Key Points
Question
Among women with HIV and high-grade cervical lesions, what is the effect of cryotherapy vs loop electrosurgical excision procedure (LEEP) on cervical disease recurrence?
Findings
In this randomized clinical trial that included 400 women in Kenya with HIV and high-grade cervical lesions, treatment with cryotherapy, compared with LEEP, led to a significantly higher rate of cervical intraepithelial neoplasia grade 2 or 3 recurrence (30% vs 19%) over 24 months.
Meaning
These findings support the effectiveness of LEEP for treatment of cervical precancer in women with HIV, although cost-effectiveness analysis is necessary to understand whether the additional benefit of LEEP represents an efficient use of additional resources.
Abstract
Importance
The World Health Organization recommends cryotherapy or loop electrosurgical excision procedure (LEEP) for histologically confirmed cervical intraepithelial neoplasia (CIN) grade 2 or higher regardless of HIV status. Cryotherapy is more feasible in resource-limited settings but may be less effective for women living with HIV.
Objective
To evaluate whether cryotherapy or LEEP is a more effective treatment for high-grade cervical lesions among women with HIV.
Design, Setting, and Participants
Single-center randomized trial conducted among women with HIV and CIN grade 2 or 3. From June 2011 to September 2016, women with HIV in Kenya underwent cervical screening with Papanicolaou testing and confirmatory biopsy. The final date on which a study procedure was administered was September 7, 2016.
Interventions
Women with HIV infection and CIN grade 2 or 3 were randomized 1:1 to receive cryotherapy (n = 200) or LEEP (n = 200) and were followed up every 6 months for 24 months with a Papanicolaou test and confirmatory biopsy.
Main Outcome and Measures
The primary outcome was disease recurrence, defined as CIN grade 2 or higher on cervical biopsy, during the 24-month follow-up period.
Results
Among 400 women who were randomized (median age, 37.4 [interquartile range, 31.9-43.8] years), 339 (85%) completed the trial. Over 2 years, 60 women (30%) randomized to cryotherapy had recurrent CIN grade 2 or higher vs 37 (19%) in the LEEP group (relative risk, 1.71 [95% CI, 1.12-2.65]; risk difference, 7.9% [95% CI, 1.9%-14.0%]; P = .01). Adverse events occurred in 40 women (45 events, including change in pathology and death due to other causes) in the cryotherapy group and in 30 women (38 events, including change in pathology and unrelated gynecological complications) in the LEEP group.
Conclusions and Relevance
In this single-center study of women with HIV infection and CIN grade 2 or 3, treatment with LEEP compared with cryotherapy resulted in a significantly lower rate of cervical neoplasia recurrence over 24 months. Cost-effectiveness analysis is necessary to determine whether the additional benefit of LEEP represents an efficient use of the additional resources that would be required.
Trial Registration
ClinicalTrials.gov Identifier: NCT01298596
This randomized clinical trial compares the effect of cryotherapy vs loop electrosurgical excision procedure (LEEP) on disease recurrence (cervical intraepithelial neoplasia [CIN] grade 2 or higher or invasive cervical cancer) in women with HIV and CIN grade 2 or 3.
Introduction
Cervical cancer is the fourth most common cancer in women worldwide and the leading cause of cancer death in women in resource-limited settings, particularly in sub-Saharan Africa.1 The lack of comprehensive screening programs, prevalence of high-risk human papillomavirus (HPV) types, and HIV infection contribute to higher incidence, later presentation, and increased mortality in low-income settings.2,3 Because of immunosuppression, women with HIV have a higher risk of cervical intraepithelial neoplasia (CIN), which is more likely to persist and progress to cervical cancer than in HIV-uninfected women.4,5,6 Recurrence among women with HIV varies according to the extent of CIN and immunosuppression.7
World Health Organization guidelines for treatment of CIN grade 2 or 3 recommend either cryotherapy or loop electrosurgical excision procedure (LEEP) regardless of HIV status.8 Cryotherapy is an ablative treatment option that is low cost, can be performed in primary care centers, and is effective among HIV-uninfected women.9 Many low-resource settings use cryotherapy in a single-visit, screen-and-treat approach reducing clinic visits and risk of loss to follow-up.10 LEEP is an excisional procedure that is the first choice of treatment in high-resource settings regardless of HIV status because it provides tissue for histopathology.11 LEEP is less common in low-resource settings as it requires electrical equipment to heat the wire loop used in the procedure and clinicians must be trained in using it.
Cervical intraepithelial neoplasia grade 2 to 3 can be difficult to treat and recurs in 5% to 14% of women; among women with HIV, 12-month recurrence rates as high as 27% have been reported.12,13,14,15 Improved understanding of the relationship among CIN, HIV, and treatment is needed to guide prevention programs for women with HIV.
The aim of this randomized clinical trial was to estimate the incidence of cervical disease recurrence over 2 years of follow-up among women with HIV and CIN grade 2 or higher treated with cryotherapy or LEEP.
Methods
Trial Design, Participants, and Interventions
Ethical approval was obtained from the Kenyatta National Hospital Ethics Research Committee, the University of Washington Institutional Review Board, and the Centers for Disease Control and Prevention. The trial protocol and statistical analysis plan are available in Supplement 1. All participants provided written informed consent to participate in the study.
This was an unmasked randomized clinical trial of cryotherapy vs LEEP treatment among women with HIV with biopsy-confirmed CIN grade 2 or 3. Women with HIV receiving routine HIV care and treatment at the Coptic Hope Center for Infectious Diseases in Nairobi, Kenya, were recruited.16 Eligible women were aged 18 years or older, were living with HIV infection, had initiated sexual activity, were not pregnant, and had an intact cervix without history of hysterectomy. Exclusion criteria included a history of treatment for cervical lesions or a lesion that was not eligible for cryotherapy (including a lesion that was >75% of the cervix surface, extended >2 mm into the endocervical canal, had CIN grade 2 or higher based on endocervical curettage, or could not be fully visualized on colposcopy).
Objective
The primary objective of the trial was to compare cryotherapy and LEEP in the treatment of high-grade cervical lesions. It was hypothesized that LEEP would be associated with a lower rate of recurrent CIN grade 2 or higher over the 24-month follow-up period after adjusting for baseline differences in antecedent CIN grade 3 histology, antiretroviral therapy (ART), and CD4 cell count. The secondary objectives included (1) comparison of the rates of HIV shedding after cryotherapy vs LEEP, as previously reported and (2) CIN grade 2 or higher recurrence rates in subgroups based on HIV co-factors including CD4 cell count, HIV viral load, and ART use.17
Randomization
Eligible women were randomized in a 1:1 allocation to cryotherapy or LEEP using a permuted-block randomization with a block size of 10 (Figure 1). Investigators were masked to block number, size, and sequence. Randomization was accomplished using a computer-generated random number. The allocation sequence was concealed in sequentially numbered opaque sealed envelopes prepared by the study statistician (B.A.R.). Investigators and participants were not blinded to the interventions.
Figure 1. Participant Flow in a Randomized Clinical Trial of Cryotherapy vs LEEP Among Women With HIV and High-Grade Cervical Lesions in Kenya.
LEEP indicates loop electrosurgical excision procedure. Women were eligible for repeat screening every 12 months following a normal screening result and every 6 months after screening showing low-grade intraepithelial lesions. Multiple Papanicolaou tests were performed in 1178 women (1045 women had 2 tests, 125 had 3 tests, 7 had 4 tests, and 1 had 5 tests).
Procedures
Women were screened for cervical cancer using a Papanicolaou test. Cervical cell specimens were collected using a Cervex Brush (Rovers) inserted into the cervical os, rotated to collect cells from the endocervix and ectocervix, and inserted in Thin-Prep solution (Hologic Inc). Women with squamous cell carcinoma, women with high-grade squamous intraepithelial lesions (HSIL) or atypical squamous cells with the inability to exclude high-grade squamous intraepithelial lesions, and women who had repeat low-grade squamous intraepithelial lesion results at least 6 months apart underwent colposcopy-directed biopsy. Biopsy forceps collected punch biopsies at the site exhibiting the most severe changes. An endocervical curettage was performed among women with cytology results indicating atypical glandular epithelium abnormalities or unsatisfactory colposcopy, for example, when the squamocolumnar junction was not completely visible.
Cervical samples and biopsies were processed by a laboratory technologist. Cellular changes were classified according to the Bethesda System.18 Specimens were reviewed by a pathologist with no knowledge of treatment assignment or case history and reported based on 3-tiered CIN classification (CIN grade 1, 2, or 3). A separate pathologist, blinded to the initial histopathology reading, randomly reviewed 10% of abnormal and 3% of normal Papanicolaou test results and 100% of abnormal and 10% of normal cervical biopsy results. A third pathologist reviewed discrepant results to achieve consensus. All reported data are consensus results, although some women were randomized and received treatment based on an initial result of CIN grade 2 or 3 as reported by the first pathologist.
Women with histologically confirmed CIN grade 2 or 3 lesions eligible for cryotherapy and LEEP underwent treatment. The same study physician (E.N.) performed colposcopic examinations, collected biopsies, and performed treatment procedures. Lugol solution was applied to the cervix to outline the lesion and transformation zone. LEEP was performed according to standard practice, and an additional pass with the loop was made for large lesions to ensure complete excision. Hemostasis was achieved following LEEP with electrocoagulation, application of Monsel paste, or both. LEEP specimens were evaluated for morphological changes by a pathologist.
Cryotherapy was performed using nitrous oxide and a cryosurgical unit (LL100; Wallach Surgical Devices Inc) with a 3-minute freeze, 5-minute thaw, and 3-minute freeze. Flat probes or probes with a shallow nipple measuring 19 mm or 25 mm were selected to cover the entire lesion. Following cryotherapy, Monsel paste was applied if bleeding was observed. All women were counseled after either LEEP or cryotherapy to abstain from sexual intercourse for at least 4 weeks and were provided condoms to reduce risk of infection or HIV transmission.
Follow-up
Follow-up visits occurred at 6, 12, 18, and 24 months after treatment. At each visit, Papanicolaou tests were done and plasma samples for CD4 cell testing were collected. If the cytology results were of a lower grade than HSIL, women were scheduled for a subsequent follow-up visit. If cytology results were HSIL or more severe, women underwent a cervical biopsy and LEEP on a subsequent visit, regardless of randomization group. The last date of treatment occurred in September 2016. Women were defined as lost to follow-up if they missed a biannual Papanicolaou test and did not return for additional follow-up visits. Women who met criteria for disease recurrence and had received 2 prior LEEP treatments or had histological evidence of invasive disease were referred to the public government hospital for further management.
Women were scheduled for additional follow-up visits at 7, 14, and 21 days after baseline treatment to provide endocervical swabs for a secondary aim to measure HIV shedding after cervical treatment.19 During these visits, women had a physical examination and completed a questionnaire on treatment complications. Adverse events were graded according to the Division of AIDS Table for Grading the Severity of Adult Adverse Events version 1.0.20
Outcomes
The primary outcome was cumulative CIN grade 2 or higher over 24-month follow-up. Cervical intraepithelial neoplasia grade 2 or higher was defined as consensus interpretation of CIN grade 2 or 3 or invasive cervical cancer on cervical biopsy, endocervical curettage, or LEEP pathology at any of the 6-month intervals during 2-year follow-up. The secondary previously reported outcome was to compare rates of HIV shedding after cryotherapy vs LEEP.19 To evaluate the possibility that treatment effect varied by the degree of immunosuppression, post hoc subgroup analyses were performed by HIV cofactors of ART (<2 years vs ≥2 years), CD4 cell count (<250, 250-499, or ≥500/μL), and plasma viral load (detectable [≥60 copies/mL] vs undetectable [<60 copies/mL]). These analyses used baseline values to define the groups. Post hoc outcomes include recurrence rate over 24 months based on a screening result of HSIL or more severe disease, defined as atypical squamous cells that cannot exclude high-grade squamous intraepithelial lesions, HSIL, or squamous cell carcinoma on consensus cytology interpretation, at any of the 6-month intervals during follow-up. Additional post hoc outcomes include rate of CIN grade 2 or higher and HSIL or more severe per 100 person-years and number and severity of adverse events due to treatment procedures.
Statistical Analysis
The study was powered to detect a 10% or greater difference in cervical precancer recurrence between cryotherapy and LEEP based on a prior subgroup analysis reporting CIN grade 2 or 3 recurrence of 14.3% in women with HIV treated with cryotherapy and 4.0% after LEEP.21 Randomization of 400 women with HIV (200 per group), accounting for 20% attrition, was estimated to provide at least 80% power to detect a 10% difference in recurrence between treatment groups at a 2-sided α = .05.
Women with CIN grade 2 or higher were analyzed according to their randomization groups based on time-to-first-event analysis. Baseline characteristics were compared using a Kruskal-Wallis test for medians and a χ2 or Fisher exact test for proportions, as appropriate. Women contributed at-risk time from the date of their cervical treatment until they had an event (defined as CIN grade 2 or higher) or date of final Papanicolaou test, whichever occurred first. Women were censored at the treatment date or last Papanicolaou test date if they were lost to follow-up, withdrew from the study, died, or had a total abdominal hysterectomy during follow-up. Imputation of outcome events was not performed given the low observed rate of missingness for the primary outcome, CIN grade 2 or higher (3% [n = 6] among women treated with cryotherapy and 4% [n = 8] among women treated with LEEP). Log-rank tests and Cox proportional hazards regression analysis were used to assess risk of recurrence between treatment groups, adjusting for prespecified confounders including antecedent CIN grade 3 histology, ART, and CD4 cell count (included as a time-dependent covariate). The proportional hazards assumption of the model was checked by examining a treatment × time interaction term. Relative risks are expressed as hazard ratios (HRs) with associated 95% CIs derived using the Cox proportional hazards model. All hypothesis tests were 2-sided and performed at α = .05. There was no adjustment of the significance threshold for the secondary or other end points; because of the potential for type I error, the findings from these analyses should be considered exploratory. Analyses were conducted using Stata software, version 14.2 (StataCorp).
An independent data and safety monitoring board reviewed results after the first 100 women received treatment and then every 6 months until study completion. Five prespecified interim analyses were conducted to assess safety and evaluate the primary end point. The O’Brien-Fleming approach was used to define stopping boundaries.22
Results
Enrollment began on June 6, 2011; the last follow-up Papanicolaou test occurred on August 8, 2016; and the last treatment procedure occurred on September 7, 2016. During this period, 5330 women with HIV underwent a total of 6650 cervical screenings for study eligibility. Most women (82.2%) had no evidence of precancerous lesions and 4.1% had low-grade cytology results. For 738 women (13.8%) with high-grade cervical lesions on cytology or who received a cervical biopsy, the main exclusion criteria were a diagnostic colposcopy biopsy result of lower than CIN grade 2 (n = 226 [30.7%]) or a CIN grade 2 or higher lesion not amenable to cryotherapy (n = 109 [14.8%]). Among women with CIN grade 2 or higher who were eligible for cryotherapy, 400 were randomized to LEEP or cryotherapy.
Socioeconomic characteristics were balanced between the intervention groups. Median age was 37 years (interquartile range, 32-44 years), almost all women had at least 1 child, and fewer than one-third had a previous history of cervical cancer screening. Median age at sexual debut was 18 years (interquartile range, 16-20 years) and 58% of women reported three or more lifetime sexual partners. Half of women did not complete secondary school, and more than half of women lived in households earning less than US $150 per month. During the period of the study (2011-2016), guidelines for ART initiation were to provide ART if CD4 cell counts were less than 350/μL in 2011-2013, to provide ART if CD4 cell counts were less than 500/μL in 2013-2015, or to universally provide ART in 2015-2016. At baseline, almost 90% of women were taking ART and more than 50% had received prolonged ART (≥2 years); those not taking ART were in care. Approximately 70% of women had CD4 cell counts above 250/μL and approximately 64% had undetectable HIV-1 plasma viral load at baseline (Table 1).
Table 1. Baseline Demographic, Behavioral, and Clinical Characteristics by Treatment Groupa.
| Characteristics | Cryotherapy (n = 200) | LEEP (n = 200) |
|---|---|---|
| Age, median (IQR), y | 38.2 (32.0-42.5) [n=194] | 37.4 (31.7-44.9) [n=189] |
| Education | ||
| None | 23 (11.5) | 12 (6) |
| Primary | 70 (35) | 79 (39.5) |
| Secondary | 58 (29) | 64 (32) |
| University | 49 (24.5) | 45 (22.5) |
| Monthly household income less than US $150 | 109 (54.5) | 117 (58.5) |
| Salaried employment | 53 (26.5) | 63 (31.5) |
| Relationship status | ||
| No current partner | 120 (60) | 112 (56) |
| At least 1 current partner | 80 (40) | 88 (44) |
| Lifetime sexual partners | ||
| 1-2 | 97 (48.5) | 72 (36) |
| ≥3 | 103 (51.5) | 128 (64) |
| Parity | ||
| 0 | 7 (3.5) | 13 (6.5) |
| 1-2 | 111 (55.5) | 101 (50.5) |
| ≥3 | 82 (41) | 86 (43) |
| Previously screened for cervical cancer | 65 (34.4) [n=189] | 55 (29.1) [n=189] |
| Any hormonal contraception | 36 (18.1) [n=199] | 32 (16) [n=200] |
| CD4 cell count, /μL | ||
| Median (IQR) | 371 (211-532) [n=200] | 385 (221-522) [n=199] |
| <250 | 59 (29.5) | 59 (29.7) |
| 250-499 | 83 (41.5) | 85 (42.7) |
| ≥500 | 58 (29) | 55 (27.6) |
| ART naive | 28 (14) | 17 (8.5) |
| Duration of ART, median (IQR), mob | 29.4 (14.1-60.2) [n=172] | 34.0 (12.4-74.3) [n=183] |
| Undetectable HIV-1 plasma viral loadc | 123 (63.1) [n=195] | 126 (65.3) [n=193] |
| CIN grade 2 | 78 (39) | 58 (29) |
| CIN grade 3 | 109 (54.5) | 128 (64) |
Abbreviations: ART, antiretroviral treatment; CIN, cervical intraepithelial neoplasia; IQR, interquartile range; LEEP, loop electrosurgical excision procedure.
Data are expressed as No. (%) of participants unless otherwise indicated.
Among participants taking ART prior to treatment.
Minimum detection level <60 copies/mL.
In each group, 195 women (98%) had at least 1 follow-up Papanicolaou test. Retention, defined as completion of end-of-study visit procedures at 2 years or when disease recurrence was detected during follow-up, was 85% and did not differ between groups (Figure 1). In the cryotherapy group, there were 296 person-years at risk of recurrence and a mean follow-up time of 1.48 years (SD, 0.68 years). In the LEEP group, there were 311 person-years at risk and a mean follow-up time of 1.56 years (SD, 0.68 years). During follow-up, cervical biopsies were collected from 195 (76.8%) of 254 women with HSIL or more severe disease or atypical glandular cells on cytology. Of the 59 women without a biopsy, 21 were referred for further management, 19 received biopsy and LEEP based on a cytology result from a previous study visit, and 19 were pregnant, declined, or did not return to the study clinic until the subsequent biannual study visit. Of the 195 biopsy results, 62 (31.8%) were of a lower grade than CIN grade 2 on confirmatory biopsy or endocervical curettage.
Primary Outcome
Over 24 months, 60 women (30%) had CIN grade 2 or higher in the cryotherapy group compared with 37 (19%) in the LEEP group (relative risk, 1.71 [95% CI, 1.12-2.65]; risk difference, 7.9% [95% CI, 1.9%-14.0%]; P = .01) (Table 2). Risk of CIN grade 2 or higher at 24 months was 19.2 (95% CI, 14.9-24.7) per 100 person-years among women receiving cryotherapy vs 11.2 (95% CI, 8.1-15.5) among those receiving LEEP (P = .01). Risk of CIN grade 2 or higher recurrence was increased among women treated with cryotherapy (HR, 1.69 [95% CI 1.12-2.55]; P = .01) over 24 months. After adjusting for ART, CD4 cell count, and baseline histology, women treated with cryotherapy remained significantly more likely to have CIN grade 2 or higher (HR, 1.76 [95% CI, 1.17-2.64]; P = .01) (Figure 2A).
Table 2. Incidence of Recurrence of CIN Grade 2 or Higher and HSIL or More Severe Disease During 2-Year Follow-up by Baseline HIV Factors.
| Cryotherapy (n = 200) | LEEP (n = 200) | Absolute Difference per 100 Person-Years (95% CI) | P Value | |||||
|---|---|---|---|---|---|---|---|---|
| No. of Recurrences | Person-Years of Follow-up | Rate per 100 Person-Years (95% CI) | No. of Recurrences | Person-Years of Follow-up | Rate per 100 Person-Years (95% CI) | |||
| CIN Grade 2 or Highera | ||||||||
| Overall | 60 | 313.2 | 19.2 (14.9-24.7) | 37 | 329.9 | 11.2 (8.1-15.5) | −7.9 (−14.0 to −1.9) | .01 |
| Baseline ART use | ||||||||
| ≥2 y | 30 | 154.6 | 19.4 (13.6-27.8) | 24 | 178.6 | 13.4 (9.0-20.1) | −6.0 (−14.7 to 2.8) | .18 |
| <2 y | 21 | 113.2 | 18.5 (12.1-28.4) | 11 | 121.9 | 9.0 (5.0-16.3) | −9.5 (−19.1 to 0) | .05 |
| No ART | 9 | 45.3 | 19.8 (10.3-38.1) | 2 | 29.3 | 6.8 (1.7-27.3) | −13.0 (−29.1 to 3.0) | .16 |
| Baseline plasma viral load, copies/mL | ||||||||
| <60 | 31/123 | 203.7 | 15.2 (10.7-21.6) | 22/126 | 206.7 | 10.6 (7.0-16.2) | −4.6 (−11.5 to 2.4) | .20 |
| ≥60 | 28/72 | 101.0 | 27.7 (19.1-40.2) | 13/67 | 111.7 | 11.6 (6.8-20.0) | −16.0 (−28.2 to −4.0) | .01 |
| Baseline CD4 cell count, /μL | ||||||||
| <250 | 20 | 56.5 | 35.4 (22.8-54.9) | 7 | 52.1 | 13.4 (6.4-28.2) | −22.0 (−40.4 to −3.5) | .02 |
| 250-499 | 21 | 132.2 | 15.9 (10.4-24.4) | 15 | 135.1 | 11.1 (6.7-18.4) | −4.8 (−13.6 to 4.8) | .29 |
| ≥500 | 19 | 123.4 | 15.4 (9.8-24.1) | 15 | 142.1 | 10.6 (6.4-17.5) | −4.8 (−13.6 to 3.9) | .28 |
| HSIL or More Severe Diseaseb | ||||||||
| Overall | 74 | 296.2 | 25.0 (19.9-31.4) | 52 | 311.2 | 16.7 (12.7-21.9) | −8.0 (−15.6 to −1.0) | .03 |
| Baseline ART use | ||||||||
| ≥2 y | 35 | 144.9 | 24.2 (17.3-33.6) | 33 | 163.5 | 20.2 (14.4-28.4) | −4.0 (−14.5 to 6.6) | .46 |
| <2 y | 28 | 108.1 | 25.9 (17.9-37.5) | 15 | 117.9 | 12.7 (7.7-21.1) | −13.2 (−24.7 to −1.6) | .02 |
| No ART | 11 | 43.2 | 25.4 (14.1-45.9) | 4 | 29.9 | 13.4 (5.0-35.7) | −12.0 (−32.0 to 8.0) | .28 |
| Baseline plasma viral load, copies/mL | ||||||||
| <60 | 42/123 | 187.3 | 22.4 (16.6-30.3) | 29/126 | 197.4 | 14.7 (10.2-21.1) | −7.7 (−16.4 to 0.9) | .08 |
| ≥60 | 31/72 | 100.3 | 30.9 (21.7-43.9) | 19/67 | 104.9 | 18.1 (11.6-28.4) | −12.8 (−26.4 to 0.8) | .07 |
| Baseline CD4 cell count, /μL | ||||||||
| <250 | 22 | 54.5 | 40.3 (26.6-61.3) | 13 | 48.9 | 26.6 (15.4-45.8) | −13.8 (−36.0 to 8.5) | .24 |
| 250-499 | 29 | 121.9 | 23.8 (16.5-34.2) | 19 | 126.6 | 15.0 (9.6-23.5) | −8.8 (−19.7 to 2.2) | .12 |
| ≥500 | 23 | 118.7 | 19.4 (12.9-29.2) | 20 | 135.2 | 14.8 (9.5-22.9) | −4.6 (−14.8 to 5.6) | .38 |
Abbreviations: ART, antiretroviral treatment; CIN, cervical intraepithelial neoplasia; HSIL, high-grade squamous intraepithelial lesion; LEEP, loop electrosurgical excision procedure.
Cervical intraepithelial neoplasia is a histopathological diagnosis that describes the degree and extent of morphological changes in the cervical epithelial cells; CIN grade 2 indicates moderate changes and CIN grade 3 indicates more severe changes. Moderate to severe changes are more likely to progress to invasive cancer.
High-grade squamous intraepithelial lesions are detected by a screening examination of the squamous cells lining the cervix with a cytologic smear stained with the Papanicolaou technique. If cytoplasmic changes are observed, then a cervical biopsy is required to diagnose the extent of neoplasia.
Figure 2. Cumulative Incidence of Recurrent CIN Grade 2 or Higher and HSIL or More Severe Disease by Treatment Group.
CIN indicates cervical intraepithelial neoplasia; HR, hazard ratio; HSIL, high-grade squamous intraepithelial lesion; LEEP, loop electrosurgical excision procedure. Median observation time for CIN grade 2 or higher: cryotherapy, 720 (interquartile range [IQR], 363-731) days; LEEP, 720 (IQR, 540-728) days. Median observation time for HSIL or more severe disease: cryotherapy, 720 (IQR, 214-729) days; LEEP, 720 (IQR, 361-728) days. Hazard ratios are adjusted for baseline histology, antiretroviral therapy use, and CD4 cell count as a time-varying coefficient.
Post Hoc Outcomes
There was no significant difference in high-grade cervical disease between cryotherapy and LEEP during follow-up for women with an undetectable viral load, high CD4 cell count (>250/μL), or ART duration of longer than 2 years (Figure 3). Among women taking ART for less than 2 years, CIN grade 2 or higher occurred in 30 of 99 women (30.3%) who received cryotherapy and 13 of 91 women (14.3%) who received LEEP (HR, 2.18 [95% CI, 1.14-4.19]; P = .02; P = .24 for interaction). Among women with low CD4 cell counts (<250/μL) at baseline, CIN grade 2 or higher occurred in 20 of 59 women (33.9%) who received cryotherapy and 7 of 59 women (11.9%) who received LEEP (HR, 2.58 [95% CI, 1.12-5.94]; P = .03; P = .19 for interaction). Among women with detectable plasma viral load (≥60 copies/mL) at baseline, CIN grade 2 or higher occurred in 28 of 72 women (38.9%) who received cryotherapy and 13 of 67 women (19.4%) who received LEEP (HR, 2.44 [95% CI, 1.28-4.66]; P = .01; P = .18 for interaction). The tests for interaction were not significant for the subgroups analyzed.
Figure 3. Unadjusted Hazard Ratios for Recurrence of CIN Grade 2 or Higher or HSIL or More Severe Disease Stratified by Key Subgroups at 24 Months.
ART indicates antiretroviral treatment; CIN, cervical intraepithelial neoplasia; HSIL, high-grade intraepithelial lesion; LEEP, loop electrosurgical excision procedure. Categorization is based on baseline values.
Risk of HSIL or more severe disease at 24 months was 25.0 (95% CI, 19.9-31.4) per 100 person-years among women receiving cryotherapy vs 16.7 (95% CI, 12.7-21.9; P = .03) per 100 person-years among those receiving LEEP. Over 24 months, detection of HSIL or more severe disease was significantly higher in the cryotherapy group compared with LEEP (37% vs 26%; log-rank P = .03). Risk of HSIL or more severe disease recurrence was increased among women treated with cryotherapy (HR, 1.47 [95% CI, 1.03-2.09]; P = .03) over 24 months. After adjusting for ART, CD4 cell count, and baseline histology, women treated with cryotherapy were also more likely to have HSIL or more severe disease (absolute difference per 100 person-years, −8 [95% CI, −16 to −4]; HR, 1.53 [95% CI, 1.07-2.18]; P = .02) detected during follow-up (Figure 2B).
There were no study withdrawals as a result of study procedures or adverse events. Fifty-nine percent of the 83 adverse events were severity grade 1 or 2: 22 of 45 (54%) in the cryotherapy group and 27 of 38 (71%) in the LEEP group (P = .14). Change in pathology interpretation was the most common reported low-severity adverse event, in 11 of 22 women (50%) treated with cryotherapy and 14 of 27 women (52%) treated with LEEP. Among women treated with cryotherapy, 23 serious adverse events occurred with a severity grade of 3 or higher: death due to causes other than cervical cancer (n = 10), unrelated obstetric complications (n = 5), infections related to HIV disease (n = 2), respiratory infection (n = 2), intraoperative or postoperative bleeding (n = 2), unrelated injury (n = 1), and chronic disease (n = 1). Eleven serious adverse events with a severity grade of 3 or higher occurred in the LEEP group; death due to causes other than cervical cancer (n = 4), unrelated obstetric complications (n = 3), infections related to HIV disease (n = 2), respiratory infection (n = 1), and meningitis (n = 1). Two serious adverse events related to study procedures were reported among women who received cryotherapy for baseline treatment. On a follow-up visit, these women received LEEP for recurrent lesions. The first was an intraoperative complication when the lateral vaginal wall and anterior bladder were perforated and the participant required hospitalization for surgery to repair the vaginal wall defect. In the second case, the participant reported heavy postoperative bleeding, which was controlled by repeat application of topical Monsel paste.
Discussion
In this randomized clinical trial of women with HIV, cryotherapy was associated with significantly higher risk of recurrent cervical disease compared with LEEP over 24 months of follow-up. Despite treatment, cumulative CIN grade 2 or higher recurrence rates were high in both groups after 2 years: 30% with cryotherapy and 19% with LEEP.
Two randomized trials have compared cryotherapy with LEEP. A study in Zimbabwe reported a composite outcome of HSIL or more severe disease or CIN grade 2 or higher of 8% after cryotherapy and 2.4% after LEEP at 12 months, and a South African trial of women with HIV reported CIN grade 2 or higher at 12 months to be 27% after cryotherapy and 19% after LEEP, which was not significantly different.13,14 The Zimbabwe study largely included HIV-uninfected women while the South African trial was relatively small (n = 166) and had only 1 year of follow-up. The present study included 400 women followed up for 2 years and included comprehensive information about the severity of HIV and exposure to ART. It demonstrates the superiority of LEEP compared with cryotherapy for women living with HIV infection.
Compared with cryotherapy, the effectiveness of LEEP may be due to more complete removal of abnormal tissue. Treatment success with ablation or excision depends on effective lesion removal and HPV type-specific immune responses to prevent recurrence.23 Prior research has shown that incomplete excision or inadequate freezing of the abnormal tissue, lesion size, and multifocal lesions located outside the transformation zone are independent risk factors for disease recurrence.24,25 LEEP removes both the cervical lesion and surrounding normal tissue. Typically, the excised tissue measures at least 6 to 7 mm and the depth of tissue removal may exceed 10 mm.26,27 Cryotherapy causes necrosis of both the lesion and normal tissue to a depth up to 5 to 7 mm but may not always achieve therapeutic depth, particularly if lesions are located on the posterior lip of the cervix.25,28 The mean depth of CIN grade 2 or 3 lesions in screened populations is less than 5 mm from the surface the cervical epithelium with a linear extent of less than 8 mm.29 However, in underscreened populations, the maximal depth of CIN grade 3 has been found to be deeper, which may contribute to the high recurrence observed in this study.30
In this study, women who were taking ART for less than 2 years, were immunocompromised, or had detectable HIV viral load had higher CIN grade 2 or higher recurrence and were more likely to benefit from LEEP than from cryotherapy. Cryotherapy may decrease but not eliminate HPV viral burden, and a functional immune environment is required to eliminate recurrent CIN.31 However, LEEP was not significantly better than cryotherapy among women who were taking ART for 2 years or longer, were immunocompetent, or had achieved viral suppression. Prolonged ART and HIV viral suppression may restore functional cervical mucosal immunity to respond to HPV-induced CIN,32 and recent research has found that early ART initiation, high ART adherence, and sustained viral suppression reduces risk of CIN grade 2 or higher.33,34,35 Further research is needed to assess the value of using a patient’s HIV treatment history, immune status, and viral load status to guide treatment options for cervical precancerous lesions.
For women with HIV who screen positive for cervical preneoplasia, this trial indicates that LEEP is more effective at preventing recurrent cervical neoplasia than cryotherapy. In many low-resource settings, early detection and treatment of cervical precancer has been constrained by lack of health delivery infrastructure and limited financial resources.36 Effective cervical cancer prevention therefore must consider technological and human resource capacities. Although LEEP is an outpatient procedure that can be performed in less than 15 minutes with local anesthesia, it requires electrosurgical equipment with continuous access to electricity and a trained health care worker to implement it. Cryotherapy is a less complex procedure that can be carried out by trained nurses in a primary care setting. World Health Organization guidelines recommend follow-up 1 year after treatment for CIN grade 2 or 3 for women with and without HIV.8 Given that the majority of disease recurrence in this study was detected 6 months after treatment, these results suggest the need for more frequent intervals of repeat screening.
Limitations
This study has several limitations. First, this trial was conducted in a single center in an urban HIV care facility with 1 clinician administering all treatment procedures. While the results are internally consistent, the generalizability of these results may be limited to large-scale HIV care and treatment centers. Further implementation research may be necessary to develop local solutions to scale linkages between cervical cancer prevention services with HIV care where, for example, mid-level care providers can be trained to safely administer LEEP in low-resource settings.37 Second, HPV type-specific results would have helped to characterize the risk of recurrent CIN and distinguish between recurrent and incident infection. Third, HIV factors vary with time including viral load, ART type, ART use, and treatment guidelines, and other factors were not measured including late initiation of ART or duration of HIV infection. Informative subgroups, including women not taking ART at the time of treatment, were small. Subgroups should be interpreted cautiously given the lack of significance in the tests for interaction; however, these results are consistent with research that shows immunodeficiency is an important risk factor for cervical disease.34,35 Longer follow-up is necessary to evaluate the effect of cryotherapy and LEEP on the rates of invasive cervical cancer and cervical cancer–related mortality.
Conclusions
In this single-center study of women with HIV infection and CIN grade 2 or higher, treatment with LEEP compared with cryotherapy resulted in a significantly lower rate of cervical neoplasia recurrence over 24 months. Cost-effectiveness analysis is necessary to determine whether the additional benefit of LEEP represents an efficient use of the additional resources that would be required.
Trial Protocol
Data Sharing Statement
References
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Trial Protocol
Data Sharing Statement