Effectiveness of VIA, Pap, and HPV DNA Testing in a Cervical Cancer Screening Program in a Peri-Urban Community in Andhra Pradesh, India

Abstract

BackgroundWhile many studies have compared the efficacy of Pap cytology, visual inspection with acetic acid (VIA) and human papillomavirus (HPV) DNA assays for the detection cervical intraepithelial neoplasia and cancer, few have evaluated the program effectiveness.Methods and FindingsA population-based sample of 5603 women from Medchal Mandal in Andhra Pradesh, India were invited to participate in a study comparing Pap cytology, VIA, and HPV DNA screening for the detection of CIN3+. Participation in primary screening and all subsequent follow-up visits was rigorously tracked. A 20% random sample of all women screened, in addition to all women with a positive screening test result underwent colposcopy with directed biopsy for final diagnosis. Sensitivity, specificity, positive and negative predictive values were adjusted for verification bias. HPV testing had a higher sensitivity (100%) and specificity (90.6%) compared to Pap cytology (sensitivity = 78.2%; specificity = 86.0%) and VIA (sensitivity = 31.6%; specificity = 87.5%). Since 58% of the sample refused involvement and another 28% refused colposcopy or biopsy, we estimated that potentially 87.6% of the total underlying cases of CIN3 and cancer may have been missed due to program failures.ConclusionsWe conclude that despite our use of available resources, infrastructure, and guidelines for cervical cancer screening implementation in resource limited areas, community participation and non-compliance remain the major obstacles to successful reduction in cervical cancer mortality in this Indian population. HPV DNA testing was both more sensitive and specific than Pap cytology and VIA. The use of a less invasive and more user-friendly primary screening strategy (such as self-collected swabs for HPV DNA testing) may be required to achieve the coverage necessary for effective reduction in cervical cancer mortality.

Effectiveness of a two‐stage strategy with HPV testing followed by visual inspection with acetic acid for cervical cancer screening in a low‐income setting

“…A population-based study conducted in rural India where VIA providers were gynecologists with renowned experience who rigorously followed the JHPIEGO Cervical Cancer Prevention Guidelines for Low-Resource Settings competency-based training tool 35 and who were quality assessed on a yearly basis during the study period, showed a sensitivity of VIA for detecting CIN21 of 26.3%. 36 In a more recent study of 4,656 women in India where screening was performed by well-trained nurses with regular retraining and quality control, sensitivity of VIA to detect CIN2 1 was 21.9%. 37 Another study conducted in United States some years ago where training and monitoring of test providers should have been optimal, found sensitivity of VIA for CIN21 to be 29%.…”

Advancing Cervical Cancer Prevention in India: Implementation Science Priorities

“…Over the past decade, 14 studies have been conducted in India to evaluate the accuracy and effectiveness of cervical cancer screening [23][24][25][26][27][28][29][30][31][32][33][34]. Studies have compared the specificity and sensitivity of visual inspection with acetic acid (VIA) or Lugol's iodine (VILI) and the Papanicolaou test and HPV DNA testing.…”

“…These approaches have been implemented by health workers such as auxiliary nurse midwives ( Table 2). The majority of these studies were cross-sectional in design and involved either community-or hospital-based samples [23][24][25][26][27][28][29][30][31][32]35]; two studies were randomized controlled trials [33, 36 -38]. To determine test sensitivity and specificity, most studies performed colposcopy for all participants and biopsy of abnormalities if indicated; in some, the colposcopist was blinded to the initial screening test results [24,26,27].…”

“…Research has found test specificity of VIA (76.4%-84.2%) to be lower than that of VILI (85.4%-93.4%) and HPV testing (80.7%-81.3%). Cytology testing has the highest specificity (76.1%-99.1%) [23][24][25][26][27][28][29][30][31][32]35].…”

Cost-Effectiveness of Korea's National Cervical Cancer Screening Program

“…It may not be feasible for all women to receive regular Pap smears throughout their lives. Moreover, although the Pap smear is inexpensive, it is less accurate than the HPV-DNA test; therefore, screening at wider intervals with the highlysensitive HPV-DNA test may be more cost-effective than the current system (Gravitt et al, 2010;Levin et al, 2010;Chen et al, 2011;Flores et al, 2011;Shi et al, 2011). While HPV-DNA tests are not covered under the current NCSP, previous studies comparing screening methods have reported that the sensitivity of the Pap smear was improved markedly in combination with the HPV-DNA test (Kim et al, 2013).…”