Elsevier

The Lancet Oncology

Volume 6, Issue 1, January 2005, Pages 43-50
The Lancet Oncology

Review
See-and-treat strategy for diagnosis and management of cervical squamous intraepithelial lesions

https://doi.org/10.1016/S1470-2045(04)01712-7Get rights and content

Summary

In a see-and-treat protocol, patients referred for colposcopy because of an abnormal Pap smear in cervical-cancer screening can be treated by loop excision, without biopsy, during one visit to the clinic. However, overtreatment in the see-and-treat strategy has been reported to be 1·2–83·3% for low-grade squamous intraepithelial lesions (SIL) and to be 13·3–83·3% for high-grade SIL. Range of overtreatment narrowed to 4·0–23·5% for those with normal pathology and to 18·0–29·4% for those with normal or low-grade pathology when calculation of overtreatment was restricted to patients diagnosed with high-grade SIL on colposcopy and referral Pap smear. Most common treatment complications are bleeding and infection. Nonetheless, the strategy has become accepted internationally: low costs, decreased patient anxiety, and increased compliance make it appealing, especially in settings with limited health resources, and for patients at risk of not being treated in a timely manner or of not returning for a second appointment. Mathematical modelling may give information about the appropriateness and usefulness of this treatment while the results of long-term clinical trials are awaited.

Section snippets

Advantages and disadvantages

The see-and-treat strategy is considered as a serious alternative treatment in specific circumstances when compliance of patients,1, 2 treatment costs,3, 4, 5 and anxiety by patients6 might interfere with the effectiveness of treatment. In particular, the strategy may be recommended when the patient is unlikely to return for follow-up care, as might occur in urban and poor populations and especially in view of time lags before a colposcopy appointment is scheduled. The patient's anxiety may be

History of see-and-treat strategy

The development of this strategy is linked to knowledge of the natural history of the disease and the availability of tools for effective treatment. To date, dysplasias are known to represent a range of neoplasms, from changes induced by infection with human papillomavirus to in-situ carcinoma.

Clinicians began to consider the see-and-treat strategy after general acceptance that dysplasia is the precursor of in-situ carcinoma and that local treatment of the cervix is appropriate after invasive

Outpatient treatment for high-grade SIL

The accepted method of treatment for high-grade SIL is either ablation or excision. Ablation is done by use of electrocautery, cryosurgery, or laser surgery.24 Electrocautery was first used in 1968 by Richart and Sciarra,25 who reported on a series of patients treated with electrocoagulation 2 weeks after colposcopy and punch biopsy. Cryosurgery was first used in 1972 by Crisp,26 and later in that year by Tredway,27 to treat outpatients, and has been well accepted since then for treatment of

Clinical trials of see-and-treat

In 1990, Bigrigg and colleagues7 first described a see-and-treat strategy by use of a low-voltage diathermy loop given in one visit (table 1). Patients were referred to the colposcopy clinic because of abnormal smears, and received LLETZ as outpatients under local anaesthesia in one visit. Reported overtreatment was 27·9% if the threshold was a pathology report of low-grade SIL or negative result, and 4·7% if the pathology report was negative. Keijser and co-workers33 treated patients diagnosed

See-and-treat strategy in low-resource settings

Cervical cancer remains one of the most common health problems in developing countries. Every year more than 400000 women worldwide are found to have this disease.40 By 2000, the highest burden of the disease was reported in Latin American and African countries, and the highest age-standardised prevalence of cervical cancer were in Haiti (93·85 per 100 000 women) and Tanzania (61·43 per 100 000 women).41 By contrast, age-standardised prevalence of cervical cancer is 7·84 per 100 000 women in

Improvement of overtreatment

As the see-and-treat strategy proved to be feasible and was accepted by physicians and patients, quality indicators were included in the Standards and Quality in Colposcopy.19 The main aim was to achieve 90% correct treatment for patients undergoing the see-and-treat strategy, with the threshold for correct treatment set by a histological report of any CIN.

To assess whether these criteria were met, Smith and co-workers48 did a retrospective chart review of a colposcopy clinic in a teaching

Two-session informed consent

Das and Elias9 described the ethical issues in gaining informed consent from patients participating in a trial on a see-and-treat strategy. In a prospective study of 248 participants to compare the see-and-treat strategy with usual care, patients underwent a two-step informed-consent procedure. At colposcopy, all patients received detailed information about the procedure and treatment options, including the advantages or disadvantages of diagnosis and of having loop treatment during the same

Economic issues

Fung and co-workers3 assessed the potential of the see-and-treat strategy to save costs by assessment of data on histological results of LEEP, punch biopsies, and colposcopy diagnoses from a usual-care trial; they then modelled a decision tree to compare the costs of usual care and with those of the see-and-treat strategy for a hypothetical group of 95 patients. The cost savings were US$53 000 per year if the see-and-treat strategy was used for all patients who had a colposcopy diagnosis of

Future research

The issues of effective treatment for CIN and of how to compare see-and-treat with usual care should be considered from several perspectives. Long-term clinical outcomes, especially survival, are the most crucial objectives; however, assessment of survival in patients with cancer in a randomised clinical trial may not be practical because of the long duration of such a study. Alternative outcome measures are needed, which could be based on cytological or histological indicators—eg, cytological

Search strategy and selection criteria

Data for this review were identified by searches of MEDLINE, Current Contents, PubMed, and the references of relevant articles using the search terms “cervical cancer”, “cervical dysplasia”, “cervical intraepithelial neoplasia”, “LEEP”, “LLETZ”, “LETZ”, “loop excision”, “one session”, “one visit”, “single session”, and “see-and-treat”. Only papers published in English between 1980 and February, 2004 were included, as well as relevant references from the authors' personal collections. Papers

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