Researchers suggest VIA should be routinely taught to health workers

A simple, inexpensive method could be used to detect cervical cancer in countries where women do not have access to Pap smears or other screening programs, say researchers. The study — of 49,311 women between 30 and 59 years in Tamil Nadu, India — found that visual inspection of the cervix using acetic acid (VIA) is effective as a method of cervical cancer screening.

The findings were published in The Lancet on 4 August 2007.

The group of women who underwent VIA had a 25% reduction in cervical cancer incidence and a 35% reduction in deaths compared with the control group, who received existing care. The technique involves applying four per cent acetic acid (vinegar) to the uterine cervix and examining it with the naked eye under bright light.

If a well-defined white area on the cervix is observed after one minute, the test is positive. Women who were VIA-positive were offered immediate further treatment, including cryotherapy to remove any cancerous lesions, or a referral if they had suspected invasive cancer.

Rengaswamy Sankaranarayanan, of the France-based International Agency for Research on Cancer, who led the study, said the advantages of the technique were its simplicity and low cost. The study authors conclude that, because screening over multiple visits is often not possible in developing countries, and vaccination against human papillomavirus is currently too expensive, "VIA screening, in the presence of good training and sustained quality assurance, is an effective method to prevent cervical cancer in developing countries", they write.

But gynecologic oncologist Elizabeth Vallikad, who leads a pilot cervical cancer screening programme in Karnataka in southern India, says that the success of the findings cannot be duplicated without extra staff. Her own efforts with existing staff have failed, she says. Vallikad, from St John's Hospital in Bangalore, told SciDev.Net that the technique might have worked with the researchers because they had a dedicated staff, but the findings cannot be applied to conditions in a health clinic with no cervical cancer control programme or extra workers, she said. She also questioned the effectiveness of vinegar and said fresh acetic acid is difficult to supply in rural settings.

The authors recommend that, to overcome problems of correctly applying the method and interpreting results, VIA should be routinely taught to health workers.

Link to full paper in The Lancet* *Free registration is required to view this article.

Reference: The Lancet 307, 398 (2007)

This story, entitled Vinegar 'simple and cheap' cervical cancer test, was written by M. Sreelatha and published 6 August 2007 by SciDev.Net.

UPDATE: Screening technique is saving lives in Uganda

Excerpted from Uganda Embraces Low-Tech Test for Cervical Cancer, by Rebecca Harshbarger, Womens E News, April 20, 2009:

"In Uganda, cervical cancer is the leading cause of cancer deaths among women, although the cancer typically takes between 10 and 20 years to reach an advanced state and is very treatable if it's caught early. ...

In 2006 a group of doctors and public health activists began searching for ways to boost screenings. They belonged to the Uganda Women's Health Initiative, collaboration between Makerere University, a public university based in Kampala, and the University College London's Institute for Women's Health. They started a pilot project in Kampala to demonstrate that cervical cancer screening was possible in small health centers.

As part of that project, two clinics began screening women with a fast, innovative test that used acetic acid--or vinegar--as the primary active ingredient. The test, called visual inspection with acetic acid, or "VIA," doesn't require a pathologist, refrigeration of samples or a microscope. A nurse, midwife, or gynecologist swipes a patient's cervix with acetic acid and then inspects the tissue visually. If the cervix has lesions, the tissue turns white.

Currently, public clinics and hospitals continue to screen women using both techniques, but many gynecologists have begun using a positive visual test as a basis to start treatment on the spot. The treatment, called cryotherapy, freezes the lesions and treats the disease in its early stages, before the cancer becomes advanced. It does this by destroying abnormal cells in the cervix that may lead to cancer. The swift move from diagnosis to treatment saves patients' time and transportation costs.

"This service has prevented a lot of disease," said Dr. Dan Murokora, a gynecologist at the Kampala Dispensary who works for the Uganda Women's Health Initiative. "We screen an average of 15 women a day. We know that the Pap smear has been the standard of screening in the West, but the VIA test has considerably high accuracy rates." Currently, five hospitals and clinics in Kampala, as well as three regional hospitals in other parts of the country, offer Pap smears, the visual test and cryotherapy. The Ugandan Ministry of Health is watching research by the Uganda Women's Health Initiative to gauge patients' reaction to the technology, and to estimate the costs of rolling out screenings and cryotherapy to women in smaller clinics throughout the country who have less access to medical services."

The story also reports that community health activist Claire Judith Achieng is pushing to get the new screenings rolled out to other parts of Ugandaaaaaa. In 2006 she and a college classmate, Patience Grace Kyuomugisha, founded the Save a Woman Initiative, after losing a friend to cervical cancer. The organization of health activists and doctors has been giving presentations on the importance of screenings in churches, marketplaces and clinics in Luweero, a rural town in central Uganda, and is currently raising funds for a mobile clinic to bring screening tests and awareness to rural communities with minimal gynecological services.

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