A critical assessment of screening methods for cervical neoplasia

Preventing cancer with vaccines: progress in the global control of cancer

The cancer control community is largely unaware of great advances in the control of major human cancers with vaccines, including the dramatic control of hepatocellular (liver) cancer with hepatitis B virus (HBV) vaccine, now used routinely in more than 90% of countries. The biotechnology revolution has given us a new generation of highly effective vaccines against major global killers, global funding for immunization is orders of magnitude higher than ever before, and the vaccine delivery infrastructure has improved very significantly even in the poorest countries. Liver cancer is the greatest cause of cancer deaths in men of sub-Saharan Africa and much of Asia. Even in highly endemic countries such as China, the prevalence of HB surface antigen carriers has fallen from 10% to 1%-2% in immunized cohorts of children, and liver cancer has already fallen dramatically in Taiwanese children. The Global Alliance for Vaccines and Immunization (now called the GAVI Alliance) has greatly expedited this success by providing HBV vaccine free for five years in most of the world's 72 poorest countries. HBV vaccination can serve as a model for the global control of human papillomavirus (HPV)-related cervical and other cancers with HPV vaccines. Cervical cancer is the greatest cause of cancer death in women in many developing countries; HPV vaccines are highly effective in preventing HPV infection and precancerous lesions in women, and the quadrivalent vaccine also prevents genital warts in men and women and precancerous anal lesions in men. HPV is causing a growing proportion of oropharyngeal cancers, and HPV-related noncervical cancers (penile, anal, and oropharyngeal) may exceed the incidence of cervical cancer within a decade in industrial countries, where cervical screening is effective, causing reevaluation of male HPV immunization. In developing countries, few women are screened for cervical precancerous lesions, making immunization even more important. Currently, 26 primarily industrial countries routinely immunize girls with HPV vaccine, and GAVI will begin to accept applications in 2012 to fund vaccine in developing countries that can deliver the vaccine and if GAVI can negotiate an acceptable price (one manufacturer has already offered a price of $5 per dose).

Accuracy of optical spectroscopy for the detection of cervical intraepithelial neoplasia without colposcopic tissue information; a step toward automation for low resource settings

Optical spectroscopy has been proposed as an accurate and low-cost alternative for detection of cervical intraepithelial neoplasia. We previously published an algorithm using optical spectroscopy as an adjunct to colposcopy and found good accuracy (sensitivity=1.00 [95% confidence interval (CI)=0.92 to 1.00], specificity=0.71 [95% CI=0.62 to 0.79]). Those results used measurements taken by expert colposcopists as well as the colposcopy diagnosis. In this study, we trained and tested an algorithm for the detection of cervical intraepithelial neoplasia (i.e., identifying those patients who had histology reading CIN 2 or worse) that did not include the colposcopic diagnosis. Furthermore, we explored the interaction between spectroscopy and colposcopy, examining the importance of probe placement expertise. The colposcopic diagnosis-independent spectroscopy algorithm had a sensitivity of 0.98 (95% CI=0.89 to 1.00) and a specificity of 0.62 (95% CI=0.52 to 0.71). The difference in the partial area under the ROC curves between spectroscopy with and without the colposcopic diagnosis was statistically significant at the patient level (p=0.05) but not the site level (p=0.13). The results suggest that the device has high accuracy over a wide range of provider accuracy and hence could plausibly be implemented by providers with limited training.

'Worse than HIV' or 'not as serious as other diseases'? Conceptualization of cervical cancer among newly screened women in Zambia

Invasive cervical cancer is the second most common cancer among women worldwide, with approximately 85% of the disease burden occurring in developing countries. To date, there have been few systematic efforts to document African women's conceptualization of cervical cancer after participation in a visual inspection with acetic acid (VIA)-based "see and treat" cervical cancer prevention program. In this study, conducted between September, 2009-July, 2010, focus groups and in-depth interviews were conducted with 60 women who had recently undergone cervical cancer screening at a government-operated primary health care clinic in Lusaka, Zambia. Interviewers elicited participants' causal representations of cervical cancer, associated physical signs and symptoms, perceived physical and psychological effects, and social norms regarding the disease. The lay model of illness causation portrayed by participants after recent exposure to program promotion messages departed in several ways from causal models described in other parts of the world. However, causal conceptualizations included both lay and biomedical elements, suggesting a possible shift from a purely traditional causal model to one that incorporates both traditional concepts and recently promoted biomedical concepts. Most, but not all, women still equated cervical cancer with death, and perceived it to be a highly stigmatized disease in Zambia because of its anatomic location, dire natural course, connections to socially-condemned behaviors, and association with HIV/AIDS. No substantive differences of disease conceptualization existed according to HIV serostatus, though HIV positive women acknowledged that their immune status makes them more aware of their health and more likely to seek medical attention. Further attention should be dedicated to the processes by which women incorporate new knowledge into their representations of cervical cancer.

Pooled analysis of a self-sampling HPV DNA Test as a cervical cancer primary screening method

Background

Worldwide, one-seventh of cervical cancers occur in China, which lacks a national screening program. By evaluating the diagnostic accuracy of self-collected cervicovaginal specimens tested for human papillomavirus (HPV) DNA (Self-HPV testing) in China, we sought to determine whether Self-HPV testing may serve as a primary cervical cancer screening method in low-resource settings.

Methods

We compiled individual patient data from five population-based cervical cancer–screening studies in China. Participants (n = 13 140) received Self-HPV testing, physician-collected cervical specimens for HPV testing (Physician-HPV testing), liquid-based cytology (LBC), and visual inspection with acetic acid (VIA). Screen-positive women underwent colposcopy and confirmatory biopsy. We analyzed the accuracies of pooled Self-HPV testing, Physician-HPV testing, VIA, and LBC to detect biopsy-confirmed cervical intraepithelial neoplasia grade 2 or more severe (CIN2+) and CIN3+. All statistical tests were two-sided.

Results

Of 13 004 women included in the analysis, 507 (3.9%) were diagnosed as CIN2+, 273 (2.1%) as CIN3+, and 37 (0.3%) with cervical cancer. Self-HPV testing had 86.2% sensitivity and 80.7% specificity for detecting CIN2+ and 86.1% sensitivity and 79.5% specificity for detecting CIN3+. VIA had statistically significantly lower sensitivity for detecting CIN2+ (50.3%) and CIN3+ (55.7%) and higher specificity for detecting CIN2+ (87.4%) and CIN3+ (86.9%) (all P values < .001) than Self-HPV testing, LBC had lower sensitivity for detecting CIN2+ (80.7%, P = .015), similar sensitivity for detecting CIN3+ (89.0%, P = .341), and higher specificity for detecting CIN2+ (94.0%, P < .001) and CIN3+ (92.8%, P < .001) than Self-HPV testing. Physician-HPV testing was more sensitive for detecting CIN2+ (97.0%) and CIN3+ (97.8%) but similarly specific for detecting CIN2+ (82.7%) and CIN3+ (81.3%) (all P values <.001) than Self-HPV testing.

Conclusions

The sensitivity of Self-HPV testing compared favorably with that of LBC and was superior to the sensitivity of VIA. Self-HPV testing may complement current screening programs by increasing population coverage in settings that do not have easy access to comprehensive cytology-based screening.

Visual inspection methods for cervical cancer prevention

The need for simple, cost-effective screening approaches for cervical cancer prevention in low-resource countries has led to the evaluation of visual screening with 3-5% acetic acid. The low reproducibility and wide variation in accuracy reflect the subjective nature of the test. Pooled sensitivity, specificity, positive and negative predictive values were 80%, 92%, 10% and 99%, respectively, for detecting cervical intraepithelial neoplasia grade 2 or worse lesions. Realistic sensitivity of a quality- assured single visual inspection with acetic acid is around 50%. A single round of visual inspection with acetic acid screening has been associated with a 25-35% reduction in cervical cancer incidence and the frequency of cervical intraepithelial neoplasia grade 2 or worse lesions in randomised-controlled trials. Despite all its limitations, implementing visual inspection with acetic acid screening in low-resource countries may provide a pragmatic approach to building up human resources and infrastructure that may facilitate the highly anticipated low-cost, rapid human papilloma virus testing in the near future.

Optical technologies and molecular imaging for cervical neoplasia: a program project update

There is an urgent global need for effective and affordable approaches to cervical cancer screening and diagnosis. In developing nations, cervical malignancies remain the leading cause of cancer-related deaths in women. This reality may be difficult to accept given that these deaths are largely preventable; where cervical screening programs have been implemented, cervical cancer-related deaths have decreased dramatically. In developed countries, the challenges of cervical disease stem from high costs and overtreatment. The National Cancer Institute-funded Program Project is evaluating the applicability of optical technologies in cervical cancer. The mandate of the project is to create tools for disease detection and diagnosis that are inexpensive, require minimal expertise, are more accurate than existing modalities, and can be feasibly implemented in a variety of clinical settings. This article presents the status and long-term goals of the project.

Effectiveness of cervical cancer screening using visual inspection with acetic acid in Peru

OBJECTIVE

To evaluate the effectiveness of screening using visual inspection with acetic acid (VIA).

METHODS

In a low-resource area of Peru in 2005-2008, a randomly selected sample of women who had previously screened negative by VIA and Pap (intervention group), and a group of eligible women previously unscreened by VIA (comparison group) were screened by VIA. The outcome measures were histologically confirmed cervical intraepithelial neoplasia (CIN) 2-3 and invasive cervical cancer.

RESULTS

There were 4252 women in the intervention group and 4392 in the comparison group. Histologically confirmed CIN 2 or worse was diagnosed in 31 (0.7%) and 115 (2.6%) women, and invasive cancer was diagnosed in 4 women (0.09%) and 43 women (1.00%), in the intervention and comparison groups, respectively. The adjusted odds ratio was 4.2 (95% confidence interval [CI], 2.7-6.4) for CIN 2 or worse, and 13.9 (95% CI, 4.9-39.6) for invasive cervical cancer in the comparison group.

CONCLUSION

A lower prevalence of CIN 2-3 and invasive cervical cancer was seen in women previously screened by VIA, as compared with women not previously screened by VIA, implying that a single VIA screening can lower the population risk for cervical cancer.

Aspects of prophylactic vaccination against cervical cancer and other human papillomavirus-related cancers in developing countries

Cervical cancer and other human papillomavirus- (HPV-) related cancers are preventable, but preventive measures implemented in developing countries and especially in low-income rural regions have not been effective. Cervical cancer burden derived from sexually transmitted HPV infections is the heaviest in developing countries, and a dramatic increase in the number of cervical cancer cases is predicted, if no intervention is implemented in the near future. HPV vaccines offer an efficient way to prevent related cancers. Recently implemented school-based HPV vaccination demonstration programmes can help tackle the challenges linked with vaccine coverage, and access to vaccination and health services, but prevention strategies need to be modified according to regional characteristics. In urban regions WHO-recommended vaccination strategies might be enough to significantly reduce HPV-related disease burden, but in the rural regions additional vaccination strategies, vaccinating both sexes rather than only females when school attendance is the highest and applying a two-dose regime, need to be considered. From the point of view of both public health and ethics identification of the most effective prevention strategies is pivotal, especially when access to health services is limited. Considering cost-effectiveness versus justice further research on optional vaccination strategies is warranted.

Human papillomavirus: science and technologies for the elimination of cervical cancer

INTRODUCTION

Academic research has made a significant advancement in understanding the viral causes of cervical cancer and generating the technology for prevention, both at the primary and secondary levels. Human papillomaviruses (HPVs) have been recognized as the first necessary cause of cervical cancer, the second most common cancer in women worldwide.

AREAS COVERED

This paper reviews the epidemiological evidence of the causality of HPV in relation to cervical cancer, other genital tract cancers and some cancers of the oral cavity and oropharynx. The review also covers HPV DNA testing as a screening tool. DNA probes of high-risk HPV types in different formats have been fully validated as primary screening tests, as secondary triage tests and as a prognostic marker following treatment of high grade squamous intraepithelial lesions (HSIL). They consistently showed significant superiority over the conventional Pap smears. Biomarkers of the activation of oncogenes (HPV mRNA, p16 and other) are being tested as screening options to improve in sensitivity and specificity, with promising results. HPV vaccines against the two most common HPV types in cancer have completed their Phase III trials with excellent results in efficacy and safety. Combined strategies of HPV vaccination and HPV-based screening tests could theoretically control cervical cancer in any population in which a large coverage with both preventive options is ensured. Accessibility of developing countries to vaccination and low-cost HPV screening options are the barriers to overcome at present.

EXPERT OPINION

This paper provides a synthesis of the evidence available supporting the novel paradigm for cervical cancer prevention that has reached a large consensus within the mainstream HPV and cervical cancer prevention research communities. The available technology for prevention and its developments allows real opportunities for cervical cancer elimination in defined populations to be foreseen.

Global challenges of implementing human papillomavirus vaccines

Human Papillomavirus vaccines are widely hailed as a sweeping pharmaceutical innovation for the universal benefit of all women. The implementation of the vaccines, however, is far from universal or equitable. Socio-economically marginalized women in emerging and developing, and many advanced economies alike, suffer a disproportionately large burden of cervical cancer. Despite the marketing of Human Papillomavirus vaccines as the solution to cervical cancer, the market authorization (licensing) of the vaccines has not translated into universal equitable access. Vaccine implementation for vulnerable girls and women faces multiple barriers that include high vaccine costs, inadequate delivery infrastructure, and lack of community engagement to generate awareness about cervical cancer and early screening tools. For Human Papillomavirus vaccines to work as a public health solution, the quality-assured delivery of cheaper vaccines must be integrated with strengthened capacity for community-based health education and screening.

Knowledge attitudes and practices of cervical cancer screening among urban and rural Nigerian women: a call for education and mass screening

The incidence of cervical cancer has declined in developed nations due to routine use of cervical cancer screening services. In developing nations opportunistic screening is the practice, and many women present with late-stage disease. This study was designed to ascertain the knowledge of the women in Nigeria to cervical cancer, their practice of cervical cancer screening and factors hindering the use of available screening services. A cross-sectional study was done with interviewer-administered questionnaire. Only the consenting women attending an annual Christian religious meeting in 2007 in three towns in Enugu, South Eastern Nigeria participated. Only 15.5% of the respondents were aware of availability of cervical cancer screening services. The awareness significantly varied with the level of educational attainment (P<0.0001). Only 4.2% had ever done Pap smear test and all were referred for screening. The most important factors hindering the use of available cervical cancer screening services were lack of knowledge (49.8%) and the feeling that they had no medical problems (32.0%). There is very poor knowledge and practice of cervical cancer screening among Nigerian women. Effective female education and free mass screening are necessary for any successful cervical cancer screening programme in Nigeria.

Comparison of visual inspection with acetic acid and cervical cytology to detect high-grade cervical neoplasia among HIV-infected women in India

Human immunodeficiency virus (HIV)-infected women in India and other developing country settings are living longer on antiretroviral therapy, yet their risk for human papillomavirus (HPV)-induced cervical cancer remains unabated because of lack of cost-effective and accurate secondary prevention methods. Visual inspection after application of dilute acetic acid on the cervix (VIA) has not been adequately studied against the current standard: conventional cervical cytology (Pap smears) among HIV-infected women. We evaluated 303 nonpregnant HIV-infected women in Pune, India, by simultaneous and independent screening with VIA and cervical cytology with disease ascertainment by colposcopy and histopathology. At the cervical intraepithelial neoplasia (CIN2+) disease threshold, the sensitivity, specificity and positive and negative predictive value estimates of VIA were 80, 82.6, 47.6 and 95.4% respectively, compared to 60.5, 59.6, 22.4 and 88.7% for the atypical squamous cells of undetermined significance or severe (ASCUS+) cutoff on cytology, 60.5, 64.6, 24.8 and 89.4% for the low-grade squamous intraepithelial cells or severe (LSIL+) cutoff on cytology and 20.9, 96.0, 50.0 and 86.3% for high-grade squamous intraepithelial lesion or severe (HSIL+) cutoff on cytology. A similar pattern of results was found for women with the presence of carcinogenic HPV-positive CIN2+ disease, as well as for women with CD4+ cell counts <200 and <350 μL(-1) . Overall, VIA performed better than cytology in this study with biologically rigorous endpoints and without verification bias, suggesting that VIA is a practical and useful alternative or adjunctive screening test for HIV-infected women. Implementing VIA-based screening within HIV/acquired immunodeficiency syndrome care programs may provide an easy and practical means of complementing the highly anticipated low-cost HPV-based rapid screening tests in the near future, thereby contributing to improve program effectiveness of screening.

Eurogin 2010 roadmap on cervical cancer prevention

The EUROGIN 2010 roadmap represents a continuing effort to provide and interpret updated information on cervical cancer screening and vaccination against the cause of the disease, high-risk human papillomavirus (HPV). Contrary to the two previous reports in 2008 and 2009, the present roadmap gives equal room to HPV-based screening and HPV vaccination, as a result of the recent strengthening of the evidence on the efficacy and feasibility of both approaches. The superiority of HPV testing in primary screening compared to cytology (in more developed countries) and to cytology or visual inspection methods (in less developed countries) has been demonstrated in several randomised trials. High vaccine efficacy has been confirmed up to 7 years after vaccination; school-based programmes in some countries have been able to reach over 70% coverage among adolescent girls. Demonstration projects have indicated that the delivery of HPV vaccines in less developed countries is feasible and favourably received by populations where cervical cancer is very common. HPV-based screening can diminish cervical cancer incidence more quickly than HPV vaccination, but vaccination can eventually facilitate screening efforts, especially if new vaccines against a greater number of HPV types are introduced. The availability of two highly complementary prevention tools such as HPV testing and HPV vaccination makes it possible to conceive integrated strategies for the elimination of cervical cancer that have no precedent in the cancer field. HPV tests and HPV vaccines remain, however, too expensive, and large-scale financing of screening and vaccination in less developed countries is sorely lacking.

Human papillomavirus vaccines: new tools for accelerating cervical cancer prevention in developing countries

Despite the available knowledge and tools to prevent cervical cancer, it remains the second most common cancer in women, with four-fifths of the cases occurring in developing countries. Projections are for a 90% increase in global cervical cancer cases by 2020 if no additional public-health interventions are implemented. Prophylactic human papillomavirus (HPV) vaccines, which have proven immunogenicity, safety and efficacy, are now commercially available; and coupled together with quality screening have the potential to dramatically accelerate reductions in cervical cancer mortality rates and save millions of women's lives. The current cost of the new HPV vaccines and new screening technologies, however, are a major barrier to their widespread implementation. There is an urgent need for HPV vaccines and new technologies for effective screening to become more available and affordable, especially to poor communities everywhere.

High grade CIN diagnosis by combined visual inspection with Lugol's iodine and cytology in symptomatic women

OBJECTIVE

To investigate the diagnostic performance of combining the visual inspection with Lugol's iodine (VILI) and cytology screening to detect high-grade cervical intraepithelial neoplasia (CIN-2 or CIN-3) in symptomatic women, using histological examination as the standard reference test.

STUDY DESIGN

Cross-sectional referral study utilizing secondary data from 538 medical records from a clinic specialized in cervical pathology in Brazil.

RESULTS

Although the sensitivity reached 96.8%, the specificity was only 8.1%, with positive predictive value of 18.3% and negative predictive value of 92.3%.

CONCLUSION

The combination of both tests proved to be highly sensitive, leading to a large decrease in the false negative results. This was achieved, however, at the cost of an excess in the rate of false positive results, thus making the combination unviable for screening in symptomatic women.

Accuracy of visual inspection with acetic acid for cervical cancer screening

OBJECTIVE

To provide an updated estimation of the accuracy of visual inspection with acetic acid (VIA) in detecting true disease.

METHODS

A PubMed search provided original studies on VIA accuracy in which the gold standard for confirmatory testing was histology alone or colposcopy followed by biopsy. The numbers of true-positive, false-positive, false-negative, and true-negative results were extracted from each study. Meta-analyses were then performed with different categories of studies according to confirmatory diagnosis threshold, category of women who received confirmatory testing, and whether a medical condition that could affect VIA accuracy was present at screening. The reference category consisted of 26 studies in which VIA was performed on asymptomatic women who all underwent confirmatory testing and in which the disease threshold was cervical intraepithelial neoplasia grade 2.

RESULTS

We report an 80% sensitivity (range, 79%-82%) and a 92% specificity (range, 91%-92%) for VIA. Study region, capacity of screener, or size of the study population did not modify VIA accuracy. The positive predictive value was 10% (range, 9%-10%).

CONCLUSION

Screening for precancerous and cancerous cervical lesions using VIA is a simple, low-cost, and efficient alternative to cytologic testing in low-resource areas.

Costs of cervical cancer screening and treatment using visual inspection with acetic acid (VIA) and cryotherapy in Ghana: the importance of scale

OBJECTIVES

To estimate the incremental costs of visual inspection with acetic acid (VIA) and cryotherapy at cervical cancer screening facilities in Ghana; to explore determinants of costs through modelling; and to estimate national scale-up and annual programme costs.

METHODS

Resource-use data were collected at four out of six active VIA screening centres, and unit costs were ascertained to estimate the costs per woman of VIA and cryotherapy. Modelling and sensitivity analysis were used to explore the influence of observed differences between screening facilities on estimated costs and to calculate national costs.

RESULTS

Incremental economic costs per woman screened with VIA ranged from 4.93 US$ to 14.75 US$, and costs of cryotherapy were between 47.26 US$ and 84.48 US$ at surveyed facilities. Under base case assumptions, our model estimated the costs of VIA to be 6.12 US$ per woman and those of cryotherapy to be 27.96 US$. Sensitivity analysis showed that the number of women screened per provider and treated per facility was the most important determinants of costs. National annual programme costs were estimated to be between 0.6 and 4.0 million US$ depending on assumed coverage and adopted screening strategy.

CONCLUSION

  When choosing between different cervical cancer prevention strategies, the feasibility of increasing uptake to achieve economies of scale should be a major concern.

Comparison of Diagnostic Efficacy of Visual Inspection of Cervix with Acetic Acid and Pap Smear for Prevention of Cervical Cancer: Is VIA Superseding Pap Smear?

Objectives

To estimate diagnostic efficacy of visual inspection with acetic acid (VIA) in comparison to Pap smear.

Methods

This cross-sectional study was carried over a period of 24 months on 200 women attending colposcopy clinic at KLES Dr Prabhakar Kore Hospital and Medical Research Center, Belgaum, India. All women enrolled in study underwent Pap smear, VIA, colposcopy and biopsy. The sensitivity, specificity, PPV, NPV, false-positive rate and false-negative rate were calculated for VIA, Pap smear and colposcopy with biopsy as the reference standard.

Results

In our study, sensitivity and specificity of VIA were found to be 86.95% and 72.51% respectively, and that of Pap smear 37.68% and 92.36% respectively. Colposcopy showed higher sensitivity (94.20%) and specificity (94.65%).

Conclusion

VIA is a suitable primary screening procedure alternative to Pap smear as it has high sensitivity and negative predictive value.

The Prevention of Cervical Cancer in Africa

In this article we aim to draw attention to the burden of cervical cancer in Africa for reproductive health and review strategies for prevention, including appropriate noncytology-based cervical screening and prophylactic human papillomavirus vaccination. We consider the heavy burden of disease attributable to human papillomavirus infection borne by developing countries, particularly in Africa. Following identification of the human papillomavirus as the infectious etiological agent and elucidation of the long natural history of cervical neoplasia, cervical cancer is now one of the most preventable of all cancers. Opportunities for primary prevention by prophylactic vaccination and secondary prevention by appropriate cervical screening are discussed, together with the importance of population coverage. Qualitative work on attitudes towards cervical cancer prevention, education needs, the creation of an environment for informed choice and uptake are essential aspects of effective prevention programs. Cervical cancer poses a huge health burden in Africa. It is a disease that is eminently preventable given political will, the availability of affordable vaccines, appropriate cervical screening and access to cheap, point-of-care human papillomavirus testing. There are a number of unanswered questions for the prevention of cervical cancer and a need for demonstration projects to address these and further develop prevention strategies.

Comparison of Pap smear, visual inspection with acetic acid, and digital cervicography as cervical screening strategies

PURPOSE

To compare the sensitivity, specificity, positive and negative predictive values (PPV and NPV), and accuracy of Pap smear, visual inspection with acetic acid (VIA) and digital cervicography (DC).

METHODS

This is a cross-sectional study on 100 women in the age group of 20-60 years, sequentially using the Pap test, the VIA, and the DC for screening. All women underwent colposcopic biopsy as the gold standard in comparing the methods.

RESULTS

Of the total of 100 women with the mean age 36.0 years, 17 cases were recognized positive for abnormal cervical cell by gold standard. The sensitivity, specificity, PPV, NPV, and accuracy of the Pap test, the VIA, and the DC were 23.5, 100, 100, 86.5, and 87%; 62.5, 98.8, 90.9, 93.2, and 92.9%; and 46.7, 97.6, 77.8, 91, and 89.8%, respectively, for cervical neoplasia.

CONCLUSIONS

The Pap test had low sensitivity but high specificity, whereas VIA had a high sensitivity in addition to being easy and low-cost. Adjuvant methods of screening such as VIA can be a valuable alternative to the Pap test for cervical cancer screening in low-resource settings.

eC3--a modern telecommunications matrix for cervical cancer prevention in Zambia

OBJECTIVES

Low physician density, undercapacitated laboratory infrastructures, and limited resources are major limitations to the development and implementation of widely accessible cervical cancer prevention programs in sub-Saharan Africa.

MATERIALS AND METHODS

We developed a system operated by nonphysician health providers that used widely available and affordable communication technology to create locally adaptable and sustainable public sector cervical cancer prevention program in Zambia, one of the world's poorest countries.

RESULTS

Nurses were trained to perform visual inspection with acetic acid aided by digital cervicography using predefined criteria. Electronic digital images (cervigrams) were reviewed with patients, and distance consultation was sought as necessary. Same-visit cryotherapy or referral for further evaluation by a gynecologist was offered. The Zambian system of "electronic cervical cancer control" bypasses many of the historic barriers to the delivery of preventive health care to women in low-resource environments while facilitating monitoring, evaluation, and continued education of primary health care providers, patient education, and medical records documentation.

CONCLUSIONS

The electronic cervical cancer control system uses appropriate technology to bridge the gap between screening and diagnosis, thereby facilitating the conduct of "screen-and-treat" programs. The inherent flexibility of the system lends itself to the integration with future infrastructures using rapid molecular human papillomavirus-based screening approaches and wireless telemedicine communications.

Evaluation of 'see-see and treat' strategy and role of HIV on cervical cancer prevention in Uganda

Background

There is scant information on whether Human Immunodeficiency Virus (HIV) seropositivity has an influence on the outcome of treatment of precancerous cervical lesions using cryotherapy. We studied the prevalence of cervical abnormalities detectable by visual inspection and cervical lesions diagnosed by colposcopy according to HIV serostatus and described the outcomes of cryotherapy treatment.

Methods

Trained nurses examined women not previously screened for cervical cancer using visual inspection with acetic acid (VIA) and Lugol's iodine (VILI) in two family planning/post natal clinics in Kampala, Uganda, from February 2007 to August 2008. Women with abnormal visual inspection findings were referred for colposcopic evaluation and HIV testing. Women with precancerous cervical lesions detected at colposcopy were treated mainly by cryotherapy, and were evaluated for treatment outcome after 3 months by a second colposcopy.

Results

Of the 5 105 women screened, 834 presented a positive screening test and were referred for colposcopy. Of these 625 (75%) returned for the colposcopic evaluation and were tested for HIV. For the 608 (97.5%) women in the age range 20-60 years, colposcopy revealed 169 women with cervical lesions: 128 had inflammation, 19 had low grade squamous intraepithelial lesion (LGSIL), 13 had high grade squamous intraepithelial lesion (HGSIL), 9 had invasive cervical cancer and 2 had inconclusive findings. Detection rates per 1 000 women screened were higher among the older women (41-60 years) compared to women aged 20-40 years. They were accordingly 55% and 20% for inflammation, 10% and 2% for LGSIL, 5% and 2% for HGSIL, 6% and 1% for invasive cervical cancer.

Of the 608 women, 103 (16%) were HIV positive. HIV positivity was associated with higher likelihood of inflammation (RR = 1.7; 95% CI: 1.2-2.4).

Conclusions

Detection rates were higher among older women 41-60 years. Visual inspection of the cervix uteri with acetic acid (VIA) and Lugol's iodine (VILI) used as a sole method for cervical cancer screening would entail significant false positive results. HIV seropositivity was associated with a higher prevalence of inflammatory cervical lesions. In view of the small numbers and the relatively short follow up time of 3 months, we could not make an emphatic conclusion about the effect of HIV serostatus on cryotherapy treatment outcome.

Research on cancer prevention, detection and management in low- and medium-income countries

The burden of cancer in low- and medium-income countries (LMIC) is expected to increase in the next decades. The application of current knowledge and results of research in key areas would contribute to limit the impact of this phenomenon. Opportunities for research on cancer prevention in LMIC include investigating specific circumstances of exposure to known carcinogens and to agents which are not prevalent in other regions, as well as interactions among carcinogens and between genetic and environmental factors. Early detection both by screening and early clinical diagnosis represents an important component of cancer control in LMIC. Research has been carried out to identify effective and sustainable approaches for early detection of cervical cancer through human papillomavirus testing and visual tests and of oral cancer through visual inspection. For other important neoplasms such as breast cancer, on the other hand, no effective low-cost screening methods are currently available. Downstaging represents a potentially important approach for cancer control and a priority area for future research. Studies addressing the efficacy of treatment protocols, country-specific cost-effectiveness of various interventions and the clinical utility and cost-effectiveness of innovative heath care and communication technologies represent the priority for clinical cancer research.

Prevalence and predictors of colposcopic-histopathologically confirmed cervical intraepithelial neoplasia in HIV-infected women in India

Background

Prevalence estimates of cervical intraepithelial neoplasia (CIN) among HIV-infected women in India have been based on cervical cytology, which may have underestimated true disease burden. We sought to better establish prevalence estimates and evaluate risk factors of CIN among HIV-infected women in Pune, India using colposcopy and histopathology as diagnostic tools.

Methodology

Previously unscreened, non-pregnant HIV-infected women underwent cervical cancer screening evaluation including standardized diagnostic colposcopy by a gynecologist. Histopathologic confirmation was conducted among consenting women with clinical suspicion of CIN. The prevalence of CIN was evaluated by a composite diagnosis based on colposcopy and histopathology results. Multivariable ordinal logistic regression analysis was conducted to determine independent predictors of increasing severity of CIN.

Results

The median age of the n = 303 enrolled HIV-infected women was 30 years (interquartile range, 27–34). A majority of the participants were widowed or separated (187/303, 61.7%), more than one-third (114/302, 37.7%) were not educated beyond primary school, and nearly two-thirds (196/301, 64.7%) had a family per capita income of <1,000 Indian Rupees (∼US$22) per month. Cervical high-risk HPV-DNA was detected in 41.7% (124/297) of participants. The composite colposcopic-histopathologic diagnoses revealed no evidence of CIN in 220 out of 303 (72.6%) women, CIN1 in 33/303 (10.9%), CIN2 in 31/303 (10.2%), CIN3 in 18/303 (5.9%) and 1 (0.3%) woman was diagnosed with ICC. Thus, over a quarter of the participants [83/303: 27.7% (95% CI: 22.7–33.1)] had ≥CIN1 lesions and a sixth [50/303: 16.5% (95% CI: 12.2–21.9)] had evidence of advanced (≥CIN2) neoplastic disease. The independent predictors of increasing severity of CIN as revealed by a proportional odds model using multivariable ordinal logistic regression included (i) currently receiving antiretroviral therapy [adjusted odds ratios (aOR): 2.24 (1.17, 4.26), p = 0.01] and (ii) presence of cervical high-risk HPV-DNA [aOR: 1.93 (1.13, 3.28), p = 0.02].

Conclusions

HIV-infected women in Pune, India have a substantial burden of cervical precancerous lesions, which may progress to invasive cervical cancer unless appropriately detected and treated. Increased attention should focus on recognizing and addressing this entirely preventable cancer among HIV-infected women, especially in the context of increasing longevity due to antiretroviral therapy.

The status of cervical cytology in Swaziland, Southern Africa: a descriptive study

BACKGROUND

Cancer of the cervix is the most common cancer in women in Swaziland where most women never undergo cervical screening. The extremely high prevalence of HIV/AIDS in Swaziland complicates the management of preinvasive and invasive cervical cancer. The purpose of this study was to assess the current status of cervical cytology in Swaziland, its strengths and limitations.

METHODS

The study is a retrospective review of 12,188 conventional cervical smears received by the Central Public Health Laboratory in Swaziland from June 2004 to May 2006.

RESULTS

Review of results showed very high rates of cytologic abnormalities with 43.2% of smears screened reported as abnormal. The percentages of abnormalities were as follows: atypical squamous cells of undermined significance (ASC-US), 19.8%; atypical squamous cells, cannot exclude HSILs (ASC-H), 8.8%; low-grade squamous intraepithelial lesions (LSIL), 9.0%; high-grade squamous intraepithelial lesions (HSIL), 4.6%; squamous cell carcinomas, 0.5%; atypical endocervical cells, 0.6%; and atypical endometrial cells, 0.4%. Just over 5% of smears were inadequate. The highest rates of HSILs and invasive squamous carcinoma occurred in women aged 50-59 years.

CONCLUSIONS

This study underscores the need to reduce the incidence of cervical cancer and its precursor lesions in Swaziland women. Based on studies of human papillomavirus (HPV) types in other Southern African countries, current HPV vaccines would reduce the incidence and mortality from cervical cancer in the future, but cervical screening would still be required, both for women already infected with the HPV and for HPV subtypes not covered by current vaccines. The most cost-effective combination of screening modalities such as visual inspection, HPV DNA testing, and cytology should be investigated. Cervical cancer reduction needs to be managed within the greater framework of the HIV/AIDS epidemic.

Benefits, cost requirements and cost-effectiveness of the HPV16,18 vaccine for cervical cancer prevention in developing countries: policy implications

Approximately 70% of cases of cervical cancer worldwide are caused by genotypes 16 and 18 of human papillomavirus (HPV), which is sexually transmitted. With the availability of an effective vaccine against these HPV types, there is real hope for reducing the global burden of cervical cancer in developing countries. Stakeholders faced with decisions about where to invest money to improve health must consider the burden of disease caused by cervical cancer relative to other priorities and the comparative benefits of different interventions. We conducted a series of analyses to obtain information for agencies drafting immunisation policy recommendations, financing coordination mechanisms, and country decision-makers on the benefits, cost requirements and cost-effectiveness of the HPV16,18 vaccine. We found that making an HPV16,18 vaccine accessible to 70% of young adolescent girls in 72 of the poorest countries, China, Thailand, and all of Latin America and the Caribbean, could prevent the future deaths of more than four million women vaccinated over the next decade. Provided the cost per vaccinated girl is less than $10-$25, adolescent HPV16,18 vaccination would be cost-effective even in relatively poor countries. Concerns about financial costs and affordability highlight the need for lowering vaccine prices, cost-efficient mechanisms for delivery of vaccinations to adolescents, and creative sources of financing.

Achieving effective cervical screening coverage in South Africa through human resources and health systems development

South Africa's cervical screening policy recommends three free Pap smears at ten-year intervals for all women over 30 years of age, aiming to achieve 70% coverage by 2010 by targeting the age group most at risk of developing pre-cancerous cervical lesions. Attaining wide coverage requires an adequate supply of motivated and supported public sector health workers with appropriate training and skills, working in a functional health system. Given the dearth of doctors in South Africa, professional nurses were tasked with performing the bulk of Pap smears at primary care level. Coverage remains sub-optimal and a significant proportion of women with precursor lesions do not receive treatment. Further, health system strengthening - essential for cytology-based screening - has not happened. Research to evaluate alternative screening technologies has proliferated in recent years, but regrettably, strengthening of the health system required to make the new technology work has not received similar attention. Using the South African experience, this article argues that technological interventions and innovations alone are not sufficient to improve cervical screening programmes. Task-shifting is limited unless other human resource concerns (e.g. training, increasing demands on personnel, attrition, and skills mix) are concurrently addressed within a comprehensive workforce development strategy, alongside work to make the health care delivery system functional.

Cervical cancer screening using visual inspection with acetic acid: operational experiences from Ghana and Thailand

Thailand in 2000 and Ghana in 2001 initiated cervical cancer prevention programmes using a single-visit approach with visual inspection with acetic acid (VIA) with cryotherapy for pre-cancerous lesions. This service was integrated into existing reproductive health services, provided by trained nurses. The providers maintained a high level of competence and performance, including after the withdrawal of external funding. In Ghana, independent co-assessments revealed a high level of agreement in diagnosis between providers and a Master Trainer. In Thailand, high quality performance was associated with quality assurance mechanisms such as peer feedback and review of charts and service statistics. Provider performance was maintained at a high level in both countries: an average of 74% of providers from both countries met 85% or more of performance standards. The successful transition from a demonstration project to a national programme in Thailand was dependent on a strong commitment from government health bodies and health professionals. In contrast, the lack of health infrastructure and political will has prevented scale-up to a national programme in Ghana. However, this study shows that a single-visit approach with VIA and cryotherapy is programmatically feasible and sustainable and should be considered in national investments to control cervical cancer.

Cancer prevention in the developing world: mission impossible?

Cancer is set to become the newest epidemic in the developing world. This fact is still largely unknown. The UICC, therefore, has been acting in order to inform policymakers, with the aim of pushing them to act in order to tackle this looming disaster. The implementation of a cancer control plan, encompassing prevention, screening and treatment in each country, should therefore become the declared goal of all health policymakers worldwide.

Evaluation of cervical screening in rural North India

OBJECTIVE

To assess the accuracy of cervical screening with visual inspection and cytology testing, and the cure rate of cervical intraepithelial neoplasia (CIN) after treatment, in a rural population in North India.

METHODS

A cross-sectional study evaluated the detection rates of CIN 2 and CIN 3 lesions by cytology testing and by visual inspection of the cervix following the application of 5% acetic acid (VIA) or Lugol's iodine (VILI). It also evaluated the cure rates following treatment of CIN.

RESULTS

Of 5050 women approached in 17 villages, 3000 (59.4%) participated (range, 41%-91%). Of these, 14.2% were positive by VIA, 15.6% by VILI, and 5.4% by cytology testing at ASCUS threshold, and 37 women were diagnosed as having CIN 1 and 20 as having CIN 2 or CIN 3. Detection rates of CIN 2 or 3 using VIA, VILI, and cytologic findings of ASCUS and LSIL were 3.7, 3.3, 4.5, and 4.2 per 1000 women, respectively, and 91.4% of the treated women were cured.

CONCLUSION

Both VIA and VILI were found to be accurate screening tests and the cure rates for CIN were satisfactory.

Overview of human papillomavirus-based and other novel options for cervical cancer screening in developed and developing countries

Screening for cervical cancer precursors by cytology has been very successful in countries where adequate resources exist to ensure high quality and good coverage of the population at risk. Mortality reductions in excess of 50% have been achieved in many developed countries; however the procedure is generally inefficient and unworkable in many parts of the world where the appropriate infrastructure is not achievable. A summary and update of recently published meta-analyses and systematic reviews on four possible clinical applications of human papillomavirus (HPV) DNA testing is provided in this article: (1) triage of women with equivocal or low-grade cytological abnormalities; (2) follow-up of women with abnormal screening results who are negative at colposcopy/biopsy; (3) prediction of the therapeutic outcome after treatment of cervical intraepithelial neoplasia (CIN), and most importantly (4) primary screening HPV DNA test, solely or in combination with Pap smear to detect cervical cancer precursors. There are clear benefits for the use of HPV DNA testing in the triage of equivocal smears, low-grade smears in older women and in the post-treatment surveillance of women after treatment for CIN. However, there are still issues regarding how best to use HPV DNA testing in primary screening. Primary screening with Hybrid Capture((R)) 2 (HC2) generally detects more than 90% of all CIN2, CIN3 or cancer cases, and is 25% (95% CI): 15-36%) relatively more sensitive than cytology at a cut-off of abnormal squamous cells of undetermined significance (ASC-US) (or low-grade squamous intraepithelial lesions (LSIL) if ASC-US unavailable), but is 6% (95% CI: 4-7%) relatively less specific. Several approaches are currently under evaluation to deal with the lower specificity of HPV DNA testing as associated with transient infection. These include HPV typing for HPV-16 and -18/45, markers of proliferative lesions such as p16 and mRNA coding for the viral E6 and/or E7 proteins, with a potential clinical use recommending more aggressive management in those who are positive. In countries where cytology is of good quality, the most attractive option for primary screening is to use HPV DNA testing as the sole screening modality with cytology reserved for triage of HPV-positive women. Established cytology-based programmes should also be gradually moving towards a greater use of HPV DNA testing to improve their efficacy and safely lengthen the screening interval. The greater sensitivity of HPV DNA testing compared to cytology argues strongly for using HPV DNA testing as the primary screening test in newly implemented programmes, except where resources are extremely limited and only programmes based on visual inspection are affordable. In such countries, use of a simple HPV DNA test followed by immediate 'screen and treat' algorithms based on visual inspection in those who are HPV-positive are needed to minimise the number of visits and make best use of limited resources. A review of studies for visual inspection methods is presented. The fact that HPV is a sexually transmitted infection may lead to anxiety and concerns about sexual relationships. These psychosocial aspects and the need for more information and educational programmes about HPV are also discussed in this article.

Chapter 8: Screening for cervical cancer in developing countries

Organised and quality assured cytology-based screening programmes have substantially reduced cervical cancer incidence in many developed countries. However, there are considerable barriers to setting up cytology-based screening programs, particularly in developing countries. This has stimulated the search for novel and alternative approaches to cytology for cervical cancer prevention. These approaches generally perform as well as cytology, and sometimes better, although many of them have a lower specificity, resulting in higher false-positive rates. The possibility of linking screening to treatment in a one- or two-visit strategy appears to be safe, feasible and effective. Barriers to establishing screening programs and the pitfalls encountered differ from one country to the next. Country-specific solutions need to be found, while being cognizant of the criteria that have enabled successful screening programmes.

Optical imaging for cervical cancer detection: solutions for a continuing global problem

Cervical cancer is the leading cause of cancer death for women in developing countries. Optical technologies can improve the accuracy and availability of cervical cancer screening. For example, battery-powered digital cameras can obtain multi-spectral images of the entire cervix, highlighting suspicious areas, and high-resolution optical technologies can further interrogate such areas, providing in vivo diagnosis with high sensitivity and specificity. In addition, targeted contrast agents can highlight changes in biomarkers of cervical neoplasia. Such advances should provide a much needed global approach to cervical cancer prevention.