Screening and management of precancerous lesions to prevent cervical cancer in low-resource settings.

Cervical cancer is a leading cause of cancer death among women in low-resource settings, but it is completely preventable by screening for and treating precancerous lesions. In this article, the current approaches to screening, confirmation, and treatment of precancerous lesions of the cervix are reviewed from the perspective of low-resource settings. Cervical cytology is compared to visual inspection with acetic acid (VIA) for screening women to detect precancerous lesions. The use of colposcopy to confirm findings in women with positive screening test results and various treatment methods are discussed. With one examination, cytology appears to detect fewer precancerous lesions than VIA, but VIA has a lower specificity and labels proportionately more women falsely positive. When available, colposcopy may be used to obtain directed biopsies from abnormal areas of the cervix to pathologically confirm the findings in women with positive screening tests. Treatment with cryotherapy appears to be a safe, acceptable, and effective procedure for the majority of precancerous lesions. Lesions that are not suitable for cryotherapy because of endocervical canal involvement or large size are amenable to outpatient treatment by loop electrical excision procedure (LEEP). HIV/AIDS and immune system suppression are associated with more rapid CIN progression and HIV-positive women generally have high recurrence rates of CIN after treatment. Women tempora may more readily transmit the virus after cryotherapy and, therefore, they require counseling regarding abstinence and condom use. Highly active antiretroviral therapy (HAART) may cause CIN to regress and may decrease the risk of cervical cancer in HIV-infected women. Cost-effectiveness modeling using South African data shows that use of a single lifetime VIA test and immediate cryotherapy saves costs compared to cytology or to no screening. VIA and cryotherapy are appropriate services for low-resource settings. Colposcopy and LEEP services should be available on a referral basis.