Performance of colposcopy in five sub-Saharan African countries

Reliability and diagnostic performance of smartphone colposcopy

OBJECTIVE

To evaluate the interobserver and intraobserver reliability of smartphone colposcopy (SPC) versus conventional colposcopy and to determine diagnostic performance.

METHODS

A smartphone back camera was used to capture cervical images before and after application of acetic acid, and after application of lugol solution. Captured images were reviewed independently by two experienced colposcopists and findings were noted as per colposcopy. Smartphone-based diagnostic performance was calculated, and kappa statistics were used for measurement of agreement between SPC and conventional colposcopy findings.

RESULTS

A total of 114 women were included in the study. The kappa statistic for intraobserver reliability was 0.77 for both normal colposcopic findings and the transformation zone, indicating substantial agreement. Kappa values were 0.54 for acetowhite epithelium, 0.51 for lugol staining, and 0.51-0.60 for atypical vascularization. Kappa values for interobserver reliability were 0.76 for normal colposcopic findings, 0.56 for acetowhite epithelium, and 0.60 for lugol staining. The sensitivity, specificity, PPV, and NPV of SPC for CIN2+ were 88.2 (95% CI, 72.5-96.7), 48.7 (95% CI, 37.4-60.2), 0.42 (95% CI, 0.36-0.48), and 0.91 (95% CI, 0.79-0.96), respectively.

CONCLUSION

SPC showed substantial agreement between the histologic diagnoses based on the captured images and conventional colposcopic findings.

Histologic correlation between smartphone and coloposcopic findings in patients with abnormal cervical cytology: experiences in a tertiary referral hospital

BACKGROUND

Smartphones recently have been applied in the medical setting. However, the literature evaluating the utility of smartphones in gynecologic oncology is limited.

OBJECTIVE

To evaluate the utility of a smartphone in the detection of uterine cervical lesions in patients with abnormal cervical cytology.

STUDY DESIGN

Seventy-five women with abnormal cervical cytology were enrolled. Two doctors independently inspected the uterine cervix by using smartphone or colposcopy. Images were captured using acetic acid, and biopsies were taken as standard-of-care procedures. The diagnostic performance of the smartphone for cervical intraepithelial neoplasm 1 or worse and cervical intraepithelial neoplasm 2 or worse were evaluated, and the kappa value was calculated to determine the chance corrected agreement of the histologic diagnoses based on the smartphone and colposcopic findings.

RESULTS

There was a substantial agreement between histologic diagnoses based on the smartphone and colposcopic findings, with a kappa value of 0.67 (95% confidence interval, 0.43-0.90). The sensitivity, specificity, positive predictive value, and negative predictive value of the smartphone in the diagnosis of cervical intraepithelial neoplasm 1 or worse were 0.89 (95% confidence interval, 0.79-0.96), 0.33 (95% confidence interval, 0.08-0.70), 0.91 (95% confidence interval, 0.81-0.97), and 0.30 (95% confidence interval, 0.07-0.65), respectively. The sensitivity, specificity, positive predictive value, and negative predictive value in the diagnosis of cervical intraepithelial neoplasm 2 or worse were 0.92 (95% confidence interval, 0.81-0.98), 0.24 (95% confidence interval, 0.09-0.45), 0.71 (95% confidence interval, 0.58-0.81), and 0.60 (95% confidence interval, 0.26-0.88), respectively.

CONCLUSION

We found that there was a substantial agreement between the histologic diagnoses based on the smartphone and colposcopic findings. The smartphone seems to be useful and may be an alternative to colposcopy.

Cervical cancer prevention and treatment research in Africa: a systematic review from a public health perspective

BACKGROUND

Women living in Africa experience the highest burden of cervical cancer. Research and investment to improve vaccination, screening, and treatment efforts are critically needed. We systematically reviewed and characterized recent research within a broader public health framework to organize and assess the range of cervical cancer research in Africa.

METHODS

We searched online databases and the Internet for published articles and cervical cancer reports in African countries. Inclusion criteria included publication between 2004 and 2014, cervical cancer-related content pertinent to one of the four public health categories (primary, secondary, tertiary prevention or quality of life), and conducted in or specifically relevant to countries or regions within the African continent. The study design, geographic region/country, focus of research, and key findings were documented for each eligible article and summarized to illustrate the weight and research coverage in each area. Publications with more than one focus (e.g. secondary and tertiary prevention) were categorized by the primary emphasis of the paper. Research specific to HIV-infected women or focused on feasibility issues was delineated within each of the four public health categories.

RESULTS

A total of 380 research articles/reports were included. The majority (54.6 %) of cervical cancer research in Africa focused on secondary prevention (i.e., screening). The number of publication focusing on primary prevention (23.4 %), particularly HPV vaccination, increased significantly in the past decade. Research regarding the treatment of precancerous lesions and invasive cervical cancer is emerging (17.6 %), but infrastructure and feasibility challenges in many countries have impeded efforts to provide and evaluate treatment. Studies assessing aspects of quality of life among women living with cervical cancer are severely limited (4.1 %). Across all categories, 11.3 % of publications focused on cervical cancer among HIV-infected women, while 17.1 % focused on aspects of feasibility for cervical cancer control efforts.

CONCLUSIONS

Cervical cancer research in African countries has increased steadily over the past decade, but more is needed. Tertiary prevention (i.e. treatment of disease with effective medicine) and quality of life of cervical cancer survivors are two severely under-researched areas. Similarly, there are several countries in Africa with little to no research ever conducted on cervical cancer.

Risk of invasive cancer among women visually screened and colposcopy triaged by trained nurses in rural South India

OBJECTIVE

To estimate the long-term risk of cervical cancer among women screened by visual inspection with acetic acid (VIA) and to evaluate the benefit of additional colposcopy triage in rural south India.

METHODS

A retrospective analysis was conducted among 31 343 women who had undergone VIA at Dindigul district, India between January 1, 2000, and August 5, 2003, as part of a randomized screening trial. Women with positive VIA test results were offered colposcopy triage by trained nurses. Cervical cancer incidence data during follow-up (January 1, 2000, to December 31, 2012) were obtained from a regional cancer registry.

RESULTS

Among 3021 screen-positive women free of cancer at baseline, 2974 women underwent colposcopy; colposcopic abnormalities suggestive of precancerous lesions were detected among 2792 of these women (93.9%). Compared with the women with negative VIA screening results, the hazard ratio (HR) of cervical cancer during follow-up among the VIA-positive women without colposcopic abnormalities was 6.5 (95% confidence interval [CI], 1.6-27.1). The risk was similar among VIA-positive women with colposcopic abnormalities but without histological confirmation (HR5.2; 95% CI, 1.9-14.6).

CONCLUSION

The high risk of cancer among women without colposcopic abnormalities who tested positive by VIA suggested that screening without triage is potentially effective.

Physical after effects and clients satisfaction following colposcopy and cervical biopsy in a Nigerian population

BACKGROUND

Although Nigeria has a high prevalence of cervical cancer, screening services including colposcopy and directed cervical biopsy are not widely available.

OBJECTIVES

A prospective study among 111 women who had colposcopy and cervical biopsy following an abnormal Pap smear result at the University of Benin Teaching Hospital in Nigeria. It explored physical after effects experienced and satisfaction of clients after the procedure.

RESULTS

The mean age of the population was 49.5±8.7 years (range, 30 - 64 years) and majority (64.9%) had tertiary education. Overall, 69 women (62.2%) reported physical effects following the procedure. Common physical effects experienced included spotting blood per vaginam (65.2%), pain (34.8%) and vaginal discharge (17.4%). Spontaneous resolution of symptoms occurred within 48 hours in 90.9% of those who reported physical effects. Clients who experienced physical after effects were significantly older (p=0.002) and had tertiary education (p=0.019). Majority of the women (94.6%) were satisfied with the screening services and more than 97% were willing to accept a repeat procedure.

CONCLUSIONS

Although majority of the clients who had colposcopy and cervical biopsy reported they experienced physical side effects, more than 97% were willing to have a repeat procedure. This information can assist colposcopic service providers in counseling clients.

Cervical screening strategies in resourced and resource-constrained countries

Screening for cervical cancer is well established in resourced countries, but in resource-constrained countries, it is almost non-existent at national level. In resourced countries, the Pap test forms the hallmark of screening, with the human papillomavirus DNA test a recent adjunct. In many resourced countries, however, screening for cervical cancer is still far from ideal. A coverage around 50% prevails in some countries, and few have reached the target of 80% or more. Furthermore, the human papillomavirus test and newly developed biomarkers may lead to the development of a 'super test', which could be applied less frequently compared with present-day cytological screening. In resource-constrained countries, the movement is towards a 'screen and treat' approach. The main screening methods under investigation are the visual inspection after diluted acetic acid application test and the human papillomavirus test. Cryotherapy and large loop excision of the transformation zone have been used most often as treatment methods. The ideal seems to be the human papillomavirus test with large loop excision of the transformation zone, provided a low-cost human papillomavirus test becomes available. Coverage is even a greater problem in resource-constrained countries, a problem in need of urgent attention. Resource-constrained countries, however, must curtail the high incidence of cervical cancer, which is often a lower priority than other pressing healthcare needs.

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.