Performance of alternative strategies for primary cervical cancer screening in sub-Saharan Africa: systematic review and meta-analysis of diagnostic test accuracy studies

Abstract

ObjeCtiveTo assess and compare the accuracy of visual inspection with acetic acid (VIA), visual inspection with Lugol's iodine (VILI), and human papillomavirus (HPV) testing as alternative standalone methods for primary cervical cancer screening in sub-Saharan Africa.Design Systematic review and meta-analysis of diagnostic test accuracy studies. Data sOurCesSystematic searches of multiple databases including Medline, Embase, and Scopus for studies published between January 1994 and June 2014. review methODsInclusion criteria for studies were: alternative methods to cytology used as a standalone test for primary screening; study population not at particular risk of cervical cancer (excluding studies focusing on HIV positive women or women with gynaecological symptoms); women screened by nurses; reference test (colposcopy and directed biopsies) performed at least in women with positive screening results. Two reviewers independently screened studies for eligibility and extracted data for inclusion, and evaluated study quality using the quality assessment of diagnostic accuracy studies 2 (QUADAS-2) checklist. Primary outcomes were absolute accuracy measures (sensitivity and specificity) of screening tests to detect cervical intraepithelial neoplasia grade 2 or worse (CIN2+). results 15 studies of moderate quality were included (n=61 381 for VIA, n=46 435 for VILI, n=11 322 for HPV testing). Prevalence of CIN2+ did not vary by screening test and ranged from 2.3% (95% confidence interval 1.5% to 3.3%) in VILI studies to 4.9% (2.7% to 7.8%) in HPV testing studies. Positivity rates of VILI, VIA, and HPV testing were 16.5% (9.8% to 24.7%), 16.8% (11.0% to 23.6%), and 25.8% (17.4% to 35.3%), respectively. Pooled sensitivity was higher for VILI (95.1%; 90.1% to 97.7%) than VIA (82.4%; 76.3% to 87.3%) in studies where the reference test was performed in all women (P<0.001). Pooled specificity of VILI and VIA were similar (87.2% (78.1% to 92.8%) v 87.4% (77.1% to 93.4%); P=0.85). Pooled sensitivity and specificity were similar for HPV testing versus VIA (both P≥0.23) and versus VILI (both P≥0.16). Accuracy of VIA and VILI increased with sample size and time period. COnClusiOnsFor primary screening of cervical cancer in sub-Saharan Africa, VILI is a simple and affordable alternative to cytology that demonstrates higher sensitivity than VIA. Implementation studies are needed to assess the effect of these screening strategies on the incidence and outcomes of cervical cancer in the region. IntroductionCervical cancer is the leading cause of cancer related deaths among women in limited resource settings (about 230 000 deaths per year). 1 In sub-Saharan Africa, age standardised annual incidence and mortality rates for invasive cervical cancer are 56 and 41 per 100 000 women, respectively, which are the highest rates in the world. 2 Implementation of cytology based screening strategies has improved the control of cervical cancer in developed countries. Replicating these strategies in resource poor countries has been hamper...

Novel Concepts in Cervical Cancer Screening. A Comparison of VIA, HPV DNA Test and p16ink4a/Ki-67 Dual-Stain Cytology in Western Kenya.

“…The overall VIA positivity in our study population (7.1%), diagnosed by well trained and experienced VIA nurses was similar to reports from India 47 , Cameroon 39 and Tanzania 48 but lower than in a metaanalysis of 15 studies in SSA 49 were the pooled estimate of positivity was 17.4% (95&CI 10.4 to 25.6). A high variations in test positivity is observed among VIA studies conducted world wide 49 , such discrepancies in VIA positivity is explained by patient characteristics (age, HIV status, precancer prevalence) and inherent procedure issues (high inter-operator variability, unamenable to quality control).…”

Faisabilité du frottis cervico-utérin chez les femmes séropositives pour le VIH vivant au Tchad

“…La sensibilité de la cytologie pour détecter des lésions CIN 2-3 se situe entre 47 et 62 % et la spécificité de 60 à 95 % [13], alors que la sensibilité et la spécificité de cet examen précédé d'une inspection à l'acide acétique pour le dépistage des lésions pré-cancéreuses (≥ CIN 2), sont respectivement de 68 et 93 % [2,7]. Une méta-analyse récente montrait une légère supério-rité de la coloration au Lugol ® par rapport à celle à l'acide acétique en Afrique subsaharienne [4]. La recherche au niveau cervical par PCR de papillomavirus oncogènes pourrait aussi être un examen utile pour cibler les patientes devant bénéficier d'un suivi régulier, ce virus augmentant significativement le risque de développer un carcinome in situ [6].…”

A systematic review and meta-analysis of studies evaluating the performance of point-of-care tests for human papillomavirus screening

“…However, cervical cancer screening coverage, and linkage to care, is low in LMIC countries where infrastructure and personnel requirements put high demands on the health systems 4. Cytology-based programmes have improved cervical cancer control in developed countries, but implementation in LMIC countries is constrained by cost, lack of infrastructure and trained staff, and lag time between sample collection and availability of test result, leading to delays or losses in management 7. Visual inspection of the cervix using acetic acid (VIA) or Lugol’s iodine (VILI) is frequently practised in low-resource settings as it can be performed by trained midwives and nurses, and requires simple tools to perform (speculum, acetic acid, Lugol’s iodine, lamp).…”