Page 162 - Strategies for non-invasive managementof high-grade cervical intraepithelial neoplasia - prognostic biomarkers and immunotherapy Margot Maria Koeneman

Chapter 8
(-0.19 * 8%) and premature birth (-0.15 * 6%) in order to result in a higher utility score than that for LLETZ treatment.
Table 4. Subgroup analysis
ASC_Imiquimod
Treatment success Premature birth
Subfertility
Vaginal pruritus and/or pain Vaginal discharge
Flu-like symptoms ASC_LLETZ-treatment
Coefficient
0.173
0.081***
-0.156***
-0.190***
-0.022
-0.004
-0.006
3.35***
N.obs=305 N.ind=34
95%CI -0.21-.0.56 0.05 – 0.11 -0.25 – -0.05 -0.26 – -0.11 -0.05 – 0.01 -0.03 –0.020 -0.04 – 0.03 1.84 – 4.86
Coefficient 95%CI
0.118 -0.23–0.46
0.074*** 0.048 – 0.09
-0.054 -0.16 – 0.03
-0.008 -0.08 – 0.06
-0.027* -0.055 – -0.0008
-0.013 -0.035 – 0.008
-0.022 -0.058 – 0.013
5.76*** 4.28 – 7.23
N.obs=473 N. ind=53
Attributes
Women with desire for future pregnancy
Women without desire for future pregnancy
***: p-value< 0.01;**p-value<0.05, *p-value<0.1;
ASC = alternative specific constant
LLETZ = large loop excision of the transformation zone
Discussion
This is the first study reporting on patient preferences in the choice between imiquimod and LLETZ as treatment modalities for high-grade CIN. The results indicate that women derive a positive utility from the standard LLETZ treatment compared to imiquimod treatment. With respect to imiquimod, women prefer a higher treatment success rate and a lower risk of premature birth, infertility, and side effects. Subgroup analysis showed that for women who planned a future pregnancy, imiquimod might be a more acceptable treatment modality than for women without a pregnancy wish if the risk of subfertility and premature birth are low.
The study shows that the preference for imiquimod treatment compared to LLETZ treatment is influenced by a future pregnancy wish. This is understandable, considering that the main advantage of imiquimod treatment is a reduction in future subfertility and premature birth. These findings correspond with the results of a recent survey among gynecologists concerning their experience and attitude regarding imiquimod treatment of high-grade CIN.[10] This survey showed that off-label application of imiquimod in high-grade CIN is largely restricted to patients with a future pregnancy wish and/or recurrent lesions in which (repeated) LLETZ treatment may cause long-term morbidity. Our study shows that in women planning a future pregnancy wish, the side effects of vaginal imiquimod treatment may indeed outweigh the risks of surgical treatment, making imiquimod treatment an acceptable treatment alternative for these women. Treatment efficacy is an important attribute in the decision between LLETZ and imiquimod
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