Visual inspection of the cervix with acetic acid for cervical intraepithelial lesions.

OBJECTIVE: Evaluation of visual inspection of the cervix with acetic acid (VIA) for screening cervical intraepithelial neoplasia. METHODS: In this prospective study, 400 women were screened using the Papanicolaou (PAP) smear, VIA and colposcopy. Those who had positive results with any of the screening methods underwent large loop excision of the transformation zone (LLETZ). The sensitivity and specificity of each of the screening methods was analyzed. RESULTS: The sensitivity of VIA (96.7%) was much higher than that of the Pap smear (50%), and almost as high as that of colposcopy (100%). The specificity of VIA (36.4%) was lower than that of the Pap smear (97%) and colposcopy (96.9%), resulting in high false-positive rates for VIA. Two cases of endocervical lesions were missed with VIA. CONCLUSION: Visual inspection of the cervix with acetic acid is very sensitive for ectocervical lesions. The advantages of the VIA method are its low cost and ease of use (it can be used by paramedical workers), its high sensitivity and its immediate results (it is possible to "see and treat" at the first visit). Its main limitation is a high rate of false-positive results, which may lead to overtreatment if a "see and treat" policy is applied.     

Visual inspection with acetic acid and cytology as screening methods for cervical lesions in Cameroon.

OBJECTIVES: To assess the accuracy of visual inspection with acetic acid (VIA) as a screening method for cervical lesions. METHODS: VIA and cytological smears were carried out on the cervices of non-pregnant women aged 30-60 years with no previous history of cervical cancer. Cervices with aceto white lesions or positive Pap smears, and one in ten negative cervices (control), were biopsied. RESULTS: 5010 women were enrolled, 4813 (96.1%) were screened. 4767 (99.%) had adequate cytology smears. 574 (11.9%) had colposcopy. 1743 biopsies were obtained of which 528 were controls. The sensitivity of VIA was 70.4% versus 47.7% for Pap smear. VIA specificity was 77.6% versus 94.2% for Pap smear; PPV for VIA was 44.0% versus 67.2% for Pap smear; and NPV for VIA was 91.3% versus 87.8% for Pap smear. CONCLUSIONS: VIA has acceptable test qualities and may in low resource settings be implemented as a large scale screening method.     

Cervicography as an adjunctive test to visual inspection with acetic acid in cervical cancer detection screening.

OBJECTIVE: Validate Digital Cervicography as adjunctive cervical cancer screening test to VIA and Cytology. METHOD: Women (1292) were submitted to both cytological and VIA tests to obtain a sample of 301 positive VIA cases (23.3%) which have had the Digital Cervicography (DC) taken and evaluated. Just cases considered positive by DC (149/301 cases--49.5%) and/or positive Pap smear tests were referred to colposcopy and biopsy whenever indicated. RESULTS: Cervical smear was positive in 5.4%, including LGSIL (4%), HGSIL (1%) and one case of invasive cancer (0.4%), and 1.6% of ASCUS or AGUS). DC identified 81 positive cases (74 LGSIL; 5 HGSIL; 2 cancers). The sensitivity of cytology was 14.8%, and the DC was 100%. Corresponding specificities were 95.4% and 69.1%, respectively. The NPV and PPV for DC were 100% and 54.4%. CONCLUSION: DC increases sensitivity, specificity and positive predictive value of VIA, becoming a valid adjunctive screening test for cervical cancer in low resource settings.     

Aided visual inspection with acetic acid (VIA) and HPV detection as optional screening tools for cervical cancer and its precursor lesions

PURPOSE OF INVESTIGATION: To assess the contribution of visual inspection with acetic acid (VIA) and Hybrid Capture II (HCII) as adjunct methods to the Pap test in detecting cervical neoplasia. SUBJECTS AND METHODS: This was a cross-sectional study with 809 women who consecutively attended gynecological consultations at Campinas University, Brazil, from January 2002 to July 2003. Pap test, HCII, VIA, and colposcopy were offered to all patients. Performance of tests (alone or in combination) in detecting histologically confirmed lesions was evaluated. RESULTS: Of the 40 patients with CIN, 69% had CIN1, 26% CIN2 or CIN3 and one patient had invasive carcinoma. VIA had the best performance in detecting CIN, yielding 72% sensitivity and 91% specificity. Considering only CIN2 or worse as significant lesions, HCII had the best sensitivity (73%), while the Pap test was the most specific (93%). Combining the three exams, 92% of the CIN1 or worse were detected. When CIN1 was excluded from the analysis, Pap smear plus HCII delivered 82% sensitivity and 79% specificity. However, this combination yielded a very low (5%) PPV. CONCLUSION: VIA and HCII contributed to the screening of cervical neoplasia in a group of Brazilian women, but the cost-effectiveness of conjoint screening modalities is still debatable.     

Human papillomavirus testing for primary screening in women at low risk of developing cervical cancer. The Greek experience

OBJECTIVE: To compare the performance of human papillomavirus (HPV) DNA detection against routine Papanicolaou smear for the detection of low- and high-grade cervical intraepithelial neoplasia in a low-risk population. MATERIALS AND METHODS: A cross-sectional study was performed involving 1296 women attending six outpatient clinics in Northern Greece (Thessaloniki, Thermi, Mihaniona, Corfu, Veria, and Serres). Women underwent a gynecological examination, including collection of exfoliated cervical cells for Papanicolaou cytology and HPV DNA detection. Cytology was processed according the conventional routine manner, and HPV DNA was determined using the polymerase chain reaction technique. In positive cases of either method, a complete colposcopic evaluation was performed with directed biopsies. Tests (HPV DNA, cytology, and colposcopy) performance characteristics were determined using the histopathologic diagnosis as the reference standard. RESULTS: HPV DNA testing showed a significantly better sensitivity than the Papanicolaou smear in detecting cervical intraepithelial neoplasia (75% versus 50% for high-grade lesions and 81.2% versus 50% for lesions of any grade, respectively). Specificity, and positive and negative predictive values did not significantly differ. Even after dividing women in younger or older than 30 years, the sensitivity of the HPV DNA test was greater than cytology (100% and 70% versus 50% for cytology in both groups, respectively), with a 6.3% loss in specificity when performed in women younger than 30 years. CONCLUSION: HPV testing could be useful in screening women at low risk for cervical cancer, either as an adjunct tool to augment existing cytology programs or as a unique test of its own.     

Telomerase activity in Papanicolaou smear-negative exfoliated cervical cells and its association with lesions and oncogenic human papillomaviruses

OBJECTIVE: The goal of this study was to evaluate telomerase activity in exfoliated cervical cells and its association with cytology, pathology, and human papillomavirus (HPV). METHODS: Telomerase activity and HPV DNA sequences were examined in the exfoliated cervical cells from a general population of 245 women aged more than 30 years undergoing routine cervical screening by Papanicolaou smear. The women who were found to have telomerase activity or abnormal cytology in their exfoliated cervical cells were examined for cervical lesions by colposcopy and biopsy. RESULTS: Cytology for our population (mean, 56 years) revealed only one abnormal smear (1/245, 0.4%), in which a cervical intraepithelial neoplasia grade I (CIN I) lesion was found. The exfoliated cervical cells used to prepare the smear were negative for telomerase and contained low-risk HPV DNA. Telomerase activity was found in 16 exfoliated cell samples (16/245, 6.5%); high-risk HPV DNA was found in 9 of these samples (9/16, 56%) and 9 of the biopsy specimens that could be evaluated from patients testing positive for telomerase revealed CIN I lesions (9/11, 82%). CONCLUSIONS: Telomerase activity is often associated with high-risk HPV infection and it is suggested that telomerase assay can help to detect occult cervical lesions.     

Comparison of the diagnostic value of the visual inspection with acetic acid (VIA) and Pap smear in cervical cancer screening

ObjectiveThis study aimed to compare the diagnostic value of VIA with Pap smear in screening for cervical cancer.Materials and methodsIn this cross-sectional study, 440 women who had eligibility criteria, in Kashan city were assessed. All women underwent Pap smear test and then a visual inspection with acetic acid and colposcopy-biopsy (Gold Standard). Then, the diagnostic value indices including the specificity, sensitivity, positive and negative predictive values for the results of VIA and Pap smear were analyzed by SPSS V16 software.ResultsFinding showed that 29.9% of women had abnormal Pap smear. The false positive rate of Pap smear was 40.2%, and its false negative rate was 37.4%. For VIA, the false positive and false negative rates were 21.2% and 4.6%. The sensitivity, specificity, NPV and PPV of Pap smear was 29.7%, 85.5%, 59.8%, 62.6%, and these values for VIA was 94.6%, 81.6%, 78.8%, 95.4% respectively. Combination of Pap smear and VIA showed the sensitivity of 97.3% and 100% in low grade and high grade cervical lesions.ConclusionVIA has a higher sensitivity than Pap smear in detection of low and high grade cervical lesions, however, its specificity is less than Pap smears. Therefore it is recommended to use of VIA along with Pap smear to reach a higher sensitivity.     

Can visual inspection with acetic acid be used as an alternative to Pap smear in screening cervical cancer?

ObjectiveTo evaluate the value of visual inspection with acetic acid (VIA) in screening cervical cancer in comparison to Pap smear.Material and methods200 women attending the obstetric and gynecology Department in Zagazig University hospital from December 2011 to November 2012 were included. They were screened using Pap smear and VIA. Colposcopy was done for all women. Positive cases on any screening test were subjected to cervical biopsy.ResultsAcetic acid (VIA) was positive in 24/200 (12%) patients and Pap smear was abnormal in 8 (4%). There were 5 LSIL, 2 HSIL and one with cells suspicious of malignancy. Colposcopy was recorded abnormal in 35 cases (17.5) .18 cases (51.4%) had a Reid score of 0–2 and considered negative .17 cases (48.6%) had a positive colposcopy (Reid 3–8). Cervical biopsy was done on all 35 cases. 44% biopsies were positive and 56% were negative .15 positive biopsies incorporated 11 mild dysplasia, 2 moderate dysplasia, 1 sever dysplasia and one carcinoma in situ. The Pap smear had a sensitivity of 50.1%, specificity of 93.1%, and positive predictive value of 89.3% and negative predictive value of 65.6%. VIA had a sensitivity of 90%, specificity of 37%, and positive predictive value of 52% and negative predictive value of 81%.ConclusionVIA a good screening, simple test, has low cost and high sensitivity in comparison to Pap smear. So, it can be used as alternative screening modality for cervical cancer in low resource locations.     

Visual inspection of cervix with acetic acid (VIA) in early diagnosis of cervical intraepithelial neoplasia (CIN) and early cancer cervix

Objectives

To study the place of visual inspection of cervix with acetic acid in screening for CIN and cancer cervix and to compare and correlate the efficacy of VIA with cervical cytology in early detection of cancer cervix.

Methods

This cross sectional study took place in the Gynaecology out patient department (GGOPD) of NSCB Medical College, Jabalpur between June 2005 and September 2006. Out of the total 16,400 women who attended GOPD during this period, 750 women were screened for CIN and early cancer cervix. VIA and pap smears were done concurrently and their sensitivity and specificity compared. For ethical reasons all those who were found positive were subjected to colposcopy and further management as per standard guidelines.

Results

Out of the 750 women screened VIA was positive in 122 (16.26%) women and cytology was positive in 39 (5.2%) cases of the true positive (27 cases). The difference between the two tests was statistically significant (P=0.000001) VIA being highly sensitive (93.1%) buy less specific than cytology.

Conclusion

The high sensitivity of VIA shows that the test could be valuable in detection of precancerous lesions of the cervix.     

The clinical significance of the poor correlation of cervical dysplasia and cervical malignancy with referral cytologic results.

OBJECTIVE: We prospectively studied the diagnostic utility of our Bethesda system-based cervical cytology screening program with colposcopy and biopsy as the criterion standard. STUDY DESIGN: We prospectively collected and studied the correlation of cytologic, colposcopic, and histologic data in women referred for colposcopic examination because of "nonnormal" cytologic results or other risk factors. RESULTS: We found that 771 of 5585 initial colposcopic visits yielded high-grade (cervical intraepithelial neoplasia II or worse) biopsies (13.8% prevalence); 13 showed invasive cancer (0.23% prevalence). Only 132 of 771 cases of high-grade dysplasia (17%) and 5 of 13 cases of invasive cancer (38%) followed Papanicolaou smears suggesting high-grade intraepithelial lesions or cancer, with 77% being discovered after "minor" Papanicolaou smear abnormalities. High-grade disease or cancer was confirmed in 1 of 2 high-grade or cancer Papanicolaou referrals and in 1 of 11 referrals with atypical squamous cells of undetermined significance. CONCLUSION: Papanicolaou smears, especially those that are low grade, should not be equated with histologic sampling in association with poor cytohistopathologic correlation. Most high-grade dysplasias and cancers occur in women with either minor Papanicolaou smear abnormalities or visible lower genital tract lesions or both. Colposcopy for women with any "nonnormal" screening result is feasible.     

Human papillomavirus testing as triage for atypical squamous cells of undetermined significance and low-grade squamous intraepithelial lesions: Sensitivity,specificity, and cost-effectiveness

OBJECTIVE: Our purpose was to evaluate the cost-effectiveness of the use of a Food and Drug Administration–approved human papillomavirus test in triaging patients with Papanicolaou smears showing atypical squamous cells of undetermined significance or a low-grade squamous intraepithelial lesion for colposcopy compared with an algorithm that used cytologic follow-up.STUDY DESIGN: Four hundred sixty-two women referred to our Colposcopy Clinic with a Papanicolaou smear report of atypical squamous cells of undetermined significance or a low-grade squamous intraepithelial lesion underwent repeat Papanicolaou smear, cervical colposcopy, directed cervical biopsy, and endocervical curettage. In addition, human papillomavirus testing by the Food and Drug Administration–approved HPV Profile (Digene Diagnostics, Silver Spring, Md.) test was done. A comparision of sensitivity, specificity, and cost-effectiveness of an algorithm determining the need for colposcopy on the basis of repeat cytologic testing versus an algorithm that incorporated repeat cytologic testing and human papillomavirus screening was done. The cost-effectiveness of both of these triage algorithms was also compared.RESULTS: As expected, high-risk human papillomavirus deoxyribonucleic acid was detected with greater frequency in relation to increasing severity of cervical intraepithelial neoplasia. In 268 women, the follow-up smear obtained in our clinic was reported as negative. High-risk human papillomavirus types were found in 23.5% of these women. In the human papillomavirus–negative women, 5.9% had grade 2 or 3 cervical intraepithelial neoplasia confirmed on cervical biopsy. In comparison, 20.6% of those with a positive result of the human papillomavirus test had grade 2 or 3 cervical intraepithelial neoplasia on biopsy (p < 0.001). Despite this difference, the sensitivity of a positive result of a high-risk human papillomavirus test in predicting the presence of grade 2 or 3 cervical intraepithelial neoplasia was only 52%. Among the women for whom a follow-up clinic Papanicolaou smear was reported as showing atypical squamous cells of undetermined significance or a low-grade squamous intraepithelial lesion, there was no difference in the frequency of biopsy-proved grade 2 or 3 cervical intraepithelial neoplasia between those women with a positive human papillomavirus test result and those with a negative test result. Colposcopy would have been recommended for 194 women because of a repeat clinic smear revealing atypical squamous cells of undetermined significance, a low-grade squamous intraepithelial lesion, or a high-grade squamous intraepithelial lesion, and in 21.6% of these women grade 2 or 3 cervical intraepithelial neoplasia was shown on biopsy (sensitivity 63%, specificity 62%). Colposcopy would have been recommended for 180 women because high-risk human papillomavirus or a high-grade squamous intraepithelial lesion was detected at the clinic visit, and in 25% of this group grade 2 or 3 cervical intraepithelial neoplasia was evident on biopsy (sensitivity 67%, specificity 66%). Sensitivity and specificity were virtually identical for the two algorithms, but the cost of human papillomavirus testing was nearly double that of triage based on repeat cytologic testing alone ($692 vs $1246 per case).CONCLUSION: The Food and Drug Administration–approved HPV Profile test is not a cost-effective triage for patients referred with Papanicolaou smears reported as showing atypical squamous cells of undetermined significance or low-grade squamous lesions. (Am J Obstet Gynecol 1997;177:930-6.)     

Comparison of pap smear, visual inspection with acetic acid, human papillomavirus DNA-PCR testing and cervicography.

OBJECTIVE: To assess the test qualities of four screening methods to detect cervical intra-epithelial neoplasia in an urban African setting. METHOD: Six hundred fifty-three women, attending a family planning clinic in Nairobi (Kenya), underwent four concurrent screening methods: pap smear, visual inspection with acetic acid (VIA), PCR for high risk human papillomavirus (HR HPV) and cervicography. The presence of cervical intra-epithelial neoplasia (CIN) was verified by colposcopy or biopsy. RESULT: Sensitivity (for CIN2 or higher) and specificity (to exclude any CIN or cancer) were 83.3% (95% CI [73.6, 93.0]) and 94.6% (95% CI [92.6, 96.5]), respectively, for pap smear; 73.3% (95% CI [61.8, 84.9]) and 80.0% (95% CI [76.6, 83.4]) for VIA; 94.4% (95% CI [84.6, 98.8]) and 73.9% (95% CI [69.7, 78.2]) for HR HPV; and 72.3% (95% CI [59.1, 85.6]) and 93.2% (95% CI [90.8, 95.7]) for cervicography. CONCLUSION: The pap smear had the highest specificity (94.6%) and HPV testing the highest sensitivity (94.4%). The visual methods, VIA and cervicography, were similar and showed an accuracy in between the former two tests.     

内蒙古少数民族地区宫颈癌的筛查方法研究

目的探讨内蒙古少数民族聚居区宫颈癌及癌前病变适宜的筛查方法。方法2009年4月-8月对内蒙古自治区鄂尔多斯、兴安盟、通辽三个地区的2958名年龄30～59岁的已婚妇女进行了宫颈癌筛查。取宫颈脱落细胞,做人乳头瘤病毒（HPV-HC2）检测;同时用醋酸着色及碘着色（VIA/VILI）肉眼观察的方法进行筛查。对HPV-HC2阳性或VIA/VILI肉眼观察异常或两者均异常者,行阴道镜检查,在可疑处取宫颈组织活检,必要时行颈管诊刮术（ECC）;送组织病理学检查确诊。结果内蒙古鄂尔多斯、通辽、兴安盟三地区HPV总感染率为17.36%,中度及以上宫颈上皮内瘤样病变（≥CIN2）和宫颈癌的检出率为0.9%;应用HPV-HC2筛出阳性者最后确诊≥CIN2者27例,而用VIA/VILI仅确诊13例,漏诊14例。结论HPV检测结合醋酸、碘肉眼观察是宫颈癌筛查的有效方法。在内蒙等经济发展不均衡地区,可尝试采用HPV检测进行初筛,对HPV阳性患者用VIA＋VILI或者细胞学筛查的方法进行分流的筛查策略,降低漏诊率,也相对降低HPV阳性患者阴道镜的转诊率。     

Cytology versus visual inspection with acetic acid among women treated previously with cryotherapy in a low-resource setting

Objective

To compare visual inspection with acetic acid (VIA) with conventional cervical cytology as a follow-up cervical cancer screening method in women who had been treated previously with cryotherapy.

Methods

Salvadoran women screened with VIA and treated with cryotherapy within 3 years were eligible to participate. Study participants were rescreened with VIA, Pap smear, colposcopy, 4-quandrant biopsy, and endocervical curettage.

Results

Of 147 women enrolled in the study, post-cryotherapy VIA was positive in 39 women (26.5%; 95% CI, 19.6%-34.4%). Of these 39, 1 woman had CIN 1 or higher on biopsy. Post-cryotherapy Pap smear was positive (ASCUS or higher) in 6 women (4.1%; 95% CI, 1.5%-8.7%). Of these 6, 2 women had CIN 1 or higher on biopsy. Post-cryotherapy specificity was significantly higher for Pap compared with VIA (95.8% [138/144]; 95% CI, 91.2%-98.5% vs 73.6% [106/144]; 95% CI, 65.6%-80.6%; P < 0.001).

Conclusion

As the single-visit approach for cervical cancer screening gains popularity, more women will have been treated with cryotherapy. Appropriate follow-up screening is therefore vital. Cytology may be a more suitable screening method than VIA in low-resource settings for women treated previously with cryotherapy.     

肉眼观察法在宫颈癌及癌前病变筛查中的应用

目的：探讨醋酸肉眼观察（VIA）和碘染色肉眼观察（VILI）在宫颈癌及癌前病变筛查中的可行性。方法：以天津市大港区2003例妇女为研究对象,进行癌症综合知识、危险因素的问卷调查．用VIA和VILI行宫颈癌及其癌前病变筛查。VIA或VILI阳性者行电子阴道镜检查,阴道镜检查异常者行阴道镜下宫颈活检,病理学检查明确诊断。结果：单纯VIA阳性者257例。VIA或VILI阳性者共计265例．其中197例阴道镜检查异常,在阴道镜指导下行宫颈活检,以病理学检查结果作为诊断的金标准,宫颈上皮内瘤变（CIN）的检出率为7．04％,其中CINI116例,CINⅡ14例,CINIII11例。结论：在资源有限、经济欠发达的地区,由经过培训的医生实施VIA或VIU做宫颈癌初筛的方案可行。     

HPV DNA test and Pap smear in detection of residual and recurrent disease following loop electrosurgical excision procedure of high-grade cervical intraepithelial neoplasia

OBJECTIVE: We compared the performance of cervical cytology and HPV DNA test in detection of residual or recurrent disease following the treatment of cervical intraepithelial neoplasia (CIN) 2/3 with loop electrosurgical excision procedure (LEEP). SUBJECTS AND METHODS: A series of 107 women subjected to LEEP due to histologically confirmed CIN 2/3 between March 2001 and December 2002 were followed-up biannually until January 2004. Follow-up visits consisted of interview and gynecological examination including cervical cytology, hybrid capture II (HCII), and colposcopy. Patients presenting with abnormal colposcopy or high-grade squamous intraepithelial lesion (HSIL) smear were subjected to new excision procedure, and presence of histologically confirmed CIN 2/3 or higher was considered as residual or recurrent disease. Performance indicators were calculated for cytology and HCII assay in detecting residual or recurrent disease. RESULTS: Eleven (10.2%) women showed residual or recurrent disease during the follow-up. Considering HCII and Pap smear as stand-alone tests, both techniques showed similar sensitivity, detecting 100% of CIN 2/3 at the first follow-up visit. At the second follow-up visit, Pap smear showed better specificity and positive predictive value (PPV) than HCII, and both tests had fairly the same high negative predictive value (NPV) and sensitivity. The combined positive HCII and abnormal cytology had the same sensitivity as each of the tests alone, but specificity and PPV were significantly higher than those of single tests. When only one of the tests was positive, the sensitivity and the NPV of the combination remained the same, but its specificity and PPV were lower than that of the combined two positive tests and that of the individual test, at both follow-up visits. CONCLUSIONS: Both tests performed well in detecting residual or recurrent disease after LEEP and combination of the tests did not increase sensitivity of the single tests.     

Performance of visual inspection with acetic acid for cervical cancer screening: a qualitative summary of evidence to date

Developing countries often lack the necessary resources to use the Papanicolaou (Pap) smear as a screening tool for cervical abnormalities. Because the burden of cervical cancer is highest in such low-resource settings, alternative techniques have been sought. Recently, interest in visual inspection with acetic acid (VIA) has increased. Numerous studies have been conducted on its accuracy and its ability to detect cervical lesions when compared with other techniques, both conventional and nonconventional. This review summarizes key findings from the literature to provide researchers and policymakers with an up-to-date summary on VIA. PubMed was used to identify relevant journal articles published between 1982 and 2002. Key words were cervical cancer screening, visual inspection, VIA (visual inspection with acetic acid), DVI (direct visual inspection), AAT (acetic acid test), and cervicoscopy. Studies were eligible for review only if they involved analysis of primary VIA data (ie, not review articles); studies involving magnification devices were excluded. Fifteen studies were reviewed in total; key results were extracted and a summary analysis was performed for sensitivity and specificity parameters. When reported, sensitivity ranged between 66% and 96% and specificity between 64% and 98%. Authors comparing VIA with cytology noted that the overall usefulness of VIA compares favorably with that of the Pap test. The reported findings reviewed here suggest that VIA has the potential to be a cervical cancer screening tool, especially in low resource settings. TARGET AUDIENCE: Obstetricians & Gynecologists, Family Physicians. LEARNING OBJECTIVES: After completion of this article, the reader will be able to describe how visual inspection of the cervix for cervical cancer screening (VIA) is performed, to summarize the current literature on VIA, and to list potential advantages of VIA.     

A comparison of four screening methods for cervical neoplasia.

OBJECTIVE: To evaluate the sensitivity and accuracy of 4 screening methods for cervical neoplasia. METHODS: Cervical samples from 450 women were evaluated for human papillomavirus DNA with a second-generation hybridization assay. Visual inspection, colposcopy, and liquid-based cytology were also performed for 273 of these women. The sensitivity, specificity, efficiency, positive predictive value (PPV), negative predictive value (NPV), Youden index, and kappa value of the different screening methods were compared. RESULTS: Liquid-based cytology was superior in specificity (98.63%) and PPV (92.86%) to visual inspection and colposcopy, while human papillomavirus DNA testing was superior in sensitivity (88.89%) and NPV (97.10%) to visual inspection and colposcopy. The best concordance with histologic findings was achieved by using both liquid-based cytology and viral DNA hybridization. CONCLUSION: Visual inspection and colposcopy should not be used when screening for early stage cervical lesions. The DNA hybridization assay is the best choice in primary screening, if available. Screening should begin at the age of 20 years.     

Screening for cervical carcinoma using visual inspection with acetic acid.

OBJECTIVE: To assess the performance of visual inspection with acetic acid (VIA) as a screening test for early detection of cervical carcinoma in the Dakahlia Governorate in Egypt. METHODS: Diluted acetic acid (5%) was applied to the cervix during routine gynecologic examination. Women with positive results were referred for colposcopy. Those with negative results were referred for colposcopy only when they had clinical indications. RESULTS: Among the 5,000 women who were screened using VIA, 409 were referred for colposcopy. Cervical intraepithelial neoplasia (CIN) was diagnosed in 151 (60%) of the 253 women with positive screening results and in 4 of the 156 women with negative screening results. There were 39 women with high-grade and 116 with low-grade CIN. The sensitivity and negative predictive value of the VIA screening test was 97%. Its positive predictive value was 60% for all grades of CIN and 90% for high-grade CIN. CONCLUSION: Visual inspection with acetic acid, although associated with a relatively high rate of false-positive results, is a valuable test for the screening of cervical carcinoma.     

Adjunctive testing for cervical cancer in low resource settings with visual inspection, HPV, and the Pap smear.

OBJECTIVE: To test whether the performance of visual inspection using acetic acid (VIA) could be improved through adjunctive testing and to determine whether the combination of visual inspection of the cervix and HPV testing could prove useful for identifying those at highest risk of cervical precancer. METHODS: Between October 1995 and August 1997, 2199 women willing to be screened for cervical cancer in peri-urban clinics in Harare, Zimbabwe received VIA, Pap smear and HPV as screening tests. The presence or absence of (pre)cancer was confirmed via colposcopy with biopsy as indicated for >97% of all women. Computerized simulations of sequential testing scenarios provided estimates of the joint (net) test qualities of different paired combinations of the three tests and allowed for comparisons with the individual test qualities. RESULTS: Using HGSIL/CIN II-III as the reference threshold of disease, the net sensitivity and specificity of VIA and HPV when used sequentially were 63.6 and 81.9%, respectively, compared to 43.3 and 91%, respectively, when Pap smears were followed by HPV testing. VIA followed by the Pap smear yielded a net sensitivity of 37.5% and net specificity of 94.3%. CONCLUSIONS: For programs with limited resources but with the capacity for HPV testing, sequential testing involving the use of VIA followed by HPV could yield fewer false positives than the use of VIA alone at a cost of relatively few additional false negatives.