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Atlas of visual inspection of the cervix with acetic acid for screening, triage, and assessment for treatment

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Cervical cancer screening followed by treatment of screen-detected precancers and cancers is a key strategy, along with vaccination against human papillomavirus (HPV), to eliminate this deadly cancer, which kills more than 300 000 women per year worldwide. Visual inspection after application of acetic acid (VIA) is widely used as the screening test of choice in low- and middle-income countries (LMICs), because of its simplicity, point-of-care nature, and low cost. In high-income countries, cervical cancer screening programmes are switching from cytology-based (Pap smear) screening to the detection of high-risk HPV types. However, large-scale adoption of HPV testing in LMICs will only be possible when there is a technologically less demanding, point-of-care, and affordable HPV detection test available. Until that happens, VIA will continue to be practised. VIA will be relevant in LMICs even after the introduction of HPV testing, because VIA can be effectively used to triage HPV-positive women for further assessment or treatment. In a screen-and-treat programme, determining the eligibility of a screen-positive woman (irrespective of whether the test is VIA or HPV detection) for ablative treatment requires application of acetic acid to the cervix, and many of the principles and techniques of VIA are followed.

This atlas of visual inspection of the cervix with acetic acid for screening, triage, and assessment for treatment, from the International Agency for Research on Cancer (IARC), covers a wide spectrum, including the use of VIA as a primary screening test, VIA as a triage test for HPV-positive women, the technique for determining eligibility for ablative treatment after application of acetic acid, and the use of Lugolís iodine to direct treatment. I expect that this atlas will be an extremely useful resource for providers of cervical cancer screening in LMICs and will remain relevant irrespective of the screening and management algorithm used in a particular setting.

The atlas is freely available online. It describes in clear language the anatomical and physiological basis of the visual techniques, the equipment and consumables needed, the steps to be followed to perform the procedures, and post-procedural management. The nearly 500 annotated images collected from field settings in LMICs will enable providers to learn about a wide variety of normal and abnormal features that they would encounter while performing the procedures. The atlas is very interactive, allowing readers to magnify the images, see the annotations, and even perform self-evaluation. Following IARCís principle of open science, all the images can be downloaded to be used for self-improvement and training of providers.

IARC gratefully acknowledges the contribution of Dr Srabani Mittal, the lead author of this atlas. She was a long-time collaborator of IARC, an excellent researcher, and a great teacher. She collected all the images used in the atlas with great care and organized the contents in a simple yet informative manner. Her untimely death left a great void, but the atlas will remain as a great testament to her contribution to the field of cervical cancer prevention.

I am confident that this atlas will be an invaluable tool for capacity-building of providers of screening in LMICs, and will provide a meaningful contribution to the World Health Organization call for action to eliminate cervical cancer as a public health problem globally. This new atlas will also be a great complement to the Atlas of Colposcopy: Principles and Practice, which is also freely available online.

   Dr Elisabete Weiderpass
   Director, International Agency for Research on Cancer

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