Screen-and-treat approach in managing cervical cancer precursor lesions: An observational study with 524 women

Published:November 21, 2022DOI:


      • The screen-and-treat approach aims to reduce the losses ascribed to follow-up.
      • No difference was observed in the LLETZ diagnosis in terms of who used this approach.
      • Negative colposcopic findings are more often associated with overtreatment.



      To detect factors related to overtreatment with the “Screen-and-treat” approach (S&T) in women with suspicious cervical precancerous lesions.

      Study design

      A retrospective observational study of 524 women with high-grade squamous intraepithelial lesions (HSIL) or more severe (HSIL+) in cytology, treated by the Large Loop Excision of the Transformation Zone (LLETZ): 161 without a previous biopsy (S&T group) and 363 with a previous biopsy (biopsy group) from January 2017 to July 2020. The main outcome was a diagnosis of LLETZ: negative (negative or low-grade squamous intraepithlelial lesion LSIL) or HSIL+. A negative diagnosis was interpreted as “overtreatment.” Results were analyzed as a function of the S&T approach (whether previous biopsy or not). Variables were obtained from medical records, and were compared with Chi-square or Fisher's exact test (p, p-value), to estimate the chances of a logistic regression analysis (Odds Ratio, OR, or admitting a Confidence Interval (CI) of 95 %).


      No differences were observed in groups regarding menopausal status, smoking, hormonal contraceptive use, colposcopy findings, LLETZ diagnosis, and recurrence. Comparing biopsy vs S&T groups, the frequency of women over 40 years was 28.4 % vs 39.7 % (p = 0.011), and transformation zone type 3 was 12.2 vs 26.8 % (p < 0.001), respectively. In women managed by S&T, when compared to a LLETZ diagnosis, an HSIL+ result was more frequent in women presenting with TZ 1 (93.1 % TZ1 vs 78.5 % TZ2 vs 73.8 % TZ3, p = 0.008) and in women with abnormal colposcopy (92.9 % abnormal vs 38.1 % negative, p < 0.001). Multiple regression analysis found that women with negative colposcopic findings presented a higher risk for negative LLETZ diagnosis (LSIL/Negative final histology) (18.6; 6.18–56.02).


      No difference was observed in the LLETZ diagnosis in women who did or did not use the S&T approach: it was adequate for women referred by cytological HSIL along with high-grade colposcopic findings.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


        • Sung H.
        • Ferlay J.
        • Siegel R.L.
        • Laversanne M.
        • Soerjomataram I.
        • Jemal A.
        • et al.
        Global Cancer Statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries.
        CA Cancer J Clin. 2021; 71: 209-249
        • Vale D.B.
        • Teixeira J.C.
        • Bragança J.F.
        • Derchain S.
        • Sarian L.O.
        • Zeferino L.C.
        Elimination of cervical cancer in low- and middle-income countries: Inequality of access and fragile healthcare systems.
        Int J Gynaecol Obstet Off Organ Int Fed Gynaecol Obstet. 2020;
      1. World Health Organization. A Global Strategy for elimination of cervical cancer n.d. (accessed June 14, 2020).

        • Numnum T.M.
        • Kirby T.O.
        • Leath C.A.
        • Huh W.K.
        • Alvarez R.D.
        • Straughn J.M.
        A prospective evaluation of “see and treat” in women with HSIL Pap smear results: is this an appropriate strategy?.
        J Low Genit Tract Dis. 2005; 9: 2-6
        • Holschneider C.H.
        • Ghosh K.
        • Montz F.J.
        See-and-treat in the management of high-grade squamous intraepithelial lesions of the cervix: a resource utilization analysis.
        Obstet Gynecol. 1999; 94: 377-385
        • Balasubramani L.
        • Orbell S.
        • Hagger M.
        • Brown V.
        • Tidy J.
        Do women with high-grade cervical intraepithelial neoplasia prefer a see and treat option in colposcopy?.
        BJOG Int J Obstet Gynaecol. 2007; 114: 39-45
        • Prendiville W.
        • Cullimore J.
        • Norman S.
        Large loop excision of the transformation zone (LLETZ). A new method of management for women with cervical intraepithelial neoplasia.
        Br J Obstet Gynaecol. 1989; 96: 1054-1060
        • Cárdenas-Turanzas M.
        • Follen M.
        • Benedet J.-L.
        • Cantor S.B.
        See-and-treat strategy for diagnosis and management of cervical squamous intraepithelial lesions.
        Lancet Oncol. 2005; 6: 43-50
      2. Kyrgiou M, Athanasiou A, Kalliala IEJ, Paraskevaidi M, Mitra A, Martin-Hirsch PP, et al. Obstetric outcomes after conservative treatment for cervical intraepithelial lesions and early invasive disease. Cochrane Database Syst Rev 2017;11:CD012847. 10.1002/14651858.CD012847.

        • Kyrgiou M.
        • Arbyn M.
        • Bergeron C.
        • Bosch F.X.
        • Dillner J.
        • Jit M.
        • et al.
        Cervical screening: ESGO-EFC position paper of the European Society of Gynaecologic Oncology (ESGO) and the European Federation of Colposcopy (EFC).
        Br J Cancer. 2020; 123: 510-517
      3. Instituto Nacional de Câncer. Diretrizes Brasileiras para o Rastreamento do Câncer do Colo do Útero 2016 - segunda edição 2016.

      4. Brasil: Instituto Nacional de Câncer. Controle do Câncer do Colo do Útero. INCA - Ações e Programas no Brasil. n.d. (accessed March 13, 2017).

        • Perkins R.B.
        • Guido R.S.
        • Castle P.E.
        • Chelmow D.
        • Einstein M.H.
        • Garcia F.
        • et al.
        2019 ASCCP risk-based management consensus guidelines for abnormal cervical cancer screening tests and cancer precursors.
        J Low Genit Tract Dis. 2020; 24: 102-131
      5. Australian Institute of Health and Welfare. National Cervical Screening Program: Guidelines for the management of screen-detected abnormalities, screening in specific populations and investigation of abnormal vaginal bleeding. Aust Inst Health Welf n.d. (accessed March 24, 2021).

        • Sadan O.
        • Yarden H.
        • Schejter E.
        • Bilavsky E.
        • Bachar R.
        • Lurie S.
        Treatment of high-grade squamous intraepithelial lesions: a “see and treat” versus a three-step approach.
        Eur J Obstet Gynecol Reprod Biol. 2007; 131: 73-75
        • Loopik D.L.
        • Siebers A.G.
        • Melchers W.J.G.
        • Massuger L.F.A.G.
        • Bekkers R.L.M.
        Clinical practice variation and overtreatment risk in women with abnormal cervical cytology in the Netherlands: two-step versus see-and-treat approach.
        Am J Obstet Gynecol. 2020; 222: 354.e1-354.e10
        • Ebisch R.M.F.
        • Rovers M.M.
        • Bosgraaf R.P.
        • van der Pluijm-Schouten H.W.
        • Melchers W.J.G.
        • van den Akker P.
        • et al.
        Evidence supporting see-and-treat management of cervical intraepithelial neoplasia: a systematic review and meta-analysis. BJOG Int.
        J Obstet Gynaecol. 2016; 123: 59-66
        • Teodoro R.P.
        • Scherer D.
        • de Camargo M.J.
        • da Costa A.C.C.
        • de Andrade C.V.
        • Russomano F.
        Negative histology in cervical specimens obtained with the “see and treat” method among women at a referral center in Rio de Janeiro, Brazil: a cross-sectional study.
        BMC Womens Health. 2021; 21: 400
      6. Kiviharju M, Heinonen A, Jakobsson M, Virtanen S, Auvinen E, Kotaniemi-Talonen L, et al. Overtreatment rate after immediate local excision of suspected cervical intraepithelial neoplasia: A prospective cohort study. Gynecol Oncol 2022:S0090-8258(22)01836-4. 10.1016/j.ygyno.2022.09.016.

        • Murdoch J.B.
        The case for early intervention ('see and treat’) in patients with dyskaryosis on routine cervical screening.
        Int J STD AIDS. 1995; 6: 415-417
        • Berdichevsky L.
        • Karmin R.
        • Chuang L.
        Treatment of high-grade squamous intraepithelial lesions: a 2- versus 3-step approach.
        Am J Obstet Gynecol. 2004; 190: 1424-1426
        • Bosgraaf R.P.
        • Mast P.-P.
        • Struik-van der Zanden P.H.T.H.
        • Bulten J.
        • Massuger L.F.A.G.
        • Bekkers R.L.M.
        Overtreatment in a see-and-treat approach to cervical intraepithelial lesions.
        Obstet Gynecol. 2013; 121: 1209-1216
        • Kuroki L.M.
        • Bergeron L.M.
        • Gao F.
        • Thaker P.H.
        • Massad L.S.
        See-and-treat loop electrosurgical excision procedure for high-grade cervical cytology: are we overtreating?.
        J Low Genit Tract Dis. 2016; 20: 247-251
        • Smith H.J.
        • Leath C.A.
        • Huh W.K.
        • Erickson B.K.
        See-and-treat for high-grade cytology: do young women have different rates of high-grade histology?.
        J Low Genit Tract Dis. 2016; 20: 243-246
        • Conner S.N.
        • Frey H.A.
        • Cahill A.G.
        • Macones G.A.
        • Colditz G.A.
        • Tuuli M.G.
        Loop electrosurgical excision procedure and risk of preterm birth: a systematic review and meta-analysis.
        Obstet Gynecol. 2014; 123: 752-761