2003).Table 7-3. Cryotherapy for Treatment of CIN: Key Studies with at Least 1 Yearof FollowupSTUDYMitchell et al.(1998)Andersen andHusth (1992)Olatunbosumet al. (1992)Berget et al.(1991)Draeby-Kristiansen etal. (1991)Wright andDavies (1981)Hemmingsonet al. (1981)NUMBEROFWOMENOVERALLCURERATE (%)CIN IIICURERATE (%)FOLLOWUPIN YEARS139 76 a N/C b 1.5 (mean)261 84 78 7 (mean)70 90 81 593 96 90 296 92 86 10152 86 75 1 to 3.5181 84 82 5 to 8a Randomized trial differences in cure rates for cryotherapy and LEEP notstatistically significant.b Not calculated.Source: Bishop, Sherris and Tsu 1995.The main advantages of cryotherapy are that the equipment needed issimple, the procedure is easy to learn and the procedure does not requireCervical Cancer Prevention Guidelines for Low-Resource Settings 7-3
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Cervical Cancer PreventionGuideline
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TABLE OF CONTENTSPREFACE AND ACKNOW
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How to High-Level Disinfect Surgica
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Table C-2Figure C-1Preparing a Dilu
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PREFACE AND ACKNOWLEDGMENTSThis ref
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ONEINTRODUCTIONMAGNITUDE OF THE PRO
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IntroductionFigure 1-3. Incidence o
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Introductionprevalence areas, a sta
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Table 1-2. Reduction in Cumulative
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Introductiontheir performance was t
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Introductionlesions, or a false pos
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IntroductionCompared to other metho
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Introductionsignificantly to women
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IntroductionBelinson JL et al. 2001
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IntroductionMitchell MF et al. 1998
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IntroductionYlitalo N et al. 1999.
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TWOHUMAN PAPILLOMAVIRUS AND CERVICA
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Human Papillomavirus and Cervical C
Page 41 and 42: Human Papillomavirus and Cervical C
Page 47 and 48: THREEPATHOPHYSIOLOGY OF CERVICAL CA
Page 49 and 50: With the onset of puberty, whichis
Page 51 and 52: Pathophysiology of Cervical Cancerp
Page 53 and 54: Pathophysiology of Cervical CancerP
Page 55 and 56: Pathophysiology of Cervical CancerI
Page 57 and 58: Pathophysiology of Cervical CancerR
Page 59 and 60: FOURTALKING WITH WOMEN ABOUTCERVICA
Page 61 and 62: Talking with Women About Cervical C
Page 69 and 70: FIVEPREVENTING INFECTIONS INHEALTHC
Page 71 and 72: Preventing Infections in Healthcare
Page 79 and 80: SIXCLIENT ASSESSMENT AND VIA TESTIN
Page 81 and 82: Client Assessment and VIA TestingFi
Page 83 and 84: Client Assessment and VIA TestingIN
Page 85 and 86: Client Assessment and VIA Testingst
Page 87 and 88: Client Assessment and VIA Testingsp
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Page 91: SEVENTREATMENT AND FOLLOWUPBACKGROU
Page 95 and 96: Treatment and FollowupFigure 7-1. L
Page 97 and 98: Treatment and FollowupTable 7-6. Co
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Page 101 and 102: Treatment and Followup• Regulator
Page 103 and 104: Treatment and FollowupCRYOTHERAPY P
Page 105 and 106: Treatment and FollowupStep 6 Point
Page 107 and 108: Treatment and FollowupNote: When CO
Page 109 and 110: Treatment and FollowupStep 5Advise
Page 111 and 112: Treatment and FollowupBerget A, B A
Page 113 and 114: APPENDIX ATESTS FOR CERVICAL CANCER
Page 115 and 116: Tests for Cervical Cancer Screening
Page 121 and 122: APPENDIX BSCREENING TEST QUALITIES
Page 123 and 124: Screening Test Qualities and Their
Page 125 and 126: APPENDIX CINFECTION PREVENTION PROC
Page 127 and 128: Infection Prevention Processesfor m
Page 129 and 130: Infection Prevention Processeswith
Page 131 and 132: Infection Prevention ProcessesFigur
Page 133 and 134: Table C-4. Preparing and Using Chem
Page 135 and 136: Infection Prevention ProcessesStora
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Page 139 and 140: APPENDIX DTECHNICAL OVERVIEW OF THE
Page 141 and 142: Technical Overview of the Cryothera
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Figure D-5. Removing Protector Tube
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Technical Overview of the Cryothera
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Figure D-11. Gas Cylinder Secured t
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APPENDIX ETROUBLESHOOTING WITH THEC
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Table E-1. Following-Up on Commonly
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APPENDIX FPROCESSING SURGICAL GLOVE
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Processing Surgical GlovesTable F-1
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Processing Surgical GlovesSTEP 10:
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APPENDIX GPERFORMING BREAST AND PEL
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Performing Breast and Pelvic Examin
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Figure G-2. Breast Puckering or Dim
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Figure G-5. Checking for Nipple Dis
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Figure G-18. Speculum in Place with
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APPENDIX HPERCEIVED BARRIERS TO PRO
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AVAILABILITY OF BASIC SUPPLIES AND
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GLOSSARYAcetic AcidAcetowhite Chang
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PatulousSquamocolumnarJunction (SCJ
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ADDITIONAL READINGAlliance for Cerv
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Reference Manual - IARC Screening Group

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