Page 0085

C

ervical cancer is a preventable neoplasia that

continues to be a public health problem in many

developing countries. The disease is associated with

chronic infection by one or more of the 14 oncogenic types of

the human papillomavirus (HPV), a sexually transmitted virus

very prevalent in most populations in the world.1 In 90% of

women, HPV infections resolve spontaneously within two

years, but in 10% of cases they persist for many years and can

evolve into precancerous lesions in either the squamous or

(less commonly) columnar epithelium of cervix.

2 Invasive

cervical cancer is preceded by 10 to 20 years of

intraepithelial precancerous changes3 that can be detected

and easily treated, interrupting the natural history of the

disease and preventing the death of women.

Cervical cytology (Pap smear) has been used for many

decades as the preferred screening test, and consequently

the incidence and mortality of cervical cancer have decreased

in most developed countries. However, the Pap smear has

had little or no impact in most developing countries due to the

lack of resources to properly implement it, especially

considering that Pap smear is a multi-step process that

requires properly trained cyto-technologists, adequately

implemented laboratories, reliable notification and referral

systems, and frequent re-screening.

4 For this reason the

burden of the disease affects disproportionally women from

developing countries, since they do not have proper

screening and treatment of the precancerous stages of the

disease.

The limitations of Pap smear prompted researchers to

explore new alternatives more suitable for areas with limited

resources. Approximately 20 years ago visual inspection with

acetic acid (VIA) was proposed and tested for primary

cervical cancer screening.5 VIA is a simple screening test

based on the principle that precancerous lesions in the

cervical epithelium turn white approximately one minute

after they are exposed to 5% acetic acid (vinegar); this is the

same principle used by colposcopy since the 1920s. The

difference is that colposcopy uses a device (colposcope) that

provides special lighting and 4 to 20x magnification. Instead,

VIA evaluates the visual changes with a naked-eye inspection

(unmagnified) using a simple light source (torch or 100v

lamp).6 Mid-level personnel like nurses and midwives have

demonstrated their ability to do VIA after just a week of

theoretical and practical training. Multiple evaluations during

the last two decades have shown that VIA is equally or more

sensitive than Pap smear for detecting precancerous lesions

of the uterine cervix. It has the additional advantage of

providing a result within a few minutes, making it possible to

provide treatment (if it is available at the facility) or

counselling about referral immediately.

In the last decade, new tests for detection of HPV have

been introduced.7-9 These new tests are highly sensitive for

VISUAL INSPECTION OF THE

CERVIX: PROGRESS TO DATE AND

THE RATIONALE FOR CONTINUED

INVESTMENT

VIVIEN DAVIS TSU, (PICTURED) ASSOCIATE DIRECTOR, REPRODUCTIVE HEALTH GLOBAL PROGRAM,

PATH; DIRECTOR CERVICAL CANCER PREVENTION PROJECT, PATH AND AFFILIATE PROFESSOR OF

EPIDEMIOLOGY, UNIVERSITY OF WASHINGTON, USA AND JOSE JERONIMO SENIOR ADVISOR,

WOMEN'S CANCERS, PATH

Cervical cancer continues to be a public health problem in many developing countries despite

the availability of effective preventive measures such as vaccination and screening. Visual

inspection with acetic acid (VIA) is a low-cost test that has now been validated for primary

cervical cancer screening. Despite the advances in vaccination and more sensitive molecular

tests, there are compelling reasons for continuing and even accelerating the investment in

programmes based on VIA and precancer treatment.

DISEASE-SPECIFIC CANCER CONTROL

84 CANCER CONTROL 2014

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