Efficacy, acceptability and safety of ablative versus excisional procedure in the treatment of histologically confirmed CIN2/3: A systematic review

Background: Outcomes of earlier systematic reviews of the efficacy of ablative and excisional techniques to treat cervical intraepithelial neoplasia grade 2 or 3 (CIN2/3) were biased, as most of the included studies did not compare the techniques head-to-head.

Objective: To systematically review the outcomes of studies comparing ablative and excisional techniques to treat CIN2/3 head-to-head.

Search strategy: Medline, Embase and Global Index Medicus were searched from inception until May 2021.

Selection criteria: Studies directly comparing the efficacy and safety of excisional and ablative treatments on histologically confirmed CIN2/3. Eligibility criteria for the women treated with ablation had to be same as those treated with excision.

Data collection and analysis: A total of 323 articles were archived. Data on the risk of persistence/recurrence and safety were extracted from the original trials. Comparison between the two procedures was reported by forest plots, stratified by follow-up intervals and by HIV status.

Main results: Six publications were included. The risk of persistence/recurrence following ablation was significantly higher than that following excision (overall, RR 1.65, 95% CI 1.25-2.19; at 6-month follow-up, RR 1.94, 95% CI 1.29-2.91; at 12-month follow-up, RR 1.78, 95% CI 1.27-2.51; at 24-month follow-up, RR 1.57, 95% CI 1.11-2.23). The findings remained similar among women living with HIV (WLHIV). Both procedures were equally safe.

Conclusions: Excisional treatment was more effective than ablative treatment, with both procedures having similar safety profiles. Other programmatic considerations will guide the selection of technique, especially in resource-limited settings.