You are on page 1of 10

Conference Theme to which the paper Belongs:- Maternal Health

Cheap & Feasible Cervical Cancer Screening Methods for Developing countries


ABSTRACT Cervical cancer is the second most common cancer in women worldwide and the leading cause of cancer deaths in women in developing countries. It is a disease of unfortunate inequities but also of exciting opportunities. The incidence and mortality rate of cervical cancer have declined significantly in industrialized countries in the past 40 or so years, but in developing countries, this disease continues to be an enormous problem.
Cervical Cancer can be prevented by screening women systematically through organized population based programmes.Cervical cytology is widely adopted cervical cancer screening method ,but because of its cost and complexities involved in its implementation ,developing countries are unable to implement it on the grass root level. As compared to developed world

only 1% women are screened in India and these reasons account for increasing incidence of cervical cancer in developing countries. Alternative cheap and feasible screening programmes are being evaluated for cervical cancer screening and Visual Inspection with Acetic acid (VIA ) and Visual inspection with Lugols Iodine (VILI). They can be implemented in low resource settings like India and can be a mile stone in decreasing incidence of cervical cancer. The alternative approaches as VIA and VILI their method, Practical benefits will be discussed in full length paper. Key words:- Cervical cancer,VIA,VILI Presenting Author:1

Paras wani

Lecturer,D/O Hifzan-e-Sehat A&U Tibbia College,Karol Bagh New Delhi,110053 Mobile No:- 09210960112 Email ID :- 2 Lecturer HAHU Medical college Dewas M.P 3 HOD, Principal & HOD A&U Tibbia College,Karol Bagh. 4 ReaderD/O TST,Jamia Hamdard. 5 HOD D/O TST,Jamia Hamdard.

INTRODUCTION Cancer of the uterine cervix is the second most common cancer among women worldwide. Worldwide, invasive cervical cancer affects 490,000 women each year, resulting in more than 270,000 deaths. Approximately 85 percent of women who die of cervical cancer reside in developing countries. Each year, 75,000 women die of the disease in India alone. If current trends continue, by the year 2050, there will be more than one million new cases of invasive cervical cancer annually1. In India this is the commonest cancer among women and this country has the largest burden of cervical cancer patients in the world. One out of every five women in the world suffering from this disease belongs to India. More than three-fourths of these patients are diagnosed at advanced stages leading to poor prospects of long-term survival and cure. It is estimated that there were 112,609 new Cervical Cancers in 2004 and this number is expected to rise to 139,864 in 20152 .The occurrence of Cervical Cancer varies widely in India and Fig.1 shows the minimum age adjusted incidence rates of Cervical Cancer per 100,000 females by districts 3. Nearly all cases of cervical cancer are associated with HPV, an easily transmissible, highly prevalent, tissue-specific DNA virus. HPV is the most common sexually transmitted infection (STI). There is no treatment for HPV infection4,5,6. Risk factors For women, the risk of contracting HPV infection is affected primarily by sexual activity, in particular the sexual behavior of their partner or partners. HPV infection differs from other STIs, however, in that HPV infection can occur even with nonpenetrative sex (after ejaculation just outside the vagina, for example). Early age at first sexual intercourse is a risk factor for HPV infection because an underdeveloped cervix has an immature epithelium, which can be penetrated more easily by the virus. Co-factors include early age at first parity and infection with HIV or other STIs (e.g., herpes virus or Chlamydia trachomatis). For men, risk factors for HPV infection include having a high number of sexual partners, having same-sex partners, and being uncircumsized7,8,9,10.

Figure 1: Minimum age adjusted Incidence Rates of Cervical Cancer per 100,000 females by district.

Cervical Cancer can be prevented by screening women systematically through organized population based programmes. Screening aims to detect the disease at the precancer stage when it is amenable to simple treatment and cure. In many of the developed countries the annual incidence and mortality from this cancer have gone down by 50-70% since the introduction of population based screening. In India, despite the public health importance that cervical cancer merits, there are only sporadic efforts in hospitals and research settings11. One estimate is that about 75% of women in industrialized countries have been screened within the preceding five years. By contrast, studies in India and estimates in Kenya found that only 1% of participants had ever undergone any screening, despite numerous efforts to improve screening programs12,13. Various studies in India and in other countries have demonstrated the usefulness of alternative strategies such as 'visual inspection with acetic acid' and VILI for 14. Present paper will discuss the details and practical implications of these alternatives approaches. VISUAL INSPECTION WITH ACETIC ACID(VIA) VIA involves applying 3% to 5% acetic acid (vinegar) to the cervix using a spray or a cotton swab and observing the cervix with the naked eye after one minute. If characteristic, well-defined aceto-white areas are seen adjacent to the transformation zone, the test is considered positive for precancerous cell changes or early invasive cancer. VIA does not require a laboratory or intensive staff training. The results are immediately available, allowing treatment during a single visit and thus reducing loss to patient follow-up15,16,17 .

Visual inspection with Lugol’s iodine (VILI)
VILI is similar to VIA but involves applying Lugol’s iodine to the cervix and then examining for mustard-yellow areas. The results of VILI are immediately available, which offers the advantage of follow-up care without delay15.

a. b.

Examination table with knee crutches or leg rests or stirrups; Good light source (preferably a bright halogen lamp that can be easily directed at the cervix or a bright halogen torch light); Sterile bivalved speculum: Cusco's, Grave's or Collin's; Pair of gloves; Cotton swabs, cotton-tipped buds, gauze; Ring forceps, pickup forceps; 5% freshly prepared acetic acid or vinegar (check the strength of acetic acid in vinegar); A steel/plastic container with 0.5% chlorine solution in which to immerse the gloves; A plastic bucket or container with 0.5% chlorine solution to decontaminate instruments.

c. d. e. f. g.



Preparation of Lugol's iodine
Dissolve 10 g of potassium iodide in 100 ml distilled water. Add 5 g of iodine after the potassium iodide is fully dissolved. Stir well until all the iodine flakes have fully dissolved.The solution should be stored in a sealed container to prevent evaporation of iodine and loss of staining activity.

Preparation of 5% dilute acetic acid
5% acetic acid is prepared by adding 5 ml of glacial acetic acid into 95 ml of distilled water. PROCEDURE  After in formed consent lie women in the lithotomy position.  Insert Vaginal Speculum and visualize Squamo-columnar junction.  Apply 5%Acetic acid or logols Idoine and observe findings after one minute.

VIA NEGATIVE VIA screening is reported as negative in the case of any of the following observations:
• • •

No acetowhite lesions are observed on the cervix (Figure 2.1). Polyps protrude from the cervix with bluish-white acetowhite areas (Figure 2.2). Nabothian cysts appear as button-like areas, as whitish acne, or pimples (Figure 2.3). Dot-like areas are present in the endocervix, which are due to grape-like columnar epithelium staining with acetic acid (Figure 2.4). There are shiny, pinkish-white, cloudy-white, bluish-white, faint patchy, or doubtful lesions with ill-defined, indefinite margins, blending with the rest of the cervix (Figures 2.5 - 2.6).

Fig 2.1,2.2,2.3

Fig 2.4,

VIA POSITIVE The VIA test outcome is reported as positive in any of the following situations:

There are distinct, well defined, dense (opaque, dull- or oyster-white) acetowhite areas with regular or irregular margins, close to or abutting the squamocolumnar junction in the transformation zone or close to the external os if the squamocolumnar junction is not visible (Figure 2.7- 2.8).

Strikingly dense acetowhite areas are seen in the columnar epithelium (Figure 2.92.12).

Fig 2.7,2.8,2.9

Fig 2.10,2.11,2.12

VILI NEGATIVE VILI screening is reported as negative in the case of any of the following observations after iodine application:

A normal cervix; the squamous epithelium turns mahogany brown or black and the columnar epithelium does not change colour Patchy, indistinct, ill-defined, colourless or partially brown areas are seen (Figures 3.1-3.3). A leopard-skin appearance (Figure 3.8) is associated with T. vaginalis infection.

Fig 3.1-3.3

VILI POSITIVE The outcome is scored as positive if dense, thick, bright, mustard-yellow or saffronyellow iodine non-uptake areas are seen in the transformation zone, close to or abutting the squamocolumnar junction or close to the os if the squamocolumnar junction is not seen. Fig 3.4,3.5,3.6.

RESULT & DISCUSSION Various studies have been conducted to assess the efficacy of VIA and VILI and almost all of the studies have shown that its sensitivity and specificity is comparable to cervical cytology.A study conducted in India have shown that VIA has sensitivity of 93.4% and specificity of 85.1%18. It can be concluded that VIA’s sensitivity is as good as or better than that of the Pap smear, but like the Pap smear, visual inspection is subjective, and supervision is needed for quality control of visual inspection methods. VIA might not work as well in postmenopausal women because the transformation zone recedes into the cervical canal at menopause15,16,17. The accuracy of VILI testing was evaluated in India and Africa by colposcopy and biopsies with good results 19,20,17,18. CONCLUSION It is evident that these alternative approaches can be used for cervical cancer screening programmes at grass root level. Allied health care professionals can also be trained and these methods can be adopted very effectively in low resource countries like India.

REFERENCES 1.RHO website Preventing cervical cancer,PATH. 2.Burden of Disease in India. Background papers. National Commission on Macroeconomics and Health. September 2005. 3. Development of an Atlas of Cancer in India. Indian Council for Medical Research, 2004 4.Spitzer M. Human papillomavirus: epidemiology, natural history, and clinical sequelae. New Options in HPV Prevention. Supplement to OBG Management. Available at: Accessed July 2006. 5.. Muñoz N, Castellsagué X, Berrington de González, Gissmann L. HPV in the etiology of human cancer. Vaccine. 2006;24(Suppl 3):S1–S10. 6.Cox JT. Introduction. Current Opinions in Obstetrics and Gynecology. 2006;18(Suppl 1):S1–S5. 7. Sankaranarayanan R, Ferlay J. Worldwide burden of gynaecological cancer: the size of the problem. Best Practice & Research Clinical Obstetrics and Gynaecology. 2006;20(2):207–225. 8. Smith JS, Lindsay L, Hoots B, et al. Human papillomavirus type distribution in invasive cervical cancer and high-grade cervical lesions: a meta-analysis update. International Journal of Cancer. 2007;Apr 5. 9. Burchell AN, Winer RL, de Sanjosé S, Franco EL. Epidemiology and transmission dynamics of genital HPV infection. Vaccine. 2006;24(Suppl 3):52–61. 10. Winer R L, Hughes JP, Feng Q, et al. Condom use and the risk of genital papillomavirus infection in young women. New England Journal of Medicine. 2006;354:2645–2654. 11.Guidelines for cervical cancer screening Programmes,Govt of India –WHO Colloboartive Programme(2004-2005),June 2006 PP 1-20. 12 Sankaranarayanan R, Gaffikin L, Jacob M, Sellors J, Robles S. A critical assessment of screening methods for cervical neoplasia. International Journal of Gynecology & Obstetrics. 2005;89(Suppl 2):S4–S12. 13. Bingham A, Bishop A, Coffey P, et al. Factors affecting utilization of cervical cancer prevention services in low-resource settings. Salud Publica de Mexico. 2003;45(Suppl 3)S283–S291.

14 Accuracy of visual screening for cervical neoplasia: results from an IARC multicentre study in India and International Journal of Cancer. 2004, 110: 907-913). 15.Denny L, Quinn M, Sankaranarayanan R. Screening for cervical cancer in developing countries. Vaccine. 2006;24(Suppl 3)S71–S77. 16. Sellors J, Lewis K, Kidula N, Muhombe K, Tsu V, Herdman C. Screening and management of precancerous lesions to prevent cervical cancer in low-resource settings. Asian Pacific Journal of Cancer Prevention. 2003;4:277–280. 17 . Sarian LO, Derchain SF, Naud P, et al. Evaluation of visual inspection with acetic acid (VIA), Lugol’s iodine (VILI), cervical cytology and HPV testing as cervical cancer screening tools in Latin America. This report refers to partial results from the LAMS (Latin American Screening) Study. Journal of Medical Screening. 2005;12(3):142–149. 18. Sankaranarayanan R, detection of cervical cancer with visual inspection methods: a summary of completed and on-going studies in India. 19. Blumenthal PD, Lauterbach M, Sellors JW, Sankaranarayanan R. Training for cervical cancer prevention programs in low-resource settings: focus on visual inspection with acetic acid and cryotherapy. International Journal of Gynecology & Obstetrics. 2005;89(Suppl 2):S30–S37. 20.Sankaranarayanan R, Gaffikin L, Jacob M, Sellors J, Robles S. A critical assessment of screening methods for cervical neoplasia. International Journal of Gynecology & Obstetrics. 2005;89(Suppl 2):S4–S12.