Treatment Options for CIN

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Treatment Options for CIN

• Cervical Cancer screening is designed to detect
  CIN
• If CIN is present treatment should theoretically
  avoid subsequent cancer by 100 (i.e. effective
  cure rate or zero percent failure rate).

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Screening Programme Guidelines

• Identify and invite eligible women (e.g. gt 25
  years to 60 years)
• Cover the population with effective and
  acceptable test (e.g. VIA)
• To give women information about benefits and
  limitations of the cervical screening test (VIA)
• To identify CIN
• To follow-up all women who are test positive and
  offer them appropriate treatment

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• To inform women how they can ? risk of CIN (delay
  early onset intercourse, avoid STI/HIV, avoid
  multiple partners, avoid cigarrette smoking
  ,grandmultiparity, prolonged use of stroidal
  contraception)
• Provide acceptable and effective treatment for
  CIN (cryotherapy or LEEP)
• Identify population at risk for target screening
• Evaluate the screening Programme and improve its
  quality performance

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• 1. Knife Cone Biopsy (Cold KCB)
• Is done under general anaesthesia and still most
  commonly performed method of Rx in Zimbabwe.
  Complications of haemorrhage, cervical stenosis,
  infertility, recurrent miscarriages, pre-term
  labour. Histological specimen is available.

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• 2. LASER
• 3. Deep Electro Diathermy
• 4. Cold Coagulation
• Cryotherapy - destroys abnormal cells by freezing
  TZ (-60C - 90C) An outpatient procedure. Is
  an ablative technique, low cost, does not require
  electricity, ease of use, low complication rates,
  good cure rates (80 - 96).

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• 6. LEEP - (Loop Electrosurgical Excision
  Procedure) uses thin wire electrode with low
  voltage high frequently alternative current An
  outpatient procedure that provides a histological
  specimen but may remove an excessive amount of
  cervical stroma.

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• 7. Hysterectomy - After invasive cancer has been
  ruled out - TAH can be performed for women with
  CIN who desire sterilization or have other
  gynaecological problems e.g. fibroids.

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• Future treatment for cervical cancer may involve
  HPV vaccinations, gene therapy and
  anti-angiogeneic agents (by blocking
  proliferative response of endothelial cells
  growth factors ? no new blood vessels)

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Reduction in cumulative cervical cancer rate with
different frequencies of screening
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HIV and Cervical Cancer

• In 1993 CDC recorded 16,784 cases of women with
  AIDS and cervical cancer was the most common
  (1.3) type of cancer recorded.
• ICC was then listed as AIDS defining illness

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• No change in ICC incidence has been recorded in
  Zimbabwe as a result of HIV epidemic (Chokunonga
  E et. Al. AIDS (1999) 13 2583 83)

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Treatment of CIN lesions in HIV positive women

• High treatment failure rates recorded among HIV
  positive women ranging from 38 to 62 compared
  with 15 to 18 among HIV negative women (Chirenje
  et.al. J.Lower Gen.Tract.Dis (2003), 7 16 21,
  Maiman M. (1999), Halkomb K. et al (1999).

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• HIV induced immunosuppression leads to impaired
  cell-mediated immunity and HPV infections rarely
  regress spontaneously.
• CDC therefore put HGSIL as B defining condition
  in HIV positive women.
• No data available yet on effort of HAART on
  incidence of ICC.

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• HIV positive women should be offered cervical
  cytology screening, referral for colposcopy, and
  follow-up with 6 monthly cervical cytology
  surveillance.
• Treatment of CIN lesions in HIV positive women
  has high recurrence rates irrespective of
  treatment modality.

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• Global data estimates 466,000 new cases a year,
  80 per cent of which are in developing countries.
• The highest age standardized incidence rates are
  in Southern Africa, Central America, South
  America, parts of Asia (gt 40 cases/100,000)
  Harare has one of the highest ASR at 54/100,000
  (1997).
• Peak incidence is early fifties in most
  countries, Zimbabwe peak age is 47 years.

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Natural History of Cervical Cancer

• Proposal that ICC arises through progression of
  pre-invasive lesion as opposed to a de novo event
  was proposed in 1908 by Schanenstein
• Carcinoma in situ was used to describe
  cancerous changes confined to the epithelium.