Cost Paradox in Cercival Cancer Screening in South India: Expensive HPV Is a Better Screening Test Than Less Expensive Techniques: Comparison of VIA, Cytology and HPV Testing
Rajan Dewar, Rashmi Khadapkar, S Jeyapandi, Ashraf Khan, BR Das. Beth Israel Deaconess Medical Center, Boston, MA; SRL Limited, Mumbai, Maharashtra, India; Hindu Mission Hospital, Thiruchirapalli, Tamilnadu, India
Background: An estimated 70,000 women die every year in India from cervical cancer. A concerted program for cervical cancer does not exist at the national level. Visual Inspection with Acetic Acid (VIA) is very strongly proposed by several organizations including the WHO based on published studies. In this study, we evaluate the efficacy of VIA based screening and cytology based screening. False positive rates of VIA and cytology were compared against Human Papilloma Virus (HPV) results.
Design: We conducted several camps in the Thiruchirapalli and Thirunelveli districts of Tamilnadu. We report the results from two cohorts. In the first cohort of 386 patients, a cervical smear was collected for HPV testing (Cervista) and Liquid Based Cytology (LBC - Thin Prep). In the second cohort of 37 patients, a gynecologist who underwent VIA / colposcopy training at a WHO approved institution, collected specimen for LBC/HPV followed by VIA / colposcopic examination of the cervix. For VIA based screening, satellite lesions, Lugols Iodine or aceto-white abnormal areas were considered positive. Cytology was positive if the results were ASCUS, LSIL and HSIL.
Results: Result 1. Comparison of LBC with HPV:58 specimens were positive for HPV. Of these 11 were positive by LBC (true positives). There were 33 cases which were positive by LBC, which were negative for HPV (false positive; 8.5% false positive rate among 386 patients). Result 2. Comparison of VIA with HPV: In the second cohort of 37 patients, 7 patients were positive for HPV. Of these 3 patients were positive by VIA. Of the 30 patients, who were negative for HPV, 11 were positive by VIA. All 37 patients were negative by cytology. Based on this the false positive rate of VIA based screening in our set-up is 29.7%.
Conclusions: VIA is increasingly being pushed as a primary screening method in developing countries. However, despite training, there is an unacceptably high degree of false positive (30%) results by VIA. This results in over-treatment in an inordinately large number of patients. The false positivity rate of cytology was 8.5%. Based on the above results, where resources are available, we propose that HPV testing followed by reflex cytology is a better screening strategy than VIA alone. This is applicable to a country such as India, where laboratory based testing and trained cytologists are available.
Monday, March 4, 2013 1:00 PM
Poster Session II # 82, Monday Afternoon