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Excisional therapy outcomes for cervical intraepithelial neoplasia (CIN) in a South African population with high HIV prevalence Priya Batra 1 , Louise Kuhn 2 and Lynette Denny 3 1 College of Physicians and Surgeons, Columbia University

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Excisional therapy outcomes for cervical intraepithelial neoplasia (CIN) in a South African population with high HIV prevalence

Priya Batra1, Louise Kuhn2 and Lynette Denny3

1College of Physicians and Surgeons, Columbia University

2Mailman School of Public Health, Columbia University 3Faculty of Health Sciences - Department of Obstetrics and Gynaecology, University of Cape Town

hiv cervical cancer in south africa
HIV/cervical cancer in South Africa
  • Most common cancer in South African women; relatively high mortality
  • Compounded by HIV (2008 adult prevalence 18.1%)
    • Annual incidence of CIN is four to five times greater in HIV-positive women

WHO/ICO HPV Information Centre, 2007

excisional therapy for cin
Excisional therapy for CIN

Normal cervical epithelium

Cellular atypia with HPV infection – non-invasive CIN

HPV-induced nuclear changes – invasive carcinoma

Large Loop Excision of the Transformation Zone (LLETZ)

William J. Mann, Jr., MD, for UTDOL

objectives
Objectives
  • Describing women undergoing LLETZ in Cape Town’s public health system
  • Evaluating the impact of HIV status on LLETZ outcomes
methods
Methods
  • Design/setting
    • Retrospective chart review
    • Groote Schuur Hospital, Cape Town (primary referral center, Western Cape)
  • Sample
    • All new patients>16 years of age undergoing LLETZ between 01/01/06 and 12/31/08 (n=778)
  • Data time points

Index visit

LLETZ visit

4-month

post-LLETZ visit

excision margins positive for residual cin
Excision margins positive for residual CIN
  • 55.1% of specimens had >1 excision margins positive for CIN
  • Women with >1 positive margins more likely to be HIV-positive (p<0.0001)
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Post-LLETZ treatment outcomes

*Incomplete treatment: LSIL or more severe lesion by Pap smear at 4 months post-LLETZ

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HIV-positive women significantly more likely to have abnormal Pap at 4 months

  • p<0.0001for effect of HIV status on post-LLETZ Pap smear result
  • No protective effect of ART use
findings summary
Findings: summary
  • Post-LLETZ loss to follow-up rate of over 20%
    • HIV-positive women significantly more likely to default
  • HIV-positive women significantly more likely to:
    • Have cervical disease by Pap smear after LLETZ
    • Have excision margins positive for residual CIN
  • No protective effect of ART therapy
    • ART use self-reported; data on duration of therapy/CD4 count unavailable
interpretation and conclusions
Interpretation and conclusions
  • Suboptimal LLETZ treatment outcomes in HIV-positive women (Adam et al. 2008, Lima et al. 2009, Massad et al. 2007)
  • Poor follow-up in HIV-positive women
  • Unclear cervix-specific treatment benefit of ART (Ahdieh-Grant et al. 2004, Heard et al. 2005, Soncini et al. 2007)
interpretation and conclusions14
Interpretation and conclusions
  • Suboptimal LLETZ treatment outcomes in HIV-positive women(Adam et al. 2008, Lima et al. 2009, Massad et al. 2007)
  • Poor follow-up in HIV-positive women
  • Unclear cervix-specific treatment benefit of ART(Ahdieh-Grant et al. 2004, Heard et al. 2005, Soncini et al. 2007)

Cervical surveillance should be emphasized for HIV-positive women in South Africa

acknowledgements
Acknowledgements

University of Cape Town

Dr. R. Soeters

Dr. N. Mbatani

Dr. P. Van Greunen

Dr. R. Boa

Colposcopy clinic staff

Columbia University

Dr. M. Sobieszczyk

Dr. J. Rubin

Western Cape Department of Health

The Doris Duke Charitable Foundation