Cervical cancer screening with acetic acid saves lives

CHICAGO — A simple approach to cervical cancer screening that can be easily implemented in resource-strapped settings could save tens of thousands of lives worldwide each year, researchers reported at the annual meeting of the American Society of Clinical Oncology.

A team led by Dr. Surendra Srinivas Shastri, a professor of preventive oncology at Tata Memorial Center in Mumbai, India, conducted a cluster-randomized trial of visual inspection with acetic acid (VIA) among more than 150,000 women living in some of India’s poorest areas.

Main results showed that women who had four rounds of biennial screening with VIA delivered by trained health workers were almost a third less likely to die from cervical cancer than peers who were not screened, which is usual care in India given the lack of infrastructure and resources for country-wide Pap screening.

Susan London/IMNG Medical Media

Of note, the health workers were women, who were drawn mainly from the local community and who had a 10th grade education, according Dr. Shastri. Such professionals can reach remote and rural areas of the country, he said. Additionally, the VIA technique does not require a laboratory and provides immediate results.

"It is widely implementable in the lowest-resource settings in India or wherever," he said in a press briefing. "If implemented nationally in India, it would prevent around 22,000 cervical cancer deaths in the country. And if taken globally in middle-income and low-resource countries, we could prevent around 72,000 deaths in developing countries annually."

On the basis of the trial’s results, India is preparing to implement the VIA program nationally. He said that training of health workers, using a train-the-trainers approach, and a quality control process could be completed within 6 months.

Women receiving a cancer diagnosis through the VIA program will have access to treatment, assured Dr. Rajendra A. Badwe, one of the trial’s co-investigators and director of the Tata Memorial Center.

"There is a cafeteria choice" in India, he explained. "Individuals can have free treatment, individuals can pay for treatment. And treatment is currently available in 34 regional cancer centers run by the government of India. The way I see it, for any screening trial, if there is something done [to identify cancer], we need to be proactively with them to see that they reach the closest treatment facility... [Treatment] will be made available – no question."

The trial has established that VIA is "a good alternative" to Pap screening in limited-resource settings, according to Electra D. Paskett, Ph.D., co-program leader of the Cancer Control Program in the Comprehensive Cancer Center at the Ohio State University in Columbus and an ASCO spokesperson. And there may well be a role for VIA screening in some settings in developed countries.

"From my perspective, it could be an alternative ... in more resource-rich countries where there are these pockets of high cervical cancer incidence and mortality that don’t have access to the same treatment resources that the rest of the country does," she said in the press briefing. "And we do have those pockets here in the United States."

The trial was conducted in 20 impoverished areas of Mumbai that were assigned evenly to VIA screening and control groups. The target population was women aged 35 to 64 years who had no prior history of cancer.

Women in both groups received cancer education. In the VIA group, women underwent four rounds of biennial screening; those with positive results were referred to a health facility for definitive diagnosis. In the control group, women were asked to report to the health workers any signs or symptoms of cervical cancer; those doing so were similarly referred to a health facility. All women receiving a cancer diagnosis were offered free treatment.

Analyses were based on 75,360 women in the VIA screening group and 76,178 women in the control group.

"The screening participation rate was 89% – huge for a country like India and most other cases," Dr. Shastri commented. Participation in education in the control group was also high, at 91%. Overall, 86% of women with a confirmed case of cervical cancer received treatment.

The screening and control groups did not differ significantly with respect to the incidence of invasive cervical cancer (26.7 vs. 27.5 per 100,000), suggesting that screening did not lead to overdiagnosis.

"Overdiagnosis is a huge problem in all screening programs and all screening trials," Dr. Shastri noted. "There was almost zero overdiagnosis in this trial. In fact, what little overdiagnosis we had, that ceased by the eighth year."

In intention-to-treat analysis, screening with VIA resulted in a 31% reduction in the cervical cancer–specific death rates (11.1 vs. 16.2 deaths per 100,000; mortality rate ratio, 0.69, P = .003).

Screened women also had a 7% reduction in overall mortality stemming from earlier diagnosis, although this difference was not statistically significant.

Dr. Shastri disclosed no relevant conflicts of interest. Dr. Badwe disclosed no relevant conflicts of interest.

CHICAGO — A simple approach to cervical cancer screening that can be easily implemented in resource-strapped settings could save tens of thousands of lives worldwide each year, researchers reported at the annual meeting of the American Society of Clinical Oncology.

A team led by Dr. Surendra Srinivas Shastri, a professor of preventive oncology at Tata Memorial Center in Mumbai, India, conducted a cluster-randomized trial of visual inspection with acetic acid (VIA) among more than 150,000 women living in some of India’s poorest areas.

Main results showed that women who had four rounds of biennial screening with VIA delivered by trained health workers were almost a third less likely to die from cervical cancer than peers who were not screened, which is usual care in India given the lack of infrastructure and resources for country-wide Pap screening.

Susan London/IMNG Medical Media

Of note, the health workers were women, who were drawn mainly from the local community and who had a 10th grade education, according Dr. Shastri. Such professionals can reach remote and rural areas of the country, he said. Additionally, the VIA technique does not require a laboratory and provides immediate results.

"It is widely implementable in the lowest-resource settings in India or wherever," he said in a press briefing. "If implemented nationally in India, it would prevent around 22,000 cervical cancer deaths in the country. And if taken globally in middle-income and low-resource countries, we could prevent around 72,000 deaths in developing countries annually."

On the basis of the trial’s results, India is preparing to implement the VIA program nationally. He said that training of health workers, using a train-the-trainers approach, and a quality control process could be completed within 6 months.

Women receiving a cancer diagnosis through the VIA program will have access to treatment, assured Dr. Rajendra A. Badwe, one of the trial’s co-investigators and director of the Tata Memorial Center.

"There is a cafeteria choice" in India, he explained. "Individuals can have free treatment, individuals can pay for treatment. And treatment is currently available in 34 regional cancer centers run by the government of India. The way I see it, for any screening trial, if there is something done [to identify cancer], we need to be proactively with them to see that they reach the closest treatment facility... [Treatment] will be made available – no question."

The trial has established that VIA is "a good alternative" to Pap screening in limited-resource settings, according to Electra D. Paskett, Ph.D., co-program leader of the Cancer Control Program in the Comprehensive Cancer Center at the Ohio State University in Columbus and an ASCO spokesperson. And there may well be a role for VIA screening in some settings in developed countries.

"From my perspective, it could be an alternative ... in more resource-rich countries where there are these pockets of high cervical cancer incidence and mortality that don’t have access to the same treatment resources that the rest of the country does," she said in the press briefing. "And we do have those pockets here in the United States."

The trial was conducted in 20 impoverished areas of Mumbai that were assigned evenly to VIA screening and control groups. The target population was women aged 35 to 64 years who had no prior history of cancer.

Women in both groups received cancer education. In the VIA group, women underwent four rounds of biennial screening; those with positive results were referred to a health facility for definitive diagnosis. In the control group, women were asked to report to the health workers any signs or symptoms of cervical cancer; those doing so were similarly referred to a health facility. All women receiving a cancer diagnosis were offered free treatment.

Analyses were based on 75,360 women in the VIA screening group and 76,178 women in the control group.

"The screening participation rate was 89% – huge for a country like India and most other cases," Dr. Shastri commented. Participation in education in the control group was also high, at 91%. Overall, 86% of women with a confirmed case of cervical cancer received treatment.

The screening and control groups did not differ significantly with respect to the incidence of invasive cervical cancer (26.7 vs. 27.5 per 100,000), suggesting that screening did not lead to overdiagnosis.

"Overdiagnosis is a huge problem in all screening programs and all screening trials," Dr. Shastri noted. "There was almost zero overdiagnosis in this trial. In fact, what little overdiagnosis we had, that ceased by the eighth year."

In intention-to-treat analysis, screening with VIA resulted in a 31% reduction in the cervical cancer–specific death rates (11.1 vs. 16.2 deaths per 100,000; mortality rate ratio, 0.69, P = .003).

Screened women also had a 7% reduction in overall mortality stemming from earlier diagnosis, although this difference was not statistically significant.

Dr. Shastri disclosed no relevant conflicts of interest. Dr. Badwe disclosed no relevant conflicts of interest.

CHICAGO — A simple approach to cervical cancer screening that can be easily implemented in resource-strapped settings could save tens of thousands of lives worldwide each year, researchers reported at the annual meeting of the American Society of Clinical Oncology.

A team led by Dr. Surendra Srinivas Shastri, a professor of preventive oncology at Tata Memorial Center in Mumbai, India, conducted a cluster-randomized trial of visual inspection with acetic acid (VIA) among more than 150,000 women living in some of India’s poorest areas.

Main results showed that women who had four rounds of biennial screening with VIA delivered by trained health workers were almost a third less likely to die from cervical cancer than peers who were not screened, which is usual care in India given the lack of infrastructure and resources for country-wide Pap screening.

Susan London/IMNG Medical Media

Of note, the health workers were women, who were drawn mainly from the local community and who had a 10th grade education, according Dr. Shastri. Such professionals can reach remote and rural areas of the country, he said. Additionally, the VIA technique does not require a laboratory and provides immediate results.

"It is widely implementable in the lowest-resource settings in India or wherever," he said in a press briefing. "If implemented nationally in India, it would prevent around 22,000 cervical cancer deaths in the country. And if taken globally in middle-income and low-resource countries, we could prevent around 72,000 deaths in developing countries annually."

On the basis of the trial’s results, India is preparing to implement the VIA program nationally. He said that training of health workers, using a train-the-trainers approach, and a quality control process could be completed within 6 months.

Women receiving a cancer diagnosis through the VIA program will have access to treatment, assured Dr. Rajendra A. Badwe, one of the trial’s co-investigators and director of the Tata Memorial Center.

"There is a cafeteria choice" in India, he explained. "Individuals can have free treatment, individuals can pay for treatment. And treatment is currently available in 34 regional cancer centers run by the government of India. The way I see it, for any screening trial, if there is something done [to identify cancer], we need to be proactively with them to see that they reach the closest treatment facility... [Treatment] will be made available – no question."

The trial has established that VIA is "a good alternative" to Pap screening in limited-resource settings, according to Electra D. Paskett, Ph.D., co-program leader of the Cancer Control Program in the Comprehensive Cancer Center at the Ohio State University in Columbus and an ASCO spokesperson. And there may well be a role for VIA screening in some settings in developed countries.

"From my perspective, it could be an alternative ... in more resource-rich countries where there are these pockets of high cervical cancer incidence and mortality that don’t have access to the same treatment resources that the rest of the country does," she said in the press briefing. "And we do have those pockets here in the United States."

The trial was conducted in 20 impoverished areas of Mumbai that were assigned evenly to VIA screening and control groups. The target population was women aged 35 to 64 years who had no prior history of cancer.

Women in both groups received cancer education. In the VIA group, women underwent four rounds of biennial screening; those with positive results were referred to a health facility for definitive diagnosis. In the control group, women were asked to report to the health workers any signs or symptoms of cervical cancer; those doing so were similarly referred to a health facility. All women receiving a cancer diagnosis were offered free treatment.

Analyses were based on 75,360 women in the VIA screening group and 76,178 women in the control group.

"The screening participation rate was 89% – huge for a country like India and most other cases," Dr. Shastri commented. Participation in education in the control group was also high, at 91%. Overall, 86% of women with a confirmed case of cervical cancer received treatment.

The screening and control groups did not differ significantly with respect to the incidence of invasive cervical cancer (26.7 vs. 27.5 per 100,000), suggesting that screening did not lead to overdiagnosis.

"Overdiagnosis is a huge problem in all screening programs and all screening trials," Dr. Shastri noted. "There was almost zero overdiagnosis in this trial. In fact, what little overdiagnosis we had, that ceased by the eighth year."

In intention-to-treat analysis, screening with VIA resulted in a 31% reduction in the cervical cancer–specific death rates (11.1 vs. 16.2 deaths per 100,000; mortality rate ratio, 0.69, P = .003).

Screened women also had a 7% reduction in overall mortality stemming from earlier diagnosis, although this difference was not statistically significant.

Dr. Shastri disclosed no relevant conflicts of interest. Dr. Badwe disclosed no relevant conflicts of interest.