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An Evaluation by Midwives and Gynecologists of Treatability of Cervical Lesions by Cryotherapy Among Human Papillomavirus-Positive Women
  1. Julia C. Gage*,
  2. Ana Cecilia Rodriguez,
  3. Mark Schiffman*,
  4. Sydney Adadevoh,
  5. Manuel J. Alvarez Larraondo§,
  6. Bandit Chumworathayi,
  7. Sandra Vargas Lejarza,
  8. Luis Villegas Araya#,
  9. Francisco Garcia**,
  10. Scott R. Budihas††,
  11. Rodney Long††,
  12. Hormuzd A. Katki*,
  13. Rolando Herrero,
  14. Robert D. Burk‡‡ and
  15. Jose Jeronimo§§
  1. *Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD;
  2. Proyecto Epidemiológico Guanacaste, San José, Costa Rica;
  3. ReproHealth Consult, Accra, Ghana;
  4. §Instituto Nacional de Enfermedades Neoplásicas, Lima, Perú;
  5. Department of Obstetrics and Gynecology, Faculty of Medicine, Khon Kaen University, Thailand;
  6. México Hospital, Caja Costarricense de Seguro Social, San José, Costa Rica;
  7. #Enrique Baltodano Hospital, Caja Costarricense de Seguro Social, San José, Costa Rica;
  8. **University of Arizona National Center of Excellence in Women's Health, Tucson, AZ;
  9. ††Communications Engineering Branch, National Library of Medicine, Bethesda, MD;
  10. ‡‡Departments of Microbiology and Immunology, and Obstetrics, Gynecology, and Women's Health, Albert Einstein Cancer Center, Albert Einstein College of Medicine, Bronx, NY; and
  11. §§Program for Appropriate Technology in Health, Seattle, WA.
  1. Address correspondence and reprint requests to Julia C. Gage, PhD, MPH, Hormonal and Reproductive Epidemiology Branch, Division of Cancer Epidemiology and Genetics (DCEG), National Cancer Institute, NIH, 6120 Executive Blvd, EPS, Room 5034b, Rockville, MD 20852. E-mail: gagej{at}


Objectives: To estimate efficacy of a visual triage of human papillomavirus (HPV)-positive women to either immediate cryotherapy or referral if not treatable (eg, invasive cancer, large precancers).

Methods: We evaluated visual triage in the HPV-positive women aged 25 to 55 years from the 10,000-woman Guanacaste Cohort Study (n = 552). Twelve Peruvian midwives and 5 international gynecologists assessed treatability by cryotherapy using digitized high-resolution cervical images taken at enrollment. The reference standard of treatability was determined by 2 lead gynecologists from the entire 7-year follow-up of the women. Women diagnosed with histologic cervical intraepithelial neoplasia grade 2 or worse or 5-year persistence of carcinogenic HPV infection were defined as needing treatment.

Results: Midwives and gynecologists judged 30.8% and 41.2% of women not treatable by cryotherapy, respectively (P < 0.01). Among 149 women needing treatment, midwives and gynecologists correctly identified 57.5% and 63.8% (P = 0.07 for difference) of 71 women judged not treatable by the lead gynecologists and 77.6% and 59.7% (P < 0.01 for difference) of 78 women judged treatable by cryotherapy. The proportion of women judged not treatable by a reviewer varied widely and ranged from 18.6% to 61.1%. Interrater agreement was poor with mean pairwise overall agreement of 71.4% and 66.3% and κ's of 0.33 and 0.30 for midwives and gynecologists, respectively.

Conclusions: In future "screen-and-treat" cervical cancer prevention programs using HPV testing and cryotherapy, practitioners will visually triage HPV-positive women. The suboptimal performance of visual triage suggests that screen-and-treat programs using cryotherapy might be insufficient for treating precancerous lesions. Improved, low-technology triage methods and/or improved safe and low-technology treatment options are needed.

  • Cervical intraepithelial neoplasia
  • Cryotherapy
  • Screen-and-treat
  • Human papillomavirus
  • Low-resource settings

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