As per GLOBOCON 2020 data, Asia has more than half of the world’s burden of cervical cancer. Keeping in mind the vast population and limited resources in low and middle-income countries, modalities like “Screen and Treat” following a positive screening test and “See and Treat” following colposcopy have been devised. This minimizes the number of visits needed with better follow up rates.
See and Treat approach after colposcopy in VIA positive women reduces the overtreatment of Screen & Treat as benign lesions like ectropion and squamous metaplasia will be excluded after Colposcopy. Since there is no grading for VIA and owing to its low specificity, the decision for SEE AND TREAT approach will need to be made by the Colposcopic score.
Most of the women in our study were married before 20 years (79.21%) with onset of sexual activity after marriage. This was comparable with studies from Asia where majority of the women were married around 18 years of age.11,12 Early age at sexual activity corresponds to a higher risk of having a pre-invasive lesion of cancer cervix and eventually a higher risk of developing cancer cervix as has been shown in many studies.3
Women in the present study had a maximum parity of 5; majority were parity 2 (44.55%). The mean parity observed was 2.58 (SD 1.03). In a similar Indian study, it was observed that the majority of women had parity 3 (43.6%) followed by 2 (39.3%) with the range being from 1 to 6.13 In another study all women with either a positive VIA and/or a positive Pap smear were of parity two or above.12 These studies showed multiparity to have more association with development of CIN.
The commonest presenting complaint noted in our women was pain in lower abdomen. The low rate of post-LLETZ complications may be due to prophylactic prescription of oral antibiotics to all women in the present study ( as per IARC guidelines). Though LLETZ was carried out without direct Colposcopic vision, resection margin was positive in only 4 out of 101 (3.96%) women; rest 97 women had a negative resection margin status. Of the women with positive resection margin, two had CIN1, 1 had CIN2 and 1 had CIN 3. One of the women with CIN1 on her HPE report also had abnormal uterine bleeding (AUB) and eventually underwent hysterectomy. One of the women had CIN3 on her HPE report with positive resection margin status and was explained the options; however she opted for hysterectomy. The remaining two women were kept on follow-up after discussion in MDT (Multidisciplinary team) meetings and informed consent.
As per the guideline of the European Federation for Colposcopy and Pathology of the Lower Genital Tract (EFC), the standard for women who underwent treatment under SEE and TREAT approach was taken as proven Cervical Intraepithelial Neoplasia (CIN) on histology for ≥ 90% of them.14 As per NHSCSP, for quality control, See-and-Treat management should be used for CIN2/3 or high-grade cervical glandular intraepithelial neoplasia which should be present in ≥ 90% of the excised specimens.15
NHSCSP has defined overtreatment if no CIN or CIN 1 was found in the LLETZ specimen. As per this definition, 34.65% would have overtreatment. None of the women in our study had normal histology, indicating that treatment was needed albeit later and was considered effective. In a low resource setting and in the absence of a follow up system, this could be considered as acceptable treatment. Using the presence of ≥ CIN 2 as adequacy of See and Treat approach, Singla et al had an overtreatment rate of 12.5% in their study using SVA in 16 women.13 Remko et al observed an overtreatment rate of 18.1% by defining overtreatment in their study as HPE report CIN 1 or less.16 Similar definition was used by Nessa et al in their study and they observed an overtreatment rate of 51.1%.11 This could be due to the differences in the study population and screening methods.
In a limited resource setting, See and Treat approach is very useful. The entire process of screening, colposcopy and treatment can be completed in one or two visits to minimize loss to follow up and delayed treatment. This decreases the anxiety following a screen positive test and provides psychological benefits. As centers for Colposcopy and treatment facilities are limited in lower income countries, this approach helps reduce the costs and time involved on an already overburdened healthcare system.
The present study being a single-center, prospective interventional study has its limitations. Though the study population was similar to the local population but the findings cannot be extrapolated for the generalized population. Only woman coming to the OPD were included in the study instead of general population. A larger multi-centric study would help in setting the cut-off.
In see and treat approach, treatment in dependent on colposcopy examination which may have variation of interpersonal skills. Extensive training in colposcopy can help decrease this limitation. In future, artificial intelligence (AI) could help in making a decision. See and Treat approach includes both ablation and excision based on the Colposcopic score. As an ablative method, cryotherapy is simple, safe and easy to perform. Lower unavailability of N2O and CO2 cylinders and leakage of equipment’s are recurrent problems.
Thermocoagulation is not yet widely available in low and middle income countries. Electrosurgical equipment are widely available and LLETZ is an easy to learn and safe to perform procedure. It can be done as a day-care procedure under local anesthesia thus excision procedures have wider application. Proper selection can minimize overtreatment. In the present study, advantages outweigh the disadvantages as the approach was efficacious with 96.04% women having complete excision and minimal short term complications.
To conclude, SEE AND TREAT approach when based on an appropriate criteria proves to be of great value in the management of pre-invasive lesions of cervical cancer and has acceptable efficacy. It saves time and financial resources of both health care providers and of the women who undergo treatment as per this approach.
See and Treat approaches using excision and ablation can be applied practically to help us achieve our goal of Elimination of cervical cancer by 2030.We recommend a SEE AND TREAT approach based on Colposcopic Swede score with a cut-off of ≥ 5 in VIA based screening for excisional treatment