Cervical cancer screening programmes in resource-limited settings

Clinical performance of digital cervicography and cytology for cervical cancer screening in HIV-infected women in Lusaka, Zambia.

Bateman AC, Parham GP, Sahasrabuddhe VV, Mwanahamuntu MH, Kapambwe S, Katundu K, Nkole T, Mulundika J, Pfaendler KS, Hicks ML, Shibemba A, Vermund SH, Stringer JS, Chibwesha. J Acquir Immune Defic Syndr. 2014 Oct 1;67(2):212-5. doi: 10.1097/QAI.0000000000000270.

Although there is a growing literature on the clinical performance of visual inspection with acetic acid in HIV-infected women, to the best of our knowledge, none have studied visual inspection with acetic acid enhanced by digital cervicography. We estimated clinical performance of cervicography and cytology to detect cervical intraepithelial neoplasia grade 2 or worse. Sensitivity and specificity of cervicography were 84% (95% confidence interval [CI]: 72 to 91) and 58% (95% CI: 52 to 64). At the high-grade squamous intraepithelial lesion or worse cutoff for cytology, sensitivity and specificity were 61% (95% CI: 48 to 72) and 58% (95% CI: 52 to 64). In our study, cervicography seems to be as good as cytology in HIV-infected women.

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Editor’s notes: Cervical cancer is the most common female malignancy in sub-Saharan Africa and the leading cause of cancer-related mortality. Women living with HIV have a higher incidence and prevalence of infection with human papilloma virus (HPV), and are less able to clear the virus. Persistence of high-risk types of HPV infection is a prerequisite for development of cervical cancer. In high-income countries, screening programmes which incorporate regular cervical cytology (one to five yearly) to detect pre-cancerous lesions, have reduced mortality; however cytology is labour intensive and technically challenging. As a result cervical screening is not widely available in resource-limited settings. Alternative screening strategies, including visual inspection with acetic acid (VIA) with onward referral for colposcopy if abnormal lesions are visualised, are practiced in some settings, although coverage is low.

This study reports on the sensitivity and specificity of VIA enhanced by digital photography. The addition of digital photography allows magnification of surface morphology, and facilitates telemedicine support and quality assurance of screening programmes.  All individuals had cytology, VIA, photographs and biopsies taken at the same visit. Cervical biopsies were taken from the abnormal area and from a normal area of the transformation zone with the gold standard defined as cervical intraepithelial neoplasia grade 2or 3 or adenocarcinoma in situ (CIN2+) lesion on histopathology of either site. VIA with digital photography had a higher sensitivity than cytology (84% and 61% respectively) but specificity was low with both techniques (58% each). Results are broadly comparable to those reported from other studies evaluating VIA in women living with HIV. This approach is certainly more feasible to implement in resource-limited settings and if programme coverage is high, may impact on mortality. However, given the low specificity, over-treatment is likely. As the authors illustrate there is definitely a need to develop other screening strategies based on point-of-care biomarkers if we are to see a significant impact on mortality due to cervical cancer in resource-limited settings.

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