ACH YEAR 471 000 CASES AND 233 000 deaths occur from cervical cancer worldwide, of which 80% occur in less-developed countries that have access to less than 5% of global cancer treatment resources. 1 The lifetime risk of a woman developing cervical cancer in a lowresource setting is approximately 2% to 4%. [2][3][4] Cytology-based screening programs have markedly reduced the incidence of cervical cancer in developed countries that have the infrastructure to support these programs. 5 However, screening programs have proven difficult to implement in low-resource settings. There are 2 predominant reasons why cytology-based programs have proven difficult to implement and sustain in low-resource settings. One is the nature of the screening test. 6 Highquality cytology laboratories are difficult to maintain and there are often substantial delays before the results become available. 7 Another is the extensive workup that is typically used for women with abnormal cytological results. In developed countries, women with abnor-

Cervical cancer screening strategies that incorporate DVI or HPV DNA testing and eliminate colposcopy may offer attractive alternatives to cytology-based screening programs in low-resource settings.

These results indicate that HPV testing of self-collected vaginal swabs is less specific than but as sensitive as Papanicolaou smears for detecting high-grade cervical disease in women aged 35 years and older, and HPV testing offers an important new way to increase screening in settings where cytology is not readily performed.

BACKGROUND Noncytologic methods of screening for cervical carcinoma and its precursor lesions are needed for resource‐poor settings in which cervical carcinoma continues to be an important cause of morbidity and mortality. METHODS Two thousand nine hundred forty‐four women ages 35–65 years were recruited from Cape Town, South Africa and screened using a combination of a Papanicolaou (Pap) smear, human papillomavirus (HPV) DNA testing, direct visual inspection after the application of a 5% acetic acid solution (DVI), and cervicography. Cervicography was considered primarily as a method with which to quality control the DVI examinations. Women with squamous intraepithelial lesions (SIL) or carcinoma on Pap smear, positive DVI examination (acetowhite lesion or cervical ulcer/growth), high levels of high risk HPV DNA (relative light units [RLU] > 10× positive control), or positive Cervigram™ were referred for colposcopy and cervical biopsy. RESULTS Pap smears were positive in 8.1% of all women screened and identified 65 (78%) of all cases of biopsy confirmed high grade disease (high grade SIL or invasive carcinoma). DVI and cervicography were classified as positive in 18.1% and 10.5%, respectively, of women screened and identified 58 (67%) and 46 (58%) of all cases of high grade disease, respectively. The results of HPV DNA testing varied depending on the cutoff value used to define a positive result. At the standard cutoff level (RLU > 1× positive control), 16.2% of women screened were classified as high risk HPV DNA positive, as were 63 women with high grade disease (73%). CONCLUSIONS DVI and HPV DNA testing identified similar numbers of high grade SIL (cervical intraepithelial neoplasia Grade 2,3) and invasive carcinoma cases as Pap smears. However, both classify considerably more women without cervical disease as being test positive. Cancer 2000;89:826–33. © 2000 American Cancer Society.

HPV DNA testing has a sensitivity equivalent to, or better than, that of cytology. Since HPV DNA testing programs may be easier to implement than cytologic screening, HPV testing should be considered for primary cervical cancer screening in low-resource settings.