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A practical manual on visual screening for cervical neoplasia
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Cervical cancer is the second most common cancer among women worldwide, accounting for 452,000 new cases per year. In many developing countries, where an estimated three-fourths of the world burden occurs, it is the most common cancer among women and the most common cause of death among middle-aged women. Despite its public health importance, there are no effective prevention programmes in most developing countries and hence the risk of disease and death from cervical cancer remains largely uncontrolled. Invasive cervical cancers are preceded by a long phase of precancerous lesions that can be detected by screening and treated effectively by simple treatments, which prevent invasive cancer. Cytology-based screening is effective, but beyond the capacity of the health services in many of these countries. Hence, other methods of early detection of cervical neoplasia, particularly those based on visual inspection, are being investigated.
Two simple, low-technology screening tests, namely visual inspection with acetic acid (VIA) and with Lugol’s iodine (VILI), which are based on the ability of the trained health-care personnel to detect acetowhite areas, or yellow non-iodine uptake areas, in the cervical transformation zone, are currently being evaluated in experimental settings as potential alternatives to cervical cytology. Published results show that VIA has similar sensitivity, but somewhat lower specificity when compared to quality cytology. For VILI, preliminary results from several studies in progress indicate that it is another promising screening test.
This manual is intended to help in the training of a range of health-care personnel such as health workers, nurses and physicians to perform VIA and VILI. Draft versions of this manual have been used over the last three years to train health care personnel in 22 training courses in the context of specific evaluation studies of cervical cancer prevention, supported by the Bill & Melinda Gates Foundation through the Alliance for Cervical Cancer Prevention (ACCP) in Angola, Burkina Faso, Congo, Guinea, India, Mali, Mauritania, Nepal, Laos, Senegal and Tanzania. Feedback from the participants in these courses and test providers has been particularly useful in revising several draft versions of the manual, which is expected to fulfil the long-felt need for a simple learning resource to provide proper and adequate training of health care personnel and to ensure skilled practice of VIA and VILI in experimental and clinical detection settings.
P. Kleihues M.D.