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LETTER TO EDITOR
Year : 2022 | Volume
: 47
| Issue : 2 | Page : 304-305
Screening for cervical cancer using visual inspection after acetic acid in a rural and semiurban population in South India
Lakshmi Seshadri, Kumar Kaliyaperumal
Department of Obstetrics and Gynecology, Thirumalai Mission Hospital, Ranipet, Tamil Nadu, India
Correspondence Address:
Dr. Lakshmi Seshadri
Department of OBGYN, Thirumalai Mission Hospital, Ranipet, Vellore, Tamil Nadu 632404
India
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/ijcm.ijcm_623_21
How to cite this article:Sir,
Globally, cervical cancer is the fourth most common malignancy in women. About 604127 new cases and 341831 deaths have been reported in 2020.[1] The number of new cases in India in 2018 was 96,922[2] and the incidence in 2020 was 123907.[3] Cervical cancer is the second most common cancer in Indian women, breast cancer being the most common. The majority of women present in late stages, with consequent high mortality.
According to the World Health Organization, strategies to eliminate cervical cancer consist of vaccination against human papillomavirus (HPV) of 90% girls by age 15, screening 70% of women at least twice in their lifetime, and providing appropriate care for 90% of women with precancerous or cancerous lesions of the cervix. HPV vaccination for all girls below 15 remains a distant target in middle-and low-income countries such as India-screening, therefore, continues to be an important strategy for the prevention of cervical cancer. Rapid, affordable HPV testing and/or cytology is the screening modality used in most developed countries now. The requirement of trained personnel and infrastructure for cytology-based screening and the expense associated with HPV testing have led to widespread use of visual inspection of cervix after application of acetic acid as the screening modality in India and other middle-and low-income countries.
We organized a systematic cervical cancer screening by visual inspection after acetic acid (VIA) in a rural and semiurban population in and around Ranipet, Vellore, Tamil Nadu, attempting to cover the entire susceptible population. The organization, implementation, and results of this screening program are presented in this communication. Screening was undertaken in the project area of a charitable organization, involved with education and primary health care through various projects for 50 years. A secondary level hospital was started in 2010. The charitable organization and hospital function as an integrated, single unit. Currently, the main thrust areas of work are prevention and management of noncommunicable diseases, promoting women's health, alcohol deaddiction, and screening for oral and cervical cancers. The organization covers a defined semiurban and rural geographic area consisting of 315 villages and 50 panchayats, covering 35,000 families (population = 160,000). Family care volunteers (FCVs), one for each 50 families, are in direct contact with the community and work under multipurpose health workers supervised by managers who report to the director.
The Government of Tamil Nadu had initiated a cervical cancer screening program in the community health centers and district hospitals in 2010-performed by nurses trained by the doctors in the district headquarters hospitals. Screening for cervical cancer by our trust was started on January 1, 2012. To ensure that there is minimum or no overlap, the FCVs asked each woman if she had already been screened by the government--only those who had not been screened were included in the study.
Women (30–50 years) with intact uterus, living in the project area were included in the study. The eligible women were identified and listed by the multipurpose workers and FCVs. They were systematically contacted, educated regarding the screening, mobilized, and brought to the screening location. Multiple such locations, each with a room for screening, a waiting area, and toilet were identified, providing easy access for participating women. Screening was performed on a fixed day every week and this information was communicated to eligible women.
A senior consultant trained nurses to perform VIA. Gynecological history of individual participants was obtained by the nurses before VIA. The cervix was visualized using a bivalved speculum under a bright light to look for any gross lesions such as polyp, growth, or ulcer. The cervix was then painted with 3% acetic acid and again examined 1 min later. Women who had acetowhite areas on the cervix were considered test positive. They underwent colposcopy by the consultant at the peripheral centers till 2015. Subsequently, due to logistic reasons, women who tested positive on VIA were taken to the main hospital for colposcopy. If colposcopy revealed abnormality, subsequent management was planned at the main hospital.
The test positives identified by the government centers were referred to district hospitals for colposcopy while those screened by the organization underwent colposcopy at the charitable mission hospital.
During the 8-year period (January 1, 2012 to December 31, 2019), total number of eligible women was 21,212. Of these, 18,885 (89%) were screened, 8625 women (40.7%) by our organization, and 10,260 women (48.3%) at government centers [Table 1]. Our results focus on women screened by our organization only because, in the group screened by the government, details regarding the number of VIA-positive women, their colposcopic findings and follow-up details, are not available to us.
Table 1: Number of women screened and visual inspection with acetic acid positiveOf the 8625 women screened by our organization, 252 (2.9%) were VIA positive. Colposcopy was performed in 213 (84.5% of VIA positive) women. Colposcopic impression was low-grade squamous intraepithelial lesion (LSIL) in 96 women, high-grade squamous intraepithelial lesion (HSIL) in 16 women, and invasive cancer in nine women [Table 2]. HSIL included cervical intraepithelial neoplasia 2 and 3.
Women with a diagnosis of LSIL were asked to come for review 3 months later. Those with HSIL underwent loop electroexcision procedure. Women with suspected invasive cancers underwent biopsy, staging and were managed accordingly.
Screening and treatment of precancerous lesions are the key strategies for the prevention of cervical cancer. In India, the organization of such programs is complex and involves planning and implementation at various levels. Partnership between government led programs and those by nongovernmental organizations are strategies which can be used to achieve wider coverage of screening programs.
Such an effort by our program yielded good results in terms of coverage of the eligible participants (89%). The key to our success was through a systematic process of information, education, and motivation, provided by a well-established community healthcare network. Our FCVs have a good rapport with the families and are the key persons behind the motivation of participants to attend the screening camps. An important reason for the success of our program was our setting up multiple peripheral locations for the screening, facilitating easy access without time lost from work. Our ability to provide colposcopy for 84.5% of those who tested positive on VIA was possible only because of the close follow-up and motivation of VIA-positive participants by our community network.
In the absence of reliable cytology-based screening and affordable HPV testing, the strategy in low-income countries should be to introduce efficient systems to screen the majority of the participants at risk using cost-effective methods, making effective use of the available resources. VIA is simple, practical, affordable, and feasible in all low-resource settings and has been recommended by the Ministry of Health and Family Welfare, 2017.[4] Among the women screened by our organization, 2.9% were VIA positive--very similar to the 3% VIA positivity rate reported in 14.5 million women screened by the Tamil Nadu screening program under the National Health Mission, between 2012 and 2017.[5]
A well-organized community service program with necessary infrastructure, appropriate training of health-care workers in a low-cost testing method, and effective health-care delivery by nongovernmental organizations to supplement the government's efforts make a successful screening program eminently feasible.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References 
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