Visual inspection screening can reduce cervical cancer, according to a report published today by IARC and Indian scientists in The Lancet.
Cervical cancer is the most common cancer in women in low-resource countries, 85% of the global cervical cancer burden of approximately 493 000 cases and 273 000 deaths being currently found in developing countries. Cervical cancer is a major problem for global public health, said Dr Peter Boyle, Director of IARC.
Age-Standardized incidence rate per 100,000
Screening still a necessity
While new vaccines have been launched recently to prevent infection by the two major types of Human Papillomavirus (HPV) responsible for cervical cancer development, cervical cancer prevention will need to rely on early detection for a number of years before a sizeable reduction in incidence and mortality is seen from affordable and efficient immunization campaigns.
All populations not equal for screening tests
For several decades now, it has been known that the Papanicolaou test ("Pap Smear") is a safe, reliable and effective test for detecting cervical cancer and pre-cancerous lesions. "However, given resources and logistics, it is impossible at present to introduce the Pap smear to all parts of the world", said Dr Rengaswamy Sankaranarayanan, principal author of the study. "On the ground," he added, "in low-resource settings where cervix cancer is very common, we need a practical approach to screening and early detection."
For this reason, Dr Sankaranarayanan and colleagues undertook a randomised controlled trial of a simple technique known as visual inspection screening, which involves the application of acetic acid (4%) on the cervix and naked eye inspection for typical acetowhite coloration of precancerous lesions.
Adapt screening methods to the various settings
In this perspective, the effort by Sankaranarayanan et al.1 assumes enormous public health importance in demonstrating the validity, efficiency and opportunity of low-tech approaches to cancer prevention said Dr Boyle.
This is the largest randomised controlled trial of visual inspection screening for cervical lesions in a low-resource setting, carried out in rural India from 2000 to the present, using a low-tech approach. The scope is wide: over 30 000 women were screened, against approximately the same number of control women. These results emanate from a rigorous study, designed to provide strong scientific evidence, and which has benefited from ethical committees' inputs and approval. A systematic registration of cancer cases from the entire Dindigul district by the Dindigul Ambilikkai Cancer Registry (DACR) played an important role in evaluating the study.
The study shows a number of important findings with wide-ranging implications, said Dr Boyle. There is now evidence from a randomised trial that screening using visual inspection with 4% acetic acid (VIA), in the presence of effective treatment for the lesions found, is effective in reducing incidence and mortality from cervical cancer.
During the study period, 31 343 women were screened using VIA. Among these, 1874 women were diagnosed with precancerous lesions, and 72% received treatment; 167 cervical cancer cases and 83 cervical cancer deaths were observed compared with 158 cases and 92 deaths in the control group during 2000-06 (i.e. women receiving the VIA screening were 25% less likely to be diagnosed with cervical cancer than those who did not and were 35% less likely to die from it).
The study concluded that VIA screening, in the presence of good training and sustained quality assurance, is an effective method for preventing cervical cancer in developing countries.
VIA offers a real-time advantage over other screening methods, particularly in low-resource settings, with the distinct improvement of diagnosis and rapid treatment at one go, meaning minimal dropouts. In addition, a range of healthcare personnel can perform it, from the nurse level up, said Dr Jacob Cherian, Director, Christian Fellowship Community Health Centre, Ambillikai, India.
Dr Sankaranarayanan emphasized that The key to success is providing highly effective training of personnel and ensuring that quality control standards at all parts of the procedure are in place.
While prevailing conditions do differ dramatically between low-resource nations, it is vital to set up organized screening programs in the population, parallel to immunization programs, if we want to have a significant impact on the incidence and mortality from this common cancer, concluded Dr Esmy, Principal Investigator at the Christian Fellowship Community Health Centre, Ambillikai, India.
This study was conducted with active collaboration from the Cancer Institute (WIA), Chennai, the PSG Institute of Medical Sciences, Coimbatore, and Dindigul district administrative authorities and health services. The study was supported by a grant from the Bill & Melinda Gates Foundation through the Alliance for Cervical Cancer Prevention (ACCP), a group of five international organizations with a shared goal of working to prevent cervical cancer in developing countries.
1 Effect of visual screening on cervical cancer incidence and mortality in Tamil Nadu, India: a cluster-randomised trial, by Rengaswamy Sankaranarayanan, Pulikkottil Okkuru Esmy, Rajamanickam Rajkumar, Richard Muwonge, Rajaraman Swaminathan, Sivanandam Shanthakumari, Jean Marie Fayette, Jacob Cherian, in The Lancet, August 4, 2007.
For more detailed information, please contact Dr Sankaranarayanan, at