Visual Inspection using Acetic Acid for Cervical Cancer in Low Resource Settings

High sensitivity but low specificity of the risk factors and symptoms questionnaire in diagnosing female genital schistosomiasis among sexually active women with genital lesions in selected villages of Maswa District, North-Western Tanzania

BACKGROUND

The diagnosis of Female Genital Schistosomiasis (FGS) which is a clinical feature of urogenital schistosomiasis caused by Schistosoma haematobium is challenging, especially in primary healthcare facilities characterized by low resources which are dependent by the majority of the FGS endemic communities. To facilitate and improve diagnosis in these settings, a simple risk factors and symptoms tool has been developed to help healthcare workers at primary healthcare facilities identify and manage FGS cases. However, the sensitivity and specificity of the tool are not known. Therefore, the objective of this study was to assess the performance of risk factors and symptoms tools in diagnosing FGS in adolescent girls and women of reproductive age in selected villages of north-western Tanzania.

METHODS

A community-based analytical cross-sectional study was conducted among 347 women aged 18-49 years in Maswa District, north-western Tanzania. A single urine sample was collected from each participant and screened for S. haematobium eggs using a urine filtration technique. Consenting participants (n = 177), underwent thorough speculum examination by trained gynaecologists using a digital portable colposcopy to capture images of the cervix and vagina. All the captured pictures were examined independently by two pairs (2 gynaecologists in each pair) of qualified obstetricians and gynaecologists. A descriptive analysis and logistic regression were used to demonstrate the prevalence, symptoms, and risk factors of FGS.

RESULTS

The mean age of 347 women enrolled in the study was 30 years (Standard Deviation (SD) ±7.7) and the prevalence of women with symptoms suggestive of FGS was 15.8% (95% CI; 10.8%- 22.0) by colposcope and 87% (95% CI; 83.0%-90.4%) using the risk factor and symptom checklist. The overall sensitivity, specificity, positive and negative predictive value of symptoms and risk factors checklist tool for diagnosing FGS schistosomiasis (≥7 score points) using colposcope as a reference test were 85.7% (95%CI; 80.6%- 90.9%), 8.7% (95%CI; 4.6%-12.9%), 15.0% (95%CI; 9.7%-20.3%) and 76.5% (95%CI; 70.2%-82.7%). Multivariate analysis showed that female genital schistosomiasis using a risk factor and symptom checklist was associated with fetching water in contaminated fresh water (aOR:21.8, 95%CI;2.8-171.2, P <0.003), self-reported pelvic pain (aOR:5.3, 95%CI; 1.1-25.9, P< 0.04) and having any urinary symptoms (aOR:12.2, 95%CI; 1.5-96.3, P<0.018). Urine microscopy results were available for 345 participants, of these, 3.5% (12/345) (95% CI; 1.8%-6.0%) were positive for S. haematobium infection.

CONCLUSION

Female genital schistosomiasis and urinary-related symptoms are common in the current study population. The risk factor and symptoms checklist for diagnosis of FGS achieved high sensitivity but low specificity for women who scored ≥7 points using colposcope as a reference diagnostic test. At present, the call to integrate FGS into the reproductive health services for women has received much attention, however, the diagnostic part of FGS remains a challenge, thus there is a need to continue evaluating this tool in different population and age structures in endemic areas.

Cervical cancer screening outcomes in public health facilities in three states in Nigeria

BACKGROUND

Cervical cancer continues to generate a significant burden of disease and death in low- and middle-income countries (LMICs). Lack of awareness and poor access to early screening and pre-cancer treatment contribute to the high mortality. We describe here cervical cancer screening outcomes in public health facilities in three states in Nigeria.

METHODS

We conducted an observational study in 177 government health facilities in Lagos, Kaduna, and Rivers State, Nigeria from January to December 2021, in which we reviewed programmatic data collected through the newly introduced Cervical Cancer Prevention Program. Women who received screening and provided consent were enrolled into the study. Data were extracted from registers in the health facilities using SurveyCTO and descriptive statistical analysis was conducted using StataSE 15 (StataCorp, College Station, TX, USA).

RESULTS

Eighty-three thousand, five hundred ninety-three women were included in the analysis including 6,043 (7%) WLHIV. 67,371 (81%) received VIA as their primary screening while 16,173 (19%) received HPV DNA testing, with 49 (< 1%) receiving both at the same time. VIA positivity was 7% for WLHIV and 3% for general population, while HPV prevalence was 16% for WLHIV and 8% for general population. Following a positive HPV result, 21% of women referred, completed triage examination. 96% of women identified with precancerous lesions, received treatment. 44% of women with suspected cancer were successfully referred to an oncology center for advanced treatment. Following treatment with thermal ablation, seven adverse events were reported.

CONCLUSIONS

The Program has successfully increased women's access to screening and treatment of precancerous lesions. Almost all women who were eligible for pre-cancerous lesion treatment received it, often on the same day when screened using VIA. However, for women referred for a triage exam or due to suspected cancer, many did not complete their referral visits. More effort is required to ensure HPV positive women and women with suspected cancer are adequately linked to care to further reduce morbidity and mortality associated with cervical cancer in Nigeria. Implementation studies should be conducted to provide insights to improve the utilization of the existing centralized and point of care (POC) platforms to facilitate same day results, and to improve triage and treatment rates.

Provision of cervical cancer prevention services in Northern Uganda: a survey of health workers from rural health centres

Background

Cervical cancer is the leading cancer among Ugandan women, contributing to 40 % of all cancer cases recorded in the cancer registry. Having identified the substantial impact of cervical cancer among Ugandan women, the Ministry of Health in 2010 launched a Strategic Plan for Cervical Cancer prevention and control. This study was conducted to determine if health workers working in rural health centres (HCs) III and IV in Northern Uganda provide cervical cancer screening services as recommended in the Strategic Plan.

Methods

A cross-sectional survey using a structured questionnaire was conducted among nurses, midwives and clinical officers working in rural HC III and IV in Northern Uganda. Data were entered in Epidata 3.1 and analysed using Stata 16 statistical software. Univariate, bivariate, and multivariate analyses were performed. Any factor with p-value ≤ 0.05 was considered a significant predictor of outcome.

Results

We surveyed 286 health workers. Fifty-one (18 %) health workers were screening women for cervical cancer. Fifty-eight (21 %) health workers have guideline for cervical cancer screening in their HCs, 93 (33 %) participants were trained to screen women for cervical cancer. Two hundred sixty-two (92 %) participants provided HPV vaccination. Two hundred forty-six (87 %) participants were conducting health education about cervical cancer in their HCs. Factors associated with screening women for cervical cancer include: being a staff member from HCs III (AOR = 0.30, 95 % CI 0.13–0.68, p = 0.00), being staff of HCs that have organization to support cervical cancer screening services (AOR = 4.38, 95 % CI 1.99–9.63, p-=0.00), being a health worker who had been trained to screen for cervical cancer (AOR = 2.21, 95 % CI 1.00–4.90, p = 0.05) and staff from HCs that has guideline for cervical cancer screening (AOR = 2.89, 95 % CI 1.22–6.86, p = 0.02).

Conclusions

This study shows an overall structural problem related to the delivery of cervical cancer screening services in HC III and IV in Northern Uganda which the Strategic Plan has not addressed. These structural problems need urgent attention if the Uganda government and other sub-Saharan African (SSA) countries are to achieve the World Health Organization (WHO) 90–70–90 targets by 2030 to be on track for cervical cancer elimination.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06795-5.

Cervical cancer prevention in El Salvador: A prospective evaluation of screening and triage strategies incorporating high-resolution microendoscopy to detect cervical precancer

Cervical cancer remains a leading cause of cancer death for women in low- and middle-income countries. The goal of our study was to evaluate screening and triage strategies, including high-resolution microendoscopy (HRME), to detect cervical abnormalities concerning for precancer at the point of care. Women (n = 1824) were enrolled at the Instituto de Cáncer de El Salvador. All underwent screening by both human papillomavirus (HPV) testing using careHPV and visual inspection with acetic acid (VIA). Screen-positives, along with 10% of screen-negatives, were invited to return for a follow-up examination that included triage with VIA, colposcopy and HRME imaging. Biopsies were taken of any abnormalities identified. If no abnormalities were identified, then the worst scoring site by HRME was biopsied. The sensitivities of HPV testing and VIA to screen for cervical intraepithelial neoplasia Grade 2 or more severe diagnoses (CIN2+) were 82.1% and 75% (P = .77), while the specificities were 90.4% and 80.9% (P < .001), respectively. The sensitivities of VIA, colposcopy and HRME as triage tests for CIN2+ were 82.1%, 82.1% and 71.4%, respectively (P ≥ .38). HRME had a significantly higher specificity (66.7%) than VIA (51.9%) (P < .001) and colposcopy (53.3%) (P < .001). When evaluating different theoretical screening and triage strategies, screening with HPV testing followed by triage with HRME would result in more women receiving appropriate care (97%) compared to screening with VIA (75%) or HPV alone (90%). Our findings demonstrate that screening with HPV is superior to VIA, and that triage with HRME imaging increases the specificity of detecting CIN2+ at the point of care in a low-resource setting.

Amplification of specific chromosomal regions assessed by fluorescent in situ hybridization on Pap smears to be added as screening tool for identifying women at risk of progressing to cervical cancer

Cervical carcinoma is a frequent malignancy in developing countries despite being a preventable disease. For the first time, four screening tests were used simultaneously for identifying women with a risk of developing cervical cancer, to help clinicians and policy makers to implement the best strategy for reducing the burden of this disease. Women visiting a hospital in India were enrolled after institutional ethics clearance and informed consent. Visual inspection using acetic acid and Pap smear tests were performed on 2683 women, and 104 had abnormal cytology: atypical squamous cells of undetermined significance (n = 29), low-grade squamous intraepithelial lesion (n = 41), high-grade squamous intraepithelial lesion (n = 17), and squamous cell carcinoma (n = 17). These and 96 samples, with normal cytology, were subjected to high-risk human papilloma virus testing and fluorescent in situ hybridization evaluation. Women with abnormal cytology were followed for 5 years and evaluated with colposcopy-guided biopsy. Three accepted methods of screening and one novel fluorescent in situ hybridization assay were carried out in 200 cases. Cutoffs for fluorescent in situ hybridization were established. The screening methods had 88%-96% negative predictive value, while positive predictive value was low (20%) for visual inspection using acetic acid, 47% for fluorescent in situ hybridization, 56% for high-risk human papilloma virus, and 73% for combined high-risk human papilloma virus and fluorescent in situ hybridization. Combined high-risk human papilloma virus and fluorescent in situ hybridization had 94% sensitivity, specificity, and negative predictive value, suggesting that simultaneous screening with these two tests is appropriate for identifying women progressing to cervical cancer and not visual inspection using acetic acid, which has low positive predictive value and Pap cytology which requires to be repeated. Policy makers and clinicians can assess feasibility of incorporating this screening strategy to prevent cervical cancer.

Current Technologies and Recent Developments for Screening of HPV-Associated Cervical and Oropharyngeal Cancers

Mucosal infection by the human papillomavirus (HPV) is responsible for a growing number of malignancies, predominantly represented by cervical cancer and oropharyngeal squamous cell carcinoma. Because of the prevalence of the virus, persistence of infection, and long latency period, novel and low-cost methods are needed for effective population level screening and monitoring. We review established methods for screening of cervical and oral cancer as well as commercially-available techniques for detection of HPV DNA. We then describe the ongoing development of microfluidic nucleic acid-based biosensors to evaluate circulating host microRNAs that are produced in response to an oncogenic HPV infection. The goal is to develop an ideal screening platform that is low-cost, portable, and easy to use, with appropriate signal stability, sensitivity and specificity. Advances in technologies for sample lysis, pre-treatment and concentration, and multiplexed nucleic acid detection are provided. Continued development of these devices provides opportunities for cancer screening in low resource settings, for point-of-care diagnostics and self-screening, and for monitoring response to vaccination or surgical treatment.

Detection of human papillomavirus in women attending Pap cervical screening camp at a peripheral hospital of North-Eastern India

Human papillomavirus (HPV) associated cervical cancer is the leading cause of deaths in India. However, cytological/HPV screening may result in early detection of cervical cancer, resulting in early treatment and reduced mortality. Although reports related to general population is available, data on HPV prevalence among women attending AFMS health care facilities is scarce. Cervical samples were collected for cytological staining by Pap test and molecular detection by PCR, genotyping by HPV specific primers and sequencing. Apart from finding of atypical cells of undetermined significance (ASCUS) in one subject, no evidence of malignancy was observed. A high prevalence of HPV was found in this study group, which was intermediate between previous reports from general population and cervical cancer patients. All the subjects had infection of high risk HPV type16. HPV prevalence was found similar between different age groups. Although, none of the study subjects had malignant changes, but due to high prevalence of high risk HPV infection and other associated risk factors, these subjects might be at an elevated risk of developing cervical cancer. Regular follow-up of these patients who were detected HPV positive are required to screen for cervical malignancy.