Mounir Khatib

Background. More than one-half a million women are diagnosed worldwide with cervical cancer annually. Of the approximately 270,000 cervical cancer-related deaths in 2015, 90% were from low-income and middle-income countries (LMIC). Screening methods include the Papanicolaou Smear (Pap Smear), which requires the harvesting of cervical cells (including the transformation zone) during a pelvic for cytology; HPV-based screening has been increasing as an alternative or adjunct, with large randomized control trials showing an improvement in detecting pre-cancerous cells¹. Both Pap smears and HPV testing are resource and personnel-intensive (requiring gynecologists, pathologists, and/or expensive specialized equipment). In LMIC, less expensive, time-efficient, point-of-care methods for screening, specifically visual inspection with acetic acid (VIA) and visual inspection with Lugol’s solution (VILI), are promising, with some detractors².

Search Methods. The study, conducted in several Latin American countries, focuses on women aged 30-64 attending cervical screening clinics. Participants undergo pelvic examinations, HPV DNA tests, and standardized colposcopy examinations for diagnosis. Various triage strategies, including VIA, cytology, HPV DNA genotyping, HPV RNA detection, and HPV-induced cell-cycle alteration markers, are assessed for their performance in detecting CIN3+ outcomes. The effectiveness and costs of these strategies are compared, considering single-method and multi-method approaches, to determine feasibility and efficiency. The International Agency for Research on Cancer and local Principal Investigators oversee the study.

Results. Visual inspection methods have shown high screening sensitivity, up to 85% of high-grade lesions, but was highly dependent upon the skill of the healthcare provider² and are also the reagents used during colposcopic excision of abnormal or cancerous cervical cells. LMIC screening approaches, typically ignored in high-income countries (HIC) may yield superior sensitivity when screening for cervical cancer than current approaches at lower cost and possibly more convenience for the patient (avoiding follow-up loss) and is the recommendation by the World Health Organization (WHO) for LMIC patients.

Conclusions. Visual inspection with acetic acid screening (acetowhitening) can be a cost-effective screening solution for high grade lesions. Exact mechanism isn’t known for the whitening effect³ but is being used for other squamous/mucosal cancer detection, including oropharyngeal and gastrointestinal lesions. VIA screening for cervical cancer potentially has higher sensitivity than cervical cytology, but can provide variable outcomes⁴; however, this can be mitigated with observer training and standardization, which was demonstrated by Benkortbi, et al¹.

Works Cited:

1. Cohen PA, Jhingran A, Oaknin A, Denny L. Cervical cancer. Lancet. Jan 12 2019;393(10167):169-182. doi:10.1016/S0140-6736(18)32470-X
2. Benkortbi K, Catarino R, Wisniak A, et al. Inter- and intra-observer agreement in the assessment of the cervical transformation zone (TZ) by visual inspection with acetic acid (VIA) and its implications for a screen and treat approach: a reliability study. BMC Womens Health. Jan 19 2023;23(1):27. doi:10.1186/s12905-022-02131-z
3. Marina OC, Sanders CK, Mourant JR. Effects of acetic acid on light scattering from cells. J Biomed Opt. Aug 2012;17(8):085002-1. doi:10.1117/1.JBO.17.8.085002

4.       Baena A, Mesher D, Salgado Y, et al. Performance of visual inspection of the cervix with acetic acid (VIA) for triage of HPV screen-positive women: results from the ESTAMPA study. Int J Cancer. Apr 15 2023;152(8):1581-1592. doi:10.1002/ijc.34384