Concurrent HPV DNA testing and a visual inspection method for cervical precancer screening: A practical approach from Battor, Ghana

Abstract

Cytology-based cervical cancer screening programs have been difficult to implement and scale up in developing countries. Thus, the World Health Organization recommends a ‘see and treat’ approach by way of hr-HPV testing and visual inspection. We aimed to evaluate concurrent HPV DNA testing and visual inspection in a real-world low-resource setting by comparing the detection rates of concurrent visual inspection with dilute acetic acid (VIA) or mobile colposcopy and hr-HPV DNA testing to standalone hr-HPV DNA testing (using the careHPV, GeneXpert, AmpFire, or MA-6000 platforms). We further compared their rates of loss to follow-up. This retrospective, descriptive cross-sectional study included all 4482 women subjected to cervical precancer screening at our facility between June 2016 and March 2022. The rates of EVA and VIA ‘positivity’ were 8.6% (95% CI, 6.7–10.6) and 2.1 (95% CI, 1.6–2.5), respectively, while the hr-HPV-positivity rate was 17.9% (95% CI, 16.7–19.0). Overall, 51 women in the entire cohort tested positive on both hr-HPV DNA testing and visual inspection (1.1%; 95% CI, 0.9–1.5), whereas a large majority of the women tested negative (3588/4482, 80.1%) for both and 2.1% (95% CI, 1.7–2.6) tested hr-HPV-negative but visual inspection ‘positive’. In total, 191/275 (69.5%) participants who tested hr-HPV positive on any platform, as a standalone test for screening, returned for at least one follow-up visit. In light of factors such as poor socioeconomic circumstances, additional transportation costs associated with multiple screening visits, and lack of a reliable address system in many parts of Ghana, we posit that standalone HPV DNA testing with recall of hr-HPV positives will be tedious for a national cervical cancer prevention program. Our preliminary data show that concurrent testing (hr-HPV DNA testing alongside visual inspection by way of VIA or mobile colposcopy) may be more cost-effective than recalling hr-HPV-positive women for colposcopy.

Prevalence of high-risk human papillomavirus infection among women with diabetes mellitus in Accra, Ghana

“…The hr-HPV positivity rate in this cohort of women was almost twice that reported in a group of women screened at an outpatient gynecologic clinic in Accra (10.7%) [ 24 ]. This rate was again higher than the prevalence of 17.9% (95% CI, 16.7–19.0) we found in a prior cohort of women also screened via concurrent testing (hr-HPV DNA testing and visual inspection) using the same tools and test platforms applied in this study [ 25 ]. In contrast, our estimate was much lower than the value reported for another group of women screened in the general population of the North Tongu District of Ghana ( n = 628/1943, 32.3%), with a statistically significant absolute difference of 10.6% (95% CI, 4.5–16.7; p -value = 0.002) [ 26 ].…”

“…Three out of 198 (1.5%) women had thin acetowhitening on visual inspection and were managed conservatively without biopsies. The respective rate was 2.1% (95% CI, 1.6–2.5) in our prior unselected cohort screened with concurrent testing [ 25 ]. It is worth noting that this cohort was much older (median age, 60.2 years) than previously investigated cohorts in Ghana, in which most women screened were in their thirties.…”

Tritesting in Battor, Ghana: an integrated cervical precancer screening strategy to mitigate the challenges of multiple screening visits and loss to follow-up

“…There was the option, after discussion with women with cervical lesions (major/minor changes) on visual inspection, to have a ‘see and treat’ approach, where they undergo ablative treatment (thermal coagulation) even before the results of HPV DNA and Pap tests came in. Such women were required to satisfy the criteria for ablation (no suspicion of invasion and upper limit of the lesion seen) and made to understand that this may result in overtreatment as not all acetowhite lesions are cervical intraepithelial neoplasia (CIN) [ 4 ]. If they could afford the cost of histopathology and consented to it, a biopsy of the lesion would be taken and treatment deferred till the histopathology report was in ( Figure 1 ).…”

“…Because often HPV test results are not immediately available in screening units as a point-of-care test, this sequential approach to screening requires that women visit screening centres at another (sometimes multiple) times. This may be overcome by performing concurrent HPV DNA testing and visual inspection [ 4 ]. At follow-up of hr-HPV-positive women, the visual inspection method (colposcopy or VIA) aims to examine the transformation zone (TZ) where almost all cancers develop [ 5 , 6 ].…”

Enhancing cervical cancer detection and robust classification through a fusion of deep learning models

“…In total, 51 women in the group tested positive on both measures. Out of the 274 individuals who tested positive for hr-HPV in a standalone test, a significant proportion, 191 (69.5%), returned for at least one follow-up visit 18 . Author study explores four distinct subsets: breast vs. cervical cancer, internal vs. external validation, comparing mammography, ultrasound, cytology, and colposcopy, and assessing the performance of deep learning (DL) algorithms versus human doctors.…”