We evaluated the feasibility and performance of visual inspection with acetic acid (VIA) and Lugol's iodine (VILI) for cervical cancer screening in a primary health-care setting in Kinshasa, Congo. Women (1,528) aged 30 years were screened independently by nurses and physicians by VIA and VILI and Pap cytology. Biopsy samples were obtained from women with abnormal colposcopies and from 290 randomly chosen women with normal colposcopy. Cytological and histological examinations were performed in Lyon and Montreal, respectively. The prevalence of cervical intraepithelial neoplasia (CIN) of grades 1, 2 and 3 was 4.5, 1.3 and 4%, respectively. Using biopsy as the reference, the sensitivity, specificity and negative predictive value (NPV) for CIN 2 for VIAnurse were 55.5% (95% CI: 34.7-76.2), 64.6% (95% CI: 62.0-67.1) and 96.8% (95% CI: 93.5-98.7), respectively. The corresponding values for VILI-nurse were 44.0% (95% CI: 24.2-63.8), 74.6% (95% CI: 72.3-76.9) and 96.7% (95% CI: 93.7-98.6). The equivalent parameters for physicians were 71.1% (95% CI: 46.7-95.5), 71.3% (95% CI: 68.9-73.6) and 98.6% (95% CI: 96.0-99.7) for VIA and 68.3% (95% CI: 42.5-94.0), 76.2% (95% CI: 74.0-78.4) and 97.2% (95% CI: 95.3-98.5) for VILI. The sensitivity of cytology ranged between 31 and 72%, depending on the abnormality threshold used to define positivity, with a corresponding specificity range of 94-99% and a NPV range of 97-99%. Our results show that VIA and VILI performed by nurses and physicians are slightly more sensitive but less specific than Pap cytology across multiple combinations of test and lesion thresholds. Given their lower cost and easy deployment, visual inspection methods merit further assessment as cervical cancer screening methods for low-resource countries. ' 2006 Wiley-Liss, Inc.Key words: cervical cancer; screening; Pap cytology; visual inspection; cervical intraepithelial neoplasia Cervical cancer is the most common cancer among women in the developing world, and 60% of all cases occur in South Asia, sub-Saharan Africa and Latin America. 1 In developed countries, Pap smear screening has been successful in reducing the incidence and mortality due to invasive cervical cancer. 2 Cytology-based screening models, however, require technical capabilities and financial support that are not readily available in most developing countries. In the Democratic Republic of Congo (DRC), the scarcity of pathologists and cytotechnologists has prevented the implementation of cytology-based screening programs, which has contributed to that country's high incidence of invasive cervical cancer and to the fact that most cases (80%) present at advanced stage. It is, therefore, critical to seek feasible and cost-effective screening methods as the primary strategy for cervical cancer control in low resource settings.A number of alternative screening methods have been proposed for implementation in developing countries 3 including visual inspection with acetic acid (VIA) and with Lugol's iodine (VILI). VIA and VILI involve inspection of the...
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