Visual inspection screens for cervical cancer in developing countries
Cervical cancer is still a common cancer among women in developing countries – in 2005 developing countries accounted for 85% of the estimated 493 000 new cases and 273 000 deaths that occurred worldwide. In the developed world, regular cervical cancer screening programmes have substantially reduced the burden of disease among women. But such programmes are not available in the countries that carry the highest burden of disease – namely sub-Saharan Africa, south and south-east Asia, Oceania, Central and South America and the Caribbean.
As a result, visual inspection (VIA) with 3-5% acetic acid has been proposed as an alternative screening method. Several studies have shown VIA to have an acceptable sensitivity in detecting cervical intraepithelial neoplasia (CIN). Modelling has suggested that, in resource-poor countries, single-round VIA screening once a lifetime is a cost effective method to reduce disease burden, but whether or not it can achieve a significant reduction in cervical cancer incidence and mortality in real programme settings is not clear. The Christian Fellowship Community Health Centre, India, and the International Agency for Research on Cancer (IARC) of WHO, France, jointly did a cluster randomised trial to assess the efficacy of VIA screening to reduce cervical cancer incidence and mortality in a high-risk population in India.
This study shows that single-round VIA screening can substantially reduce the incidence of cervical cancer and mortality from the disease. Of the 114 study clusters in Dindigul district, India, 57 were randomised to one round of VIA by trained nurses, and 57 to a control group. Healthy women aged 30 to 59 years were eligible for the study. Screen-positive women had colposcopy, directed biopsies, and, where appropriate, cryotherapy by nurses during the screening visit. Those with larger precancerous lesions or invasive cancers were referred for appropriate investigations and treatment. Of the 49 311 eligible women in the intervention group, 31 343 (63•6%) were screened during 2000–03; 30 958 control women received the standard care. Of the 3 088 (9•9%) screened positive, 3 052 had colposcopy, and 2 539 directed biopsy. Of the 1 874 women with precancerous lesions in the intervention group, 72% received treatment. In the intervention group, 274 430 person years, 167 cervical cancer cases, and 83 cervical cancer deaths were accrued compared with 178 781 person-years, 158 cases, and 92 deaths and in the control group during 2000–06.
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