SAN FRANCISCO--For physicians who treat cervical lesions, abandonment of traditional colposcopy for one-step loop excision procedures could lead to excessive treatment and excessive expense, Philip Roland, MD, said at the Society of Gynecologic Oncologists meeting.
Published reports have suggested that immediate LLETZ (large loop excision of the transformation zone) may be performed at the initial patient visit, providing diagnosis and treatment in a single procedure, said Dr. Roland, a GYN Oncology Fellow at the University of Alabama at Birmingham.
Proponents of immediate LLETZ see it as an effective way to save time and money by eliminating the expertise needed for colposcopy, he said.
However, a decision analysis study by Dr. Roland and his colleagues at Birmingham showed that colposcopy followed by observation of mild dysplasia and treatment of moderate to severe dysplasia was the most cost effective of four possible management scenarios and offered the least opportunity for overtreatment of lesions.
The results did indicate that a subset of patients with high-grade squamous intraepithelial lesion (SIL)/severe dysplasia may be better candidates for immediate LLETZ, he said.
The researchers constructed clinical algorithms for four different philosophies for the management of a patient with an abnormal Pap smear, and used decision analysis methodology to evaluate the expense of each algorithm and the potential for excessive treatment. The algorithms were as follows:
- Colposcopy with treatment of all biopsy-proven dysplasia (cryotherapy of mild dysplasia and LLETZ of moderate to severe dysplasia).
- Colposcopy with observation of biopsy-proven mild dysplasia (a spontaneous regression rate of 50% at 1 year was assumed) and treatment of moderate dysplasia (cryotherapy) and severe dysplasia (LLETZ).
- Colposcopy of Bethesda System low-grade SIL and immediate LLETZ of high-grade SIL.
- Immediate LLETZ of all high-grade SIL and low-grade SIL Pap smears.
These algorithms were theoretically applied to 614 dysplasia patients at the Birmingham colposcopy clinic, based on referral Pap smear results: 47% had smears showing low-grade SIL; 52% showed high-grade SIL.