title: An evaluation by midwives and gynecologists of treatability of cervical lesions by cryotherapy among human papillomavirus-positive women.
abstract: OBJECTIVE
  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 kappa'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.
authors.affiliation: Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Rockville, MD 20852, USA. gagej@mail.nih.gov
authors.forename: Julia C
authors.initials: JC
authors.lastname: Gage
authors.forename: Ana Cecilia
authors.initials: AC
authors.lastname: Rodriguez
authors.forename: Mark
authors.initials: M
authors.lastname: Schiffman
authors.forename: Sydney
authors.initials: S
authors.lastname: Adadevoh
authors.forename: Manuel J Alvarez
authors.initials: MJ
authors.lastname: Larraondo
authors.forename: Bandit
authors.initials: B
authors.lastname: Chumworathayi
authors.forename: Sandra Vargas
authors.initials: SV
authors.lastname: Lejarza
authors.forename: Luis Villegas
authors.initials: LV
authors.lastname: Araya
authors.forename: Francisco
authors.initials: F
authors.lastname: Garcia
authors.forename: Scott R
authors.initials: SR
authors.lastname: Budihas
authors.forename: Rodney
authors.initials: R
authors.lastname: Long
authors.forename: Hormuzd A
authors.initials: HA
authors.lastname: Katki
authors.forename: Rolando
authors.initials: R
authors.lastname: Herrero
authors.forename: Robert D
authors.initials: RD
authors.lastname: Burk
authors.forename: Jose
authors.initials: J
authors.lastname: Jeronimo
mesh_terms: D000328:Adult; D017679:Cryotherapy; D005260:Female; D006176:Gynecology; D006801:Humans; D008875:Middle Aged; D008880:Midwifery; D030361:Papillomavirus Infections / Q000175:diagnosis* / Q000473:pathology / Q000628:therapy* / Q000821:virology; D014218:Triage; D002577:Uterine Cervical Diseases / Q000175:diagnosis* / Q000473:pathology / Q000628:therapy* / Q000821:virology; D002583:Uterine Cervical Neoplasms / Q000175:diagnosis* / Q000473:pathology / Q000628:therapy* / Q000821:virology