Visual inspection of the uterine cervix after the application of acetic acid in the detection of cervical carcinoma and its precursors

Sankaranarayanan, Rengaswamy; Wesley, Ramani; Somanathan, Thara; Dhakad, Namrata; Shyamalakumary, B.; Amma, N. Sreedevi; Parkin, D. Maxwell; Nair, Muralidharan

doi:10.1002/(sici)1097-0142(19981115)83:10<2150::aid-cncr13>3.3.co;2-s

Cited by 38 publications

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“…The ndings from our cross-sectional study are consistent with the results of published studies from developing countries [12][13][14][15][16][17][18] and several reviews of accuracy of cervical cytology. [20][21][22][23][24][25][26] Our study con rms the large variation in sensitivity between cytology laboratories and indicates that cytology is unable to achieve concurrently high sensitivity and speci city in most situations.…”

Section: Discussionmentioning

confidence: 99%

“…In the cross-sectional studies with veri cation bias, [12][13][14][15][16]18 the sensitivity of cervical cytology to detect HSIL and cancer varied from 13-90% and the speci city ranged from 62-98%. In the cross-sectional study in Harare 17 , the sensitivity, speci city and positive predictive values of cytology were 44.3%, 90.2% and 33.2%, respectively.…”

Section: Discussionmentioning

confidence: 99%

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Accuracy of conventional cytology: results from a multicentre screening study in India

et al. 2004

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Objective:We conducted a multi-centre cross-sectional study in India to evaluate the accuracy of conventional cytology to detect high-grade squamous intraepithelial lesions (HSIL). Setting:Cross-sectional studies in Jaipur, Kolkata, Mumbai and Trivandrum, India, during 1999-2003. Methods: A common protocol and questionnaire were used to test 22,663 women aged 25-65 years with conventional cytology in ve cross-sectional studies. Three thresholds were used to de ne test positivity: atypical squamous cells of uncertain signi cance (ASCUS), low-grade squamous intraepithelial lesion (LSIL), or HSIL. All screened women were investigated with colposcopy, and biopsies were taken when necessary. The reference standard for nal disease status was histology or negative colposcopy. Data from the studies were pooled to evaluate the test characteristics for the detection of histologically con rmed HSIL. Results:The test positivity rates of cytology were 8.8% at ASCUS, 6.2% at LSIL and 1.8% at HSIL thresholds, and 355 women had histologically con rmed HSIL while 74 had invasive cancer. The pooled sensitivity, speci city, positive and negative predictive values at ASCUS threshold were 64.5%, 92.3%, 11.8% and 99.4% respectively. The corresponding values at LSIL threshold were 58.0%, 94.9%, 15.2% and 99.3%, while at the HSIL threshold they were 45.4%, 99.2%, 46.3% and 99.1%. The sensitivity varied between 37.8-81.3% at ASCUS , 28.9-76.9% at LSIL and 24.4-72.3% at HSIL thresholds. A signi cantly low sensitivity was observed in women aged 25-39 years (p<0.001). The wide variation in sensitivity across study sites persisted even after age standardisation. Conclusion:The sensitivity of cytology varied widely between the study sites. Findings from our study and other reviews indicate that sustained efforts in improving sampling, preparation and reading of cytological specimens and improvements in clinical judgement are essential to achieve concurrently high sensitivity and speci city. Cervical cytology screening programmes in developed countries of Western and Northern Europe, North America and Australia have been followed by a substantial reduction in disease burden. However, no signicant reduction in incidence and mortality from cervical cancer has been observed in developing countries where cytology screening programmes exist.2,3 The reasons for the lack of success include poor quality cytology and suboptimal coverage of target women with testing and treatment. Insuf cient sampling of cervical cells, imperfect preparation and staining of smears or failure to correctly identify cellular abnormalities in the smear lead to errors and a high frequency of false-negative reporting. The best estimates of the accuracy of conventional cytology screening based on the currently available data from cross-sectional studies, mostly conducted in developed countries, suggest that the range of sensitivity to detect cervical neoplasia is wide. There have been very few studies in developing countries addressing the test characteristics of cytology.W...

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Accuracy of conventional cytology: results from a multicentre screening study in India

et al. 2004

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“…On the other hand, several studies have shown that, for high-grade dysplasias, visual inspection with acetic acid (VIA) has a high sensitivity (similar to, or better than, cytology under the same study conditions) and with a specificity higher than that obtained by downstaging. [27][28][29][30] The potential of this approach as a screening test suitable for lowresource settings is now under active investigation. 7 …”

Section: Discussionmentioning

confidence: 99%

Evaluation of downstaging in the detection of cervical neoplasia in Kolkata, India

Basu

Sankaranarayanan

Mandal

et al. 2002

Intl Journal of Cancer

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Unaided visual inspection or "downstaging" has been suggested as a potential alternative method for cervical cancer screening in developing countries. Our study was designed to evaluate the accuracy of downstaging to detect cervical neoplasia in a low-resource setting. A total of 6,399 women aged 30 -64 years were screened with downstaging by trained nonmedical health workers. Two thresholds were used to define positive downstaging: "low threshold" when any visible abnormality on the cervix was considered positive and "high threshold" when selected abnormalities such as bleeding on touch, bleeding erosion, hypertrophied oedematous cervix, congested stippled cervix and growth or ulcer constituted the positive test. All women underwent a colposcopy examination. Biopsies were directed when colposcopy revealed abnormal lesions. True disease status was defined as histologically proven moderate dysplasia and worse lesions. Since all the participants received a diagnostic (reference) investigation (biopsy and/or colposcopy), sensitivity, specificity and predictive values were estimated directly. Low-and high-threshold downstaging were positive in 1,585 (24.8%) and 460 (7.2%) women, respectively. Cytology screening for cervical cancer has been successful in reducing the incidence of and mortality from cervical cancer in many developed countries. 1-3 On the other hand, cervical cancer incidence and mortality rates have either remained unchanged or slowly declined in many low-resource developing countries. 4 -7 The primary reason for this is that most of these countries and regions lack effective cervical cancer screening programmes. Some of them have implemented cytology-based screening programmes nationally or regionally that have had very little impact on the incidence and mortality from cervical cancer. 7-9 The prerequisites for the success of cytology-based screening programmes are high coverage of the target population, preparation of goodquality cytology smears, well-equipped laboratory service with internal and external quality-control measures, adequate numbers of well-trained technical personnel, stringent quality assurance, efficient referral system and treatment and follow-up of those with precursor lesions, most of which are not feasible in underdeveloped countries. Therefore, the need for a relatively inexpensive and low-technology alternative to detect cervical neoplasia in low-resource settings has long been felt.Naked-eye visualization of the cervix (without application of acetic acid) by trained health workers has been considered as an option for low-resource countries to detect cervical cancer early and to improve the survival from the disease. 10,11 This approach, known as downstaging or unaided visual inspection (UVI), has been defined as "the detection of the disease in an earlier stage when still curable, by nurses and other nonmedical health workers using a speculum for visual inspection of the cervix". 11Here we report the findings from a cross-sectional study that evaluated the performance of d...

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“…If the outcome of screening and treating women on the basis of a positive DVI test were associated with a low complication rate, high acceptability among women, and a significant reduction in the prevalence of cervical carcinoma and its precursors, then a higher sensitivity at the expense of a lower specificity would be preferable in resource-poor settings. Sankaranarayanan et al 15 trained paramedical personnel to screen 3000 Indian women using DVI (without magnification) and cytology. In that study, the screeners were trained to grade the acetowhite lesions as positive only if a distinct acetowhite area was noted (equivalent to a definite lesion in our study).…”

Section: Using Different Definitions For An Acetowhite Lesionmentioning

confidence: 99%

Direct visual inspection for cervical cancer screening

Denny

Kuhn

Pollack

et al. 2002

Cancer

137

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BACKGROUNDThe authors evaluated direct visual inspection of the cervix after the application of 5% acetic acid (DVI) as a cervical cancer screening test for use in low‐resource settings.METHODSFour tests were used to screen 2754 previously unscreened women: DVI with and without ×4.5 magnification and differentiating between all lesions and well‐circumscribed lesions; testing for high‐risk types of human papillomavirus DNA using the Hybrid Capture II assay, cervical cytology, and Cervicography™. Women with positive results on any of the four screening tests were referred for colposcopy and histologic sampling. All women were tested for N. gonorrhea, C. trachomatis, T. vaginalis, and human immunodeficiency virus 1.RESULTSHistologically confirmed carcinoma was diagnosed in 21 women (0.8%), high‐grade squamous intraepithelial lesions (SILs) were diagnosed in 96 women (3.5%), and low‐grade SILs were diagnosed in 102 women (3.7%). The estimated sensitivity of DVI when performed without magnification for high‐grade SILs was 70%, with an estimated specificity of 79%. Magnification did not significantly improve sensitivity for high‐grade SILs (74% with magnification) but significantly reduced specificity (77%). Restricting the definition of a positive DVI test to a well‐defined acetowhite lesion reduced sensitivity and significantly improved specificity. Infection with T. vaginalis, N. gonorrhea, and C. trachomatis did not alter sensitivity or specificity.CONCLUSIONSThis study confirmed the utility of DVI as a primary screening test. Evaluation of the clinical effectiveness of screening with this low‐cost and simple test in low‐resource settings is necessary. Cancer 2002;94:1699–707. © 2002 American Cancer Society.DOI 10.1002/cncr.10381

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Visual inspection of the uterine cervix after the application of acetic acid in the detection of cervical carcinoma and its precursors

Cited by 38 publications

References 0 publications

Accuracy of conventional cytology: results from a multicentre screening study in India

Accuracy of conventional cytology: results from a multicentre screening study in India

Evaluation of downstaging in the detection of cervical neoplasia in Kolkata, India

Direct visual inspection for cervical cancer screening

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