Visual inspection with Acetic
Acid (VIA) as an Alternative to Colposcopy in Detection of Cervical
Carcinoma in low recourses setting
Masand D1, Smarika Dubey2
1Dr Deepa Masand, Associate Professor, Department of Obstetrics
& Gynaecology,2Dr Smarika Dubey, Post graduate
student, Obstetric & Gynaecology. Both are affiliated with NIMS
Medical College, Shobhanagar ,Jaipur, Rajasthan, India
Abstract
Objective:
To evaluate visual inspection with acetic acid ( VIA ) as an
alternative to colposcopy in detection of cervical carcinoma in low
resource setting. Introduction: Cervical cancer is a major public
health problem in developing countries, with India itself accounting
for one-fifth of the global burden of the disease. In low resource
settings, screening of CIN and carcinoma cervix by colposcopy can be
replaced by cheaper and easily available visual methods like VIA, which
has the high sensitivity to detect any grade of dysplasia. Method: VIA was
performed in two hundred symptomatic women as a pre colposcopy
attending the gynaecology department at National Institute of Medical
Science ( NIMS ) Hospital Jaipur. Sensitivity of VIA was calculated. Result: Out of 200
patients VIA was positive in 48 (24%) cases. In VIA positive cases,
Colposcopy was abnormal in 30 ( 62.5%). In VIA negative cases
colposcopy was abnormal in only in 2 (1.3%) cases. 32 cases with
abnormal colposcopic finding were subjected to biopsy. Conclusion: The high
Sensitivity of 86.6% of VIA shows that most of the preinvasive and
invasive lesion were picked up by VIA. Thus VIA could be valuable in
detection of precancerous lesion of the cervix in low resource setting.
Key Words:
Visual Inspection with Acetic Acid, Colposcopy, Cervical Cancer, Low
Resource Setting.
Manuscript received:
24th June 2014, Reviewed:
07th July 2014
Author Corrected:
14th July 2014, Accepted
for Publication: 26th July 2014
Introduction
Cervical cancer is an avoidable cause of death among women with 528000
new cases every year. Cervical cancer is the fourth most common cancer
affecting women worldwide, after breast, colorectal and lung cancers ;
it is most notable in the lower-resource countries of sub-Saharan
Africa. It is also the fourth most common cause of cancer death (266000
deaths in 2012) in women worldwide. Almost 70% of the global burden
falls in areas with lower levels of development and more than one fifth
of all new cases are diagnosed in India [1]. Cervical cancer is
preceded by a long phase of cytological changes, known as cervical
intraepithelial neoplasia ( CIN ) and takes a long period of 15-20
years before the invasive cancer develops [2] . Thus cervical cancer
can be prevented if cellular changes are detected and treated in early
stage. In western countries, cervical cancer incidence and death have
been brought under control using organised cytology based screening
program (pap smear)[3]. Though cytology (pap smear) is reliable, the
laboratory infrastructure and logistic including technical expertise
may not be available in low resource setting. The cost factor in
testing for human papillomavirus using DNA testing, coupled with
requirement of trained manpower makes this option non-viable for
developing countries [4]. India with its highest share of global burden
of cervical cancer has to implement a population based cervical cancer
control programme to reduce the number of death [5]. Visual inspection
using acetic acid (VIA) has emerged as a promising, cost effective,
non-cytology based, “see and treat” alternative for
economically underprivileged geographic regions. The present study was
undertaken to find the value of VIA in picking up pre-invasive or
invasive cancer in an abnormal cervix. All VIA positive cases were
further evaluated with a colposcopy. A directed biopsy was taken in
cases with abnormal colposcopy
Material
and Methods
This prospective study was conducted in department of Obstetrics and
Gynaecology National Institute of Medical Science (NIMS) Jaipur
(Rajasthan). 200 symptomatic women over a period of one year attending
Gynaecology clinic were studied. Approval of the institutional ethical
committee and informed consent was obtained from each women. Relevant
obstetric and gynaecological history was obtained and recorded.
Inclusion criteria:
Age - >25 yrs
Marrital life >3yrs
Parous
Non Pregnant
Symptomatic cases
Exclusion criteria:
Virgin
Pregnant
In menstrual phase
H/o hysterectomy
Confirmed cases of carcinoma cervix
After General physical examination, local examination, cervix was
exposed by Cusco’s vaginal speculum. Any evidence of
infection, ectopy, any visible growth etc were examined. Then 3-5 %
acetic acid solution was applied to the cervix for 1 minute (with the
help of swab stick ) and then the cervix was carefully inspected for
any acetowhite lesions, particularly in the transformation zone. The
normal squamous epithelium of the cervix is pink. On application of
acetic acid, cervical intraepithelial neoplasia (CIN) lesion takes on
white colour due to increased nuclear proteins and cytokeratins in the
cervical epithelium [7].
Criteria for classifying
via positive
- Location of lesion
- Colour intensity of acetowhite lesion
- Borders and demarcation of acetowhite
lesion
- Size of lesion
- Extension of acetowhite lesion
After VIA patient were then examined by Colposcope with 12X-15X
magnification. Biopsy was taken only from those who showed abnormal
colposcopic appearances. Colposcopy and biopsy was taken as a reference
standard for statistical calculation.
Observation
Results are tabulated and discussed as follow.
Table 1: Demographic
distribution of cases
|
Age Group (years)
|
No. of Women
|
Parity
|
|
1-2
|
3-4
|
5-6
|
7
or above
|
|
18-24
|
12
|
07
|
01
|
04
|
00
|
|
29-34
|
62
|
01
|
37
|
23
|
01
|
|
35-44
|
94
|
02
|
64
|
28
|
00
|
|
45-54
|
25
|
00
|
12
|
11
|
02
|
|
>54
|
07
|
00
|
03
|
01
|
03
|
Out of 200 symptomatic women, most women belong to age group of 35-44
yrs and parity between 3- 4. The mean age of cases was 38.175 yrs with
mean parity of
4.19.
The commonest presenting complaint was vaginal discharge (62% of the
patient). Other presenting complaint were intermenstrual bleeding (25 %
of the patient), postcoital bleeding (8% of the patient) and
postmenopausal bleeding ( 5% of the patient).
On visual inspection of cervix with 3-5% acetic acid, 48 cases (24 %)
were VIA positive, Of these 30 cases (62.5%) had abnormal colposcopic
finding and 18 cases (37.5 %) had normal colposcopic finding. 152 cases
(76%) were VIA negative, Of these 2 cases (1.3%) had abnormal
colposcopic finding and 150 cases (98.6 5) had normal colposcopic
finding.
Table 2: Correlations of
histopathology with VIA result
|
HPR
|
VIA
|
Total
|
|
Negative
|
Positive
|
|
CIN 1
|
2
|
10
|
12
|
|
CIN 2
|
|
4
|
4
|
|
CIN 3
|
|
2
|
2
|
|
Invasive Cancer
|
|
1
|
1
|
|
Normal/Negative
|
|
13
|
13
|
|
Total
|
2
|
30
|
32
|
30 cases of VIA positive correlated with positive histopathological
finding. Remaining 18 VIA positive cases have normal histopathology.
Table 3: Correlations of
colposcopy and histopathology
|
Colposcopy
|
|
|
|
HPR
|
Negative
|
Positive
|
Total
|
|
CIN 1
|
|
12
|
12
|
|
CIN 2
|
|
4
|
4
|
|
CIN 3
|
|
2
|
2
|
|
Invasive Cancer
|
|
1
|
1
|
|
Chronic cervicitis
|
|
13
|
13
|
|
Total
|
0
|
32
|
32
|
As per table all the cases with abnormal colposcopy findings have
positive histopathology results.
Table 4: Correlations of
colposcopy and VIA with biopsy result
|
HPR
|
Sensitivity
|
PPV
|
|
VIA
|
Colposcopy
|
VIA
|
Colposcopy
|
|
CIN 1
|
10/12
|
12/12
|
|
|
|
CIN 2
|
4/4
|
4/4
|
|
CIN 3
|
2/2
|
2/2
|
|
Invasive Cancer
|
1/1
|
1/1
|
|
Overall
|
17/19
|
19/19
|
17/30
|
19/32
|
It is clear from table that for CIN 1 stage sensitivity of VIA is less.
For advanced lesion sensitivity of VIA & colposcopy was 100 %.
Table 5: Sensitivity and
positive predictive value of VIA and colposcopy
|
Sensitivity
|
PPV
|
|
HPR
|
VIA
|
Colposcopy
|
VIA
|
Colposcopy
|
|
CIN 1
|
83.33%
|
100.00%
|
|
|
|
CIN 2
|
100.00%
|
100.00%
|
|
CIN 3
|
100.00%
|
100.00%
|
|
Invasive Cancer
|
100.00%
|
100.00%
|
|
Overall
|
89.47%
|
100.00%
|
56.67%
|
59.375%
|
The most sensitive test for all grades of CIN and invasive cancer is
colposcopy followed by VIA which is less sensitive in CIN1.
Pearson Chi-Square= 101.609
DF=1 ‘p’
value <0.001
Kappa value=0.691
‘p’ value <0.001
As above table shows that there was 15% of positive cases and 75% of
negative cases were showing agreement. On application of Chi-square
test and kappa statistics there were significant association
(Chi-square – 101.609 and p value < 0.001 ) and
statistically significant ( k – 0.691, p < 0.001) .
Thus from above table it is clear that there is statistically
significant association between colposcopy and VIA. Thus VIA is an
alternative of Colposcopy.
Discussion
Cervical cancer is a potentially preventable cancer. It is preceded by
premalignant lesions which may take 5-15 years to progress to invasive
cancer. If detected and treated timely, pre-invasive disease has nearly
100 per cent cure rate with simple surgical procedure, while advanced
cancers have less than 35 per cent survival rates [8]. However, in
developing countries like India, universal screening has not been
achieved. The main screening method (Pap smear) is available to a small
percentage of population. Cytology based screening programmes are
difficult to organize owing to limited infrastructure, trained
personnel and funds [9]. It has been estimated that in India, even with
a major effort to expand cytology services, it will not be possible to
screen even one-fourth of the population once in a lifetime [10].
Moreover, screening programmes in India are mostly institution based
and are restricted to urban centres [11]. Thus, in developing
countries, there is a need for alternative strategies for early
detection of premalignant cervical lesions. Thus VIA is a cost
effective method which can differentiate a normal cervix from a
precancerous cervix with reasonable accuracy. Hence, if practiced by
gynaecologists routinely, it would help to avoid many panic
hysterectomies. Besides, in the absence of organized cytology screening
program and limited availability of colposcopy facilities, VIA can be
propagated on a wider scale.
In the present study, women from all the age group were included. The
mean age was 38.17 years and majority were parous women. This
observation agrees with the studies of singh kavita N et al [12]. N
Yusuf et al studies correspond well with this study that CIN is more
prone in sexually active women. Therefore, Screening for cervical
carcinoma should start ideally at the onset of sexually activity and
all the women should be screened at least once by the age of 30-35
years. In our study sensitivity of VIA was 89.47% which shows that most
of the pre-invasive and invasive lesions were picked up by VIA. Only
two patients were missed (false negative), one with post
–menopausal bleeding where transformation zone receded inside
and other case was of adenocarcinoma. Shankarnarayanan and Mahe [13]
have published results from a randomized intervention trial in India
comparing VIA to cytology and to HPV DNA testing, and found that all
three had similar detection rates of CIN 2 and 3 lesions, and the range
of sensitivity for VIA was 67-79% and specificity 49-86%.
The higher sensitivity of our study can be explained on the basis that
the study was done on a group of women in susceptible age group (mean
38.48 ± 8.9 years). Secondly, the VIA was performed using
colposcope halogen bulb (24V 250 Watt) by a gynaecologist and not by a
nurse or a paramedical person. In JHPIEGO cervical cancer project at
Zimbabwe, VIA was done by trained nurses and paramedical person on
10,934 women and was found to have sensitivity of 76.4% and specificity
of 64% in picking up pre-invasive lesions [14]. The study also inferred
that higher test qualities of VIA are likely to be observed under
better service delivery conditions like good lighting, examination
tables and specula, and more standardized VIA training. They observed
that in more than 75% of cases when a lesion was found on colposcopy or
biopsy, it was also visible on VIA [15]. Ottaviano and Torre [16], in
the first study of its kind, have published results of simultaneous VIA
and colposcopy on 2,400 unselected patients with normal or abnormal
cervical cytology. In our study, VIA and biopsy correlation is less for
CIN1 which is 83.3%., but the sensitivity increased up to 100% in
picking up CIN 2, CIN 3 which is indeed a true cancer precursor and
early invasive cancer ..Colposcopic magnification is a complimentary
method to VIA and not essential to identify a cervix with higher grade
lesions. VIA can also guide a practicing gynaecologist regarding the
site to be biopsied. Although colposcope accurately identifies the most
abnormal area for biopsy,VIA will demarcate the site precisely and give
better results than a blind biopsy of ectocervix, in absence of
facilities for colposcopy [17]. In our study it is clear that there is
statistically significant association between colposcopy and VIA. Thus
VIA is an alternative of Colposcopy.
Conclusion
VIA is attractive test in low resource settings like India. It is
simple, inexpensive low technology test that requires minimal
infrastructure. The majority of women belonging to low socioeconomic
status, remain devoid of any screening test, thus time has come to
integrate VIA based screening program at the primary care level of
health services and to down stage cancer cervix in our country.
Funding: Nil
Conflict of interest:
Nil
Permission from IRB:
Yes
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How
to cite this article?
Masand D, Dubey S. Visual inspection with Acetic Acid (VIA) as an
Alternative to Colposcopy for detection of Cervical Carcinoma in low
recourses setting. Int J Med Res Rev 2014;2(5):444- 449.doi:10.17511/ijmrr.2014.i05.08