Cervical screening by visual inspection, HPV testing, liquid‐based and conventional cytology in Amazonian Peru

Abstract

Cervical cancer is an important public health problem in many developing countries, where cytology screening has been ineffective. We compared four tests to identify the most appropriate for screening in countries with limited resources. Nineteen midwives screened 5,435 women with visual inspection (VIA) and collected cervical samples for HPV testing, liquid-based cytology (LBC) and conventional cytology (CC). If VIA was positive, a doctor performed magnified VIA. CC was read locally, LBC was read in Lima and HPV testing was done in London. Women with a positive screening test were offered colposcopy or cryotherapy (with biopsy). Inadequacy rates were 5% and 11% for LBC and CC respectively, and less than 0.1% for VIA and HPV. One thousand eight hundred eightyone women (84% of 2,236) accepted colposcopy/cryotherapy: 79 had carcinoma in situ or cancer (CIS1), 27 had severe-and 42 moderate-dysplasia on histology. We estimated a further 6.5 cases of CIS1 in women without a biopsy. Sensitivity for CIS1 (specificity for less than moderate dysplasia) was 41.2% (76.7%) for VIA, 95.8% (89.3%) for HPV, 80.3% (83.7%) for LBC, and 42.5% (98.7%) for CC. Sensitivities for moderate dysplasia or worse were better for VIA (54.9%) and less favourable for HPV and cytology. In this setting, VIA and CC missed the majority of high-grade disease. Overall, HPV testing performed best. VIA gives immediate results, but will require investment in regular training and supervision. Further work is needed to determine whether screened-positive women should all be treated or triaged with a more specific test. ' 2007 Wiley-Liss, Inc.Key words: Pap smear; hybrid capture; low-resource settings; clinical trial; screening Cervical cancer is the commonest female cancer, a major cause of death and an important public health problem in many developing countries. 1 Screening by routine cytology, using Papanicolaou stain (Pap), has had a major impact on cervical cancer rates in many developed countries, but not in any developing country despite its widespread use. 2-4 A number of other cervical screening tests have been proposed. Here, we wanted to identify the most appropriate test for use in developing countries with high rates of cervical cancer and limited resources.In Peru, as in most Latin American countries, cervical cancer is usually detected in an advanced incurable stage, despite widespread use of cytology screening. 5,6 Others have documented numerous problems of screening in Peru. Samples may be poorly collected, slides may be incorrectly labelled and some never reach the laboratory. Cytology results are sometimes wrongly transcribed or are not reported. 6 Cytology laboratories suffer from deficient infrastructure, inadequate training and supervision, staff shortages, lack of followup procedures and lack of internal and external quality control leading to suboptimal reading of cytology for which considerable expertise is required. This study was set up to investigate a variety of screening tests that may be more effective in such a setting.L...

Evidence-based Screening, Early Diagnosis and Treatment Strategy of Cervical Cancer for National Policy in Low-resource countries: Example of India

“…When physicians and mid-level workers were properly trained and supervised, VIA showed a sensitivity from 41% to 79% (Almonte et al, 2007;Belinson et al, 1999;Megevand et al, 1996;Sankaranarayanan et al, 2004a;Sankaranarayanan et al, 2005b;Sankaranarayanan et al, 2007a;Sauvaget et al, 2011; University of Zimbabwe/JHPIEGO Cervical Cancer Project 1999), and VILI presented a sensitivity from 57% to 98% (Muwonge et al, 2010;Ngoma et al, 2010;Sankaranarayanan et al, 2005a).…”

“…The screening process, along with the delays between screening, test results and ultimate treatment are major obstacles to the success of cytology-based programs in low-resource settings. Although cytology screening has been introduced in LMIC over the past 30 years, it has not resulted in the expected decreases in cervical cancer incidence and mortality similar to those observed in the HIC, primarily because of the above mentioned hurdles associated with low coverage of the target population (Dzuba et al, 2005 the CIN2 and CIN 3 (53% in HIC, and 26-65% in LMIC) (Almonte et al, 2007;Cuzick et al, 2006;Sankaranarayanan et al, 2004b;Sarian et al, 2005), repeated screening at regular intervals is necessary for the programmes to be effective. This low sensitivity in developed countries is overcome by organized periodic screening, which is not feasible with the opportunistic screening carried in low-resource setting.…”

HPV and cervical cancer: screening or vaccination?

“…In Peru, comparisons were made between conventional cytology, liquid-based cytology, VIA and HPV testing (laboratories for HPV tests were out of the country). The study concluded that a strategy involving HPV testing as the primary screening test was the best option, provided that local infrastructure is developed and new HPV testing methods that result in lower cost are used (Almonte et al, 2007). In India, a VIA programme was effective in reducing the incidence of cervical cancer, of advanced cervical cancer and of mortality due to cervical cancer (Sankaranarayanan et al, 2007).…”

Influencing Women's Actions on Cervical Cancer Screening and Treatment in Karawang District, Indonesia

“…Because VIA requires less infrastructure, training, equipment, and specialized personnel than other cervical cancer screening methods, it is well suited to low resource settings. A series of studies has demonstrated its effectiveness (Megevand et al, 1996;Belinson et al, 1999; University of Zimbabwe and Jhpiego, 1999;Mandelblatt et al, 2002;Goldie et al, 2005;Sankaranarayanan et al, 2005Almonte et al, 2007), and over 40 low-income countries have introduced VIA on either a national or pilot-study basis (CCA, 2012).…”