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.
SAN FRANCISCO--For physicians who treat cervical lesions, abandonmentof traditional colposcopy for one-step loop excision procedurescould lead to excessive treatment and excessive expense, PhilipRoland, MD, said at the Society of Gynecologic Oncologists meeting.
Published reports have suggested that immediate LLETZ (large loopexcision of the transformation zone) may be performed at the initialpatient visit, providing diagnosis and treatment in a single procedure,said Dr. Roland, a GYN Oncology Fellow at the University of Alabamaat Birmingham.
Proponents of immediate LLETZ see it as an effective way to savetime and money by eliminating the expertise needed for colposcopy,he said.
However, a decision analysis study by Dr. Roland and his colleaguesat Birmingham showed that colposcopy followed by observation ofmild dysplasia and treatment of moderate to severe dysplasia wasthe most cost effective of four possible management scenariosand offered the least opportunity for overtreatment of lesions.
The results did indicate that a subset of patients with high-gradesquamous intraepithelial lesion (SIL)/severe dysplasia may bebetter candidates for immediate LLETZ, he said.
The researchers constructed clinical algorithms for four differentphilosophies for the management of a patient with an abnormalPap smear, and used decision analysis methodology to evaluatethe expense of each algorithm and the potential for excessivetreatment. The algorithms were as follows:
These algorithms were theoretically applied to 614 dysplasia patientsat the Birmingham colposcopy clinic, based on referral Pap smearresults: 47% had smears showing low-grade SIL; 52% showed high-gradeSIL.
The dollar amounts in the cost aspect of the analysis were calculatedusing a nationwide 50th-percentile charge by physicians for proceduresand related pathology. The initial results showed a cost of $1,109per patient for algorithm 1; $947 for algorithm 2; $787 for algorithm3; and $838 for algorithm 4. However, a closer look at the datashowed that these figures overestimated the cost of the colposcopyalgorithms.
"In reviewing data from the actual study population, we noteda significant disparity between referrals based on Paps performedby local health departments and the diagnoses based on biopsiesobtained in our clinic," he said. For example, in 56% ofcases, patients with low-grade SIL referral Paps were found tohave less dysplasia on biopsy result.
This discrepancy resulted in a theoretical increased need fordiagnostic conization due to cytology-histology discrepancy, andwould have inflated the cost of colposcopic evaluation, he said.
To minimize the cost of diagnostic conization due to this discrepancy,the researcher reanalyzed the data using a repeat Pap smear obtainedat the time of colposcopy in treatment planning. To decrease thepathology-associated costs of LLETZ, they decided to submit topathology only diagnostic LLETZ specimens, and to select immediateLLETZ candidates by high-grade SIL/severe dysplasia Pap smear.
When applied to each of the theoretical algorithms, these cost-savingmeasures resulted in a 25% to 30% saving in those treatments usingcolposcopy. The cost of immediate LLETZ (algorithm 4) remainedstable at $838 and became the most expensive treatment. Traditionalcolposcopy with the observation of biopsy-proven mild dysplasia(algorithm 2) became the least expensive procedure at $718 perpatient.
"The results suggest that colposcopy, with its lower costand low potential for excessive treatment, should continue toplay an important primary role in the evaluation and treatmentof cervical dysplasia," he commented.
To determine the degree of excessive treatment in the applicationof immediate LLETZ, the investigators estimated the proportionof immediate LLETZ procedures that would not have been performedif the patient had been first evaluated with traditional colposcopy.
They discovered an 18% incidence of excessive treatment with ahigh-grade SIL referral Pap smear, and a 3% incidence with high-gradeSIL/severe dysplasia only (eliminating that subset of high-gradeSILs comprising moderate dysplasia). "This finding suggeststhat the subset of patients with high-grade SIL/severe dysplasiawould make better candidates for immediate LLETZ," he said.