OJOG  Vol.3 No.3 , May 2013
Same day colposcopic examination and loop electrosurgical excision procedure (LEEP) presents minimal overtreatment and averts delay in treatment of cervical intraepithelial neoplasia in Kenyatta National Hospital, Kenya

Background: Screening for cancer of the cervix at Kenyatta National Hospital (KNH), follows the recommended three-step strategy; Papanicolaou (Pap) smear, colposcopy/biopsy and loop electrosurgical excision procedure (LEEP)/biopsy. This approach poses the following challenges: multiple clinic visits, costly, time consuming, long turnaround time to treatment, non-compliance and loss-to-follow-up. Objective: To determine the agreement between histologies following colposcopy and LEEP amongst women in KNH as a forerunner for opportunity to shift from the three-step approach to the two-step “see and treat” (same-day colposcopy and LEEP) approach. Methods: This was a retrospective descriptive cohort of Women who underwent LEEP procedure between January 2008 and 31st December 2010 following the three-step approach at KNH, Kenya. Results: A total of 124 patients out of the 132 patients who underwent LEEP were included in the analysis. The 8 patients excluded had missing files. HIV infected, uninfected or unknown women are similar socio-demographically. The mean (SD) age for the HIV infected, uninfected and unknown is 37 (6), 33 (10) and 35 (9) years respectively. Colposcopic and LEEP biopsy histology within patients demonstrated a high weighted kappa statistics agreement of 84%. LEEP increased diagnosis of invasive cancer. Patients had a median (IQR) 5 (4 - 6) clinic visits from Pap smear to LEEP treatment. It took median (IQR) 55 (27 - 116) days between Pap smear to colposcopy result and 167 (101 - 276) days between Pap smear results to LEEP treatment. If a LEEP procedure were to be performed in this cohort of women on the same day of the colposcopy biopsy a median (IQR) 77 (55 - 137) days could have been saved. Conclusion: There is a high agreement between colposcopy and LEEP biopsies in our setting offering a window of opportunity to perform “See and Treat” same-day colposcopy and LEEP treatment procedure, skipping the colposcopy biopsy stage.

Cite this paper
Muruka, K. , Nelly, M. , Gichuhi, W. , Anne-Beatrice, K. , Eunice, C. and Rose, K. (2013) Same day colposcopic examination and loop electrosurgical excision procedure (LEEP) presents minimal overtreatment and averts delay in treatment of cervical intraepithelial neoplasia in Kenyatta National Hospital, Kenya. Open Journal of Obstetrics and Gynecology, 3, 313-318. doi: 10.4236/ojog.2013.33058.
[1]   Li, Z.G., Qian, D.Y., Cen, J.M., Chen, G.D. and Shu, Y.H. (2009) Three-step versus “see-and-treat” approach in women with high-grade squamous intraepithelial lesions in a low-resource country. International Journal of Gynecology & Obstetrics, 106, 202-205. doi:10.1016/j.ijgo.2009.04.011

[2]   Bosch, F.X., Manos, M.M., Munoz, N., et al. (1995) Prevalence of human papillomavirus in cervical cancer: A worldwide perspective. Journal of the National Cancer Institute, 87, 796-802. doi:10.1093/jnci/87.11.796

[3]   De Andrade, A.C., Luz, P.M., Velasque, L., et al. (2010) Factors associated with colposcopy-histopathology confirmed cervical intraepithelial neoplasia among HIV-infected women from Rio De Janeiro, Brazil. PLoS One, 6, e18297. doi:10.1371/journal.pone.0018297

[4]   Frisch, M., Biggar, R.J. and Goedert, J.J. (2000) Human papillomavirus-associated cancers in patients with human immunodeficiency virus infection and acquired immunodeficiency syndrome. Journal of the National Cancer Institute, 92, 1500-1510. doi:10.1093/jnci/92.18.1500

[5]   Clifford, G.M., Polesel, J., Rickenbach, M., et al. (2005) Cancer risk in the Swiss HIV Cohort Study: Associations with immunodeficiency, smoking, and highly active antiretroviral therapy. Journal of the National Cancer Institute, 97, 425-432. doi:10.1093/jnci/dji072

[6]   Cho, H. and Kim, J.H. (2009) Treatment of the patients with abnormal cervical cytology: A “see-and-treat” versus three-step strategy. Journal of Gynecologic Oncology, 20, 164-168. doi:10.3802/jgo. 2009.20.3.164

[7]   Goldie, S.J., Kuhn, L., Denny, L., Pollack, A. and Wright, T.C. (2001) Policy analysis of cervical cancer screening strategies in low-resource settings: Clinical benefits and cost-effectiveness. The Journal of the American Medical Association, 285, 3107-3115. doi:10.1001/jama.285.24.3107

[8]   Katz, I.T. and Wright, A.A. (2006) Preventing cervical cancer in the developing world. The New England Journal of Medicine, 354, 1110. doi:10.1056/NEJMp068031

[9]   Aue-Aungkul, A., Punyawatanasin, S., Natprathan, A., Srisomboon, J. and Kietpeerakool, C. (2011) “See and treat” approach is appropriate in women with high-grade lesions on either cervical cytology or colposcopy. Asian Pacific Journal of Cancer Prevention, 12, 1723-1726.

[10]   Kyrgiou, M., Tsoumpou, I., Vrekoussis, T., et al. (2006) The up-to-date evidence on colposcopy practice and treatment of cervical intraepithelial neoplasia: The cochrane colposcopy & cervical cytopathology collaborative group (C5 group) approach. Cancer Treatment Reviews, 32, 516-523. doi:10.1016/j.ctrv.2006.07.008

[11]   Luesley, D. and Leeson, S. (2010) Colposcopy and Programme Management: Guidelines for the NHS Cervical Screening Programme. 2nd Edition, Public Health England, London.

[12]   Kietpeerakool, C., Srisomboon, J., Khunamornpong, S., Siriaunkgul, S. and Sukkawattananon, W. (2007) How can the overtreatment rate of “see and treat” approach be reduced in women with high-grade squamous intraepithelial lesion on cervical cytology? Asian Pacific Journal of Cancer Prevention, 8, 206-208.

[13]   Monsonego, J., Bosch, F.X., Coursaget, P., et al. (2004) Cervical cancer control, priorities and new directions. International Journal of Cancer, 108, 329-333. doi:10.1002/ijc.11530

[14]   Cuschieri, K.S., Cubie, H.A., Whitley, M.W., et al. (2005) Persistent high risk HPV infection associated with development of cervical neoplasia in a prospective population study. Journal of Clinical Pathology, 58, 946-950. doi:10.1136/jcp.2004.022863

[15]   Palefsky, J.M. (2003) Cervical human papillomavirus infection and cervical intraepithelial neoplasia in women positive for human immunodeficiency virus in the era of highly active antiretroviral therapy. Current Opinion in Oncology, 15, 382-388. doi:10.1097/00001622-200309000-00007

[16]   Mandelblatt, J.S., Fahs, M., Garibaldi, K., Senie, R.T. and Peterson, H.B. (1992) Association between HIV infection and cervical neoplasia: Implications for clinical care of women at risk for both conditions. AIDS, 6, 173-178. doi:10.1097/00002030-199202000-00005

[17]   Parham, G.P., Sahasrabuddhe, V.V., Mwanahamuntu, M.H., et al. (2006) Prevalence and predictors of squamous intraepithelial lesions of the cervix in HIV-infected women in Lusaka, Zambia. Gynecologic Oncology, 103, 1017-1022. doi:10.1016/j.ygyno.2006.06.015

[18]   Moodley, J.R., Hoffman, M., Carrara, H., et al. (2006) HIV and pre-neoplastic and neoplastic lesions of the cervix in South Africa: A case-control study. BMC Cancer, 6, 135. doi:10.1186/1471-2407-6-135