CLINICAL ARTICLE See-and-treat management of high-grade squamous intraepithelial lesions in a resource-constrained African setting ☆ Chibuike O. Chigbu a, ⁎, Azubuike K. Onyebuchi b a Department of Obstetrics and Gynecology, University of Nigeria Teaching Hospital, Ituku-Ozalla, Nigeria b Department of Obstetrics and Gynecology, Federal Teaching Hospital, Abakaliki, Nigeria abstract article info Article history: Received 9 April 2013 Received in revised form 24 August 2013 Accepted 27 November 2013 Keywords: Africa High-grade squamous intraepithelial lesions Loop electrosurgical excision procedure See and treat Objective: To compare the treatment outcomes of women with high-grade squamous intraepithelial lesions (HSIL) who underwent immediate loop electrosurgical excision procedure (LEEP) and those who had directed biopsies prior to subsequent LEEP. Methods: Women who were referred for HSIL to 2 centers in southeast Nigeria were examined via colposcopy. Those with positive colposcopic findings were randomized to receive either immediate LEEP (see-and-treat group) or directed biopsies (3-step group). Women with directed biopsy- confirmed results underwent follow-up LEEP. Overtreatment rate, cost, default rate, and cytology–treatment inter- val were compared between the 2 groups. Results: In total, 314 women were included in the study. The overtreat- ment rate was similar between the groups. Treatment cost and cytology–treatment interval were significantly higher in the 3-step group (P = 0.0001). The default rate was significantly lower in the see-and-treat group (P = 0.0001). Most (219 [69.7%]) participants preferred the see-and-treat approach. Conclusion: Immediate see- and-treat LEEP for women with HSIL in southeast Nigeria is cheaper, less time-consuming, and associated with bet- ter patient compliance than the 3-step management procedure. Furthermore, it does not lead to significantly higher overtreatment. The immediate see-and-treat approach may be ideal for the management of women with HSIL in low-resource countries. © 2013 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. 1. Introduction Conventional management of high-grade squamous intraepithelial lesions (HSIL) involves colposcopic examination for abnormalities, colposcopically directed cervical punch biopsies, and recall of biopsy- confirmed cases for loop electrosurgical excision procedure (LEEP). This is sometimes referred to as the 3-step procedure for management of abnormal cervical cytology. This procedure requires repeated clinic visits for diagnosis, confirmation, and treatment procedures—which are time consuming, costly, and associated with considerable loss to follow-up, especially in low-income countries. Evidence from high-income countries indicates that some patients express frustration, anxiety, and other psychological distresses associat- ed with the 3-step procedure [1–3]. This derives mainly from the inter- val between colposcopic biopsy and definitive treatment. Abnormal Papanicolaou (Pap) smear results are associated with anxiety for many patients, and the waiting period between colposcopic biopsy and definitive treatment would certainly compound this anxiety. In Nigeria and other resource-constrained settings, cost and loss of patients to follow-up procedures are important concerns. Few health in- stitutions in Nigeria offer colposcopic services, with currently only 3 in southeastern Nigeria (which has a population of more than 20 million) [4]. Many patients travel long distances to these centers. A previous study from this setting reported that the majority of women in south- eastern Nigeria expect to receive immediate treatment for abnormali- ties detected during cervical cancer screening [5], and anecdotal evidence indicates that some of these women express frustration and anxiety when told that they have to undergo further diagnostic proce- dures before definitive treatment. To these women, this means yet an- other clinic visit, more anxiety, and additional cost. The rate of default from initial colposcopic appointments in southeastern Nigeria has been reported to be slightly above 33% [6], meaning that approximately one-third of women scheduled for initial colposcopic examination do not attend the procedure. It stands to reason that rates of default from further colposcopic procedures after the initial procedure would proba- bly be as high, if not higher. There is, therefore, a need to examine approaches that could reduce the cost and number of clinic visits without compromising efficiency. The see-and-treat approach seems to be promising in this regard. In this approach, definitive treatment is carried out for colposcopically confirmed lesions at the initial colposcopic visit, without prior histologic confirmation. This eliminates the need for a further clinic visit for defin- itive treatment, as occurs in the 3-step procedure. The potential demerit International Journal of Gynecology and Obstetrics 124 (2014) 204–206 ☆ Abstract presented at the 14th Biennial Meeting of the International Gynecologic Cancer Society; October 13–16, 2012; Vancouver, Canada. Chigbu C. ‘See and treat’ man- agement of high-grade abnormal cervical cytology in a resource-constrained African setting: a randomised study. Int J Gynecol Cancer 2012;22(Suppl 3). ⁎ Corresponding author at: Department of Obstetrics and Gynecology, University of Nigeria Teaching Hospital, Ituku-Ozalla, Enugu 402139, Nigeria. Tel.: +234 8037027137. E-mail address: chchigbu@yahoo.com (C.O. Chigbu). 0020-7292/$ – see front matter © 2013 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijgo.2013.07.040 Contents lists available at ScienceDirect International Journal of Gynecology and Obstetrics journal homepage: www.elsevier.com/locate/ijgo