Worldwide, cervical cancer is one of the most common cancers among women accounting for 11.7% of the total cancer burden.1 In Vietnam, cervical cancer causes approximately 6000 new cases and 2500 deaths per year.2 This figure indicated the importance of a preventive program for cervical cancer in Vietnam. As the process from developing precancerous lesions of the cervix after persistent infection with human papillomavirus to becoming invasive cervical cancer often takes 10 to 15 years, it provides many opportunities for detection and treatment of precancerous lesion. In middle- and low-resource countries, people tend to seek health care only when problems arise; in the case of cervical cancer, this usually proves devastating for the woman, as at this point the cancer has frequently reached an advanced stage. If not already too late, treatment will usually require invasive surgery or radiation therapy, which, even without taking into account the significant impacts on the woman and her family, may not be available for their socioeconomic status. Vietnam still applies the opportunistic cytology-based screening model (ie, using Papanicolaou test), and this model has failed to have an impact on the increasing burden of cervical cancer in Vietnam as most cases (54%) with cervical cancer in Vietnam were diagnosed at the late stage (stages III and IV).3 A new potential model “screen and treat” using VIA (visual inspection with acetic acid), followed by treatment with cryotherapy (freezing) proposed by the Alliance for Cervical Cancer Prevention may be applied to the Vietnam context.4
In 2013, we pilot tested a community-based screening project for cervical cancer using VIA in Can Tho and Bac Ninh. The objectives of this project were (i) to develop a formal procedure that can be done at community level for screening of cervical cancer using method of VIA; (ii) to train midwife and assistant physician to do VIA at the grassroots level of the health care system; (iii) to conduct community-based cervical cancer screenings for 2000 women in Bac Ninh and Can Tho as well as to evaluate the diagnostic value of VIA compared with Papanicolaou test methods.
This article presents the main results of this pilot project as well as some in-depth analysis about the quality of this community-based screening model using the World Health Organization health system framework.
Design and setting
Employing a pretest-posttest design, the study was done in 2 provinces of Vietnam (Bac Ninh in the North of Vietnam and Can Tho in the South). The study combined both rural and urban settings (ie, in Bac Ninh, a rural district was chosen and in Can Tho, an urban district was chosen).
The study trained in total 36 assistant physicians/midwives working at commune health centers to do VIA screening for cervical cancer. The screening project selected 2100 married women 30 to 65 years of age, currently residing in 2 provinces of Vietnam (Bac Ninh in the North of Vietnam and Can Tho in the South). Of the 2100 women selected for this study, 1945 responded (nonresponses rate of 7.4%) (Figure 1).
The pilot intervention was implemented in 6 phrases: (1) developing a formal procedure on how to do VIA to screen for cervical cancer at grassroots level and what to do with positive cases; (2) training midwives and assistant physicians who are currently working in local districts and commune health centers on how to do VIA and what to do with positive cases; (3) evaluating the capacity of midwives and assistant physicians to do VIA before implementing actual screening on field; (4) implementing screening for cervical cancers for a total of 1945 women in Can Tho and Bac Ninh by applying VIA method, implemented by trained local midwives and assistant physicians under the supervision of specialized physicians; (5) comparing the sensitivity/specificity/negative and positive predicted values of VIA test with Papanicolaou test (using the “gold standard” of cervical biopsy); and (6) giving appropriate treatment or follow-up advice for positive cases with VIA/Papanicolaou test or cervical biopsy).
The screening for cervical cancers procedure was implemented in the following order: Papanicolaou test; VIA. This sequence was chosen to ensure the effectiveness of these tests because if VIA is applied first, the acetic acid will change the surface of the cervical lining, thus affecting the quality of the specimen Papanicolaou test or it will take time to wait for the cervical mucus to return to normal after applying acid. To validate the results of Papanicolaou test and VIA test, all the women with positive VIA and Papanicolaou test results and 15% of all the negative cases (ie, 352 women) were offered cervical biopsy (Figure 1).
The feasibility of the pilot-screening model was assessed by employing the World Health Organization health system framework. Specifically, the following characteristics of the model were examined: accessibility, comprehensiveness, quality, and coverage.5 The quality of VIA screening method was done by comparing the diagnostic value of VIA method with Papanicolaou test using the gold standard of cervical biopsy).
Abnormal VIA or positive VIA was defined as after 1 minute of applying acid acetic, a well-defined, dense acetowhite area with regular margins appeared.
Abnormal Papanicolaou test or positive Papanicolaou test was defined as a cytologic diagnosis of ASC-US or more severe lesion according to the 2001 Bethesda system.
Biopsy positive indicates the presence of cervical intraepithelial neoplasia (CIN) 1 or more advanced lesions, or cancer.
The protocol was reviewed and approved by Hanoi School of Public Health Ethical Committee (ethical approval number 013/2013/YTCC-HD3).
Characteristics of study sample
Table 1 presents the characteristics of the final study sample. Women aged 40 to 49 years accounted for around 60% of total participants. The proportion of participants who reported economic status as poor or near poor was 35.8%.
Training for health care workers at grassroots level to do VIA screening for cervical cancer
Two workshops for selected health care workers (ie, assistant physicians or midwives currently working at selected commune health centers) were organized in Can Tho and Bac Ninh. In total, 36 health care workers were trained about how to implement VIA screening, how to deliver test results, and how to counsel cervical cancer. Each training workshop lasted 3 days combining lectures and practice. The participants were assessed by their skills to perform VIA screening by specialized physicians after completing the workshop. All the participants passed the final practical test.
Results of screening program
Figure 2 presents the prevalence of VIA positive among married women 30 to 65 years of age. There were 157 VIA-positive cases accouting 8.1% of a total of 1945 women enrolled in the screening survey. The VIA-positive rate was highest among women 50 to 54 years of age (P = 11.4%) and lowest among the group older than 55 years (5.4%). Papanicolaou test detected 119 (6.1%) as positive (Figure 2), including 96 (4.9%) as Ascus, 14 (0.7%) as Ascus-H, 6 (0.3%) as CIN I, and 3 (0.2%) as CIN II. A total of 12 CIN 1 cases; 3 CIN 2, 3 CIN 3, and 3 invasive cancers were detected via biopsy test.
Feasibility of the new model
The project had given evidence that cervical screening using VIA method had high diagnostic value. Specifically, for the detection of CIN 2/CIN 3, the sensitivity of VIA is 100% and specificity of VIA is 67.0%. Visual inspection with acetic acid had sensitivity comparable with Papanicolaou test but requires far fewer resources (Table 2).
The nonresponse rate of women in this study was quite low (only 7.4%), indicating that women are willing to take this screening service. After having VIA, clients reported that “there was no difference between having VIA and their normal gynecological exams and it was great to have the results right after checked up.”
This pilot program showed that screening by VIA requires fewer specialized personnel and less infrastructure and equipment. Visual inspection with acetic acid can be done at any community site with minimum efforts and can be implemented at any time; thus, this screening model is very accessible for women, especially women in rural areas with no access to specialized health care centers.
The average cost for VIA done at commune health centers is $1 to $2 per screening. If this is integrated in to routine reproductive health checkup campaigns for women, it costs almost nothing because the materials for screening are very cheap.
In this pilot study, we implemented screening for cervical cancer using VIA; all cases detected positive were referred to specialized health centers for appropriate treatment or follow-up. However, the Alliance for Cervical Cancer Prevention has recommended that once VIA is done, if abnormal lesion is detected in the cervix in a woman, we can apply cryotherapy as a treatment option for the eligible test-positive cases. So this model can be extended to be a routine screening and treatment procedure for cervical cancer.
Visual inspection with acetic acid can offer significant advantages over Papanicolaou test in low-resource settings, particularly in terms of increased screening coverage, improved follow-up care, and overall program quality. Because of the need for fewer specialized personnel and less infrastructure, training, and equipment with VIA, public health systems can offer cervical cancer screening in more remote (and less equipped) health care settings and can achieve higher coverage. Furthermore, providers can share the results of VIA with patients immediately, making it possible to screen and treat women during the same visit. This helps ensure that follow-up care can be provided on the spot and reduces the number of women who may miss out on treatment because they are not able to return to the clinic at another time.
The World Health Organization estimates that a onetime screening among women around the age of 40 years could reduce the chance of fatality due to cervical cancer by 25% to 30% if adequately followed up.6 Since cervical cancer usually progresses slowly, this once-in-a-lifetime screening could prevent abnormal cells from becoming fatal. Papanicolaou test has been shown to effectively lower the risk for developing invasive cervical cancer by detecting precancerous changes in developed countries.7 However, as in other developing countries, not many eligible Vietnamese women can undergo cytology-based screening in a 5-year period,8 especially women in rural areas because Papanicolaou test is confined to hospitals or private laboratories in urban areas. Furthermore, delays in reporting cytology results make it less likely that test-positive women ever receive their results, let alone treatment or follow-up.9
The implementation of this pilot-screening program had confirmed the following: (i) VIA-screening method offers comparable diagnostic results with Papanicolaou test; (ii) local midwives and assistant physicians who currently work at commune health centers and district health centers can be trained to do VIA efficiently; and (iii) VIA can offer significant advantages over Papanicolaou test in low-resource settings, particularly in terms of increased screening coverage, improved follow-up care, and overall program quality.
The validity of VIA-screening method was also reported in previous studies.10–14 Visual inspection with acetic acid in this present study had a sensitivity and a specificity similar to that reported in studies in other low-resource settings (sensitivities ranged from 53% to 91%; the specificities estimate ranged from 55% to 98%).11 , 15–19 Comparing to Papanicolaou test, the present study indicates the equal validity between VIA and Papanicolaou test results, regarding both sensitivity and specificities. The same findings were reported in the comparing performance VIA and cytology studies in Africa, India, and Zimbabwe,11 , 17 , 20 whereas in 2 other studies,16 , 18 there were similar specificities among VIA and Papanicolaou test but higher sensitivities in VIA were reported. This inconsistency reflects the diversity among different providers in interpreting visual tests owing to different levels of experience, training methods, monitoring, and quality assurance. These studies also mentioned that VIA provides instant results, and those eligible for treatment can receive treatment of the precancerous lesions using cryotherapy on the same day and in the same health facility. This “see and treat” method ensures adherence to treatment soon after diagnosis, hence stemming the problem of failing to honor patient referrals. This study demonstrated that commune health staffs can be trained to do VIA; however, we would need more studies to conclude whether commune staffs can be trained to do cryotherapy as well. Currently, equipment for cryotherapy is not available at the commune health center level; however, it is possible to provide cryotherapy to primary care settings because during cryotherapy, CO2, the least expensive and most accessible type of gas as the refrigerant gas to destroy abnormal cells, is used. Previous studies in other countries have suggested that cryotherapy is applicable in primary care settings with cost about $27 per treatment21 , 22 while cost of screening done by VIA test is around $3 to $4 per treatment.22 It was also suggested that cryotherapy achieved cure rates of 94.0% for CIN 1 cases, 92.0% for CIN 2 cases, and 85.0% for CIN 3 cases.23
The important lessons from this study for the scaling up of VIA-screening model are as follows: (i) Like Papanicolaou test, the validity of VIA is highly dependent on the accuracy of an individual's interpretation, which means that initial training and ongoing quality control are of paramount importance. (ii) Before implementing community-based screening for cervical cancer, it is necessary to create awareness about cervical cancer and its prevention among the community as in many rural areas, knowledge among community members about cervical cancer is limited. Nonsymptomatic women do not present for screening even if it is available, and, in most cases, precancer is a silent disease. If women ever do go to a clinic, they do so when the disease has advanced to a stage that cannot be successfully treated with local resources. We need to develop culturally appropriate materials for community education and mobilization, and train community outreach workers to effectively promote screening and access to services. (iii) A follow-up and referral system needs to be set up for the immediate period after screening or even after quick treatment by cryotherapy. All screening programs need to strengthen linkages within the health system to ensure that women receive the appropriate follow-up and treatment.
Implications for Policy & Practice
- Visual inspection with acetic acid is a simple screening test suitable for low-resource settings.
- Compared with Papanicolaou test, this screening method is more suitable for Vietnam because it increased screening coverage and improved follow-up care and overall program quality.
- Visual inspection with acetic acid can be done at community-based sites by trained local midwives or assistant physicians.
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