Role of Visual Inspection of Cervix with Acetic Acid ( VIA ) in Detecting Precancerous Lesions of Cervix

Background: Carcinoma of cervix is the most common malignancy in female and a major public health problem worldwide. It is the leading cause of death from cancer among women in low resource settings. In Bangladesh, mortality rate is high as most of the cases with cervical cancer are diagnosed in advanced stage. World Health Organization considers cervical cancer as a preventable disease as it can be identified in preinvasive stage. Considerable efforts have been given in detection and treatment of the condition all over the world. A number of cervical cancer screening tests are available. Among them, visual inspection of cervix with acetic acid is rational and can be competently performed by physicians with proper training. Objective: To find out the feasibility of the visual inspection of cervix with acetic acid for the detection of the precancerous lesions of the cervix in our country. Materials and Methods: This cross sectional, analytical study was carried out among the patients attending the outpatient department of Bangabandhu Sheikh Mujib Medical University (BSMMU) who were VIA positive and sent for colposcopy in the colposcopy clinic in the department of Obstetrics and Gynecology in BSMMU from June to December 2004. Two hundred samples were considered for this study. Results: Out of 200 cases, colposcopically 85% had CIN and invasive lesions, 4% had inflammatory lesions while 11% had normal findings. Colposcopy directed punch biopsy revealed positive lesions in 81%, 4% had inflammatory lesions while 15% had normal findings. Conclusion: The study concluded that VIA and colposcopy are the important methods in the evaluation of cervical premalignancy. VIA may be an important tool for screening of cervical cancer in low resource settings as it is simple, easy to perform and cost-effective. After screening, VIA positive cases must be referred for colposcopic evaluation. We can screen cervical cancer by VIA all over the country and thus reduce morbidity and mortality rate.


Role of Visual Inspection of Cervix with Acetic Acid (VIA) in
Detecting Precancerous Lesions of Cervix cancer each year.Eighty percent of the new cases occur in the developing countries, while this is declining in the developed world due to introduction of different screening tests.In Southeast Asia and Africa, where women live in poor condition, the incidence and mortality rate of carcinoma cervix may be 4 or 5 times higher than those seen in developed countries. 2 reliable statistical data about cancer are available for most developing countries in general and Bangladesh in particular.However, cancer is one of the leading causes of morbidity and mortality in Bangladesh. 3 Most of the cervical cancers are diagnosed in the advanced stage, so mortality is high.Based on the world health statistics, new cancer cases in Bangladesh have been estimated at 167 per 100,000 populations.An epidemiological institute of cancer research of Bangladesh (1976-83) showed that the prevalence of cancer cervix is 26% amongst all types of cancers affecting female. 4The prevention and control of cancer in developing countries deserve urgent attention since the disease is likely to double in these countries in the next 20-25 years.
The problem of cancer in Bangladesh is acute because of poverty, early age of marriage, multiple marriages, high parity, illiteracy and other diseases associated with poor nutrition and lack of basic knowledge of the people about health matters.Therefore, understanding the etiological factors is important for the successful prevention of the disease. 5World Health Organization (WHO) considers cervical cancer as a preventable disease. 5This is because cervix is easily accessible, the disease has a long premalignant phase and can be diagnosed in its precancerous stage.As it is preventable and almost curable when diagnosed early, that is, in its preinvasive stage (cervical intraepithelial neoplasia [CIN]), considerable efforts have been given in detecting and treating the condition all over the world.The decrease in cervical cancer prevalence in most of the developed countries is attributed to the success of cytology based screening program, but our country often lacks the necessary resource to use the pap smear as a screening tool for cervical abnormalities. 6As the incidence of cervical cancer is highest in low resource settings, alternative techniques have been sought.Recently, visual inspection with acetic acid (VIA) has gained popularity. 7 In some developed and developing countries, cervical cytology test for carcinoma of cervix and CIN has become a routine procedure.WHO suggested an alternative to regular cytologic screening known as "down staging screening" as an experimental approach.
It can be defined as the detection of the disease at an earlier stage by nurses and other nonmedical health personnel using a simple speculum for visual inspection of the cervix. 8 Bangladesh, where prevalence of cancer is high and cytological screening is not available, down staging screening may be useful.This approach must be coupled with cytological screening.But cytology also cannot determine the extent or location of abnormality though it is highly accurate in detecting the presence of cervical neoplasia. 9ailable cervical cancer screening tests are automated pap screening, visual inspection with acetic acid, human papilloma virus testing and the recently introduced polar probe.Among these visual inspection with acetic acid is the most suitable test because it is rational for low resource setting as it is inexpensive and usually locally available, gives immediate result, can be competently performed by physicians with proper training and drop-out during follow-up is minimal. 10,11he aim of this study was to find out the role of VIA for the detection of precancerous and early cancerous lesions of the cervix with the ultimate objective to assess whether VIA could be used as a mass screening test as an alternative to cytology.

Material and Methods
This cross sectional, analytical study was carried out among 200 VIA p o sitive patients, attending the outpatient department of Gynecology and Obstetrics of Bangabandhu Sheikh Mujib Medical University (BSMMU) and sent for colposcopy in the 'colposcopy clinic'.The period of study was from June to December 2004.Married women, aged 18-60 years with signs and symptoms of early cervical cancer were included in the study.Menstruating women, patients with obvious growth or big mass in the cervix, pregnant and hysterectomized women were excluded.
A speculum was introduced into the vagina and cervix was exposed under good light source.A cotton ball soaked with 3-5% acetic acid was applied on the cervix and retained for one minute.Then the cotton ball was removed.Abnormal cells on the cervix temporarily turned white indicating acetowhite epithelium on the cervix (VIA positive).Women with acetowhite lesions were considered for colposcopic examination and biopsy.
Colposcopy findings and colposcopy directed biopsy findings of study subjects were compared to find out the effectiveness of VIA as a mass screening test to detect precancerous lesions of cervix.

Results
The age of the patients was between 18-60 years with mean ± SD 36.4 ± 9.8.About 75% were housewives, among them 60% maintained personal hygiene.Among the husbands of the patients 37% were businessmen, 26.5% were government service holders, 12.5% farmers, 8% rickshaw pullers and 2.5% had jobs abroad.Seventy four percent patients lived in urban area and 26% in rural area.
Table I shows the menstrual history of the study subjects.Among them 180 had continued menstruation; 33% patients had irregular menstruation and 67% cases had regular menstruation with average flow and duration.Intermenstrual bleeding was found in 27.78% cases while it was absent in 72.22% cases.

Sensitivity and specificity analysis
As all the cases were VIA positive, the sensitivity and specificity could not be analyzed.But the sensitivity and specificity of colposcopy were calculated considering colposcopy directed biopsy as gold standard.VIA test was positive in 100% cases as the study planned, among them 85% cases were positive by colposcopy and 81% cases were positive in biopsy. this study most of the cases were housewives followed by garments workers, service holders and students.About one-third of the cases had unsatisfactory personal hygiene.In this study most of the cases were from urban area.This may be due to the awareness among the urban population and location of the institution where the study was done in urban area.
In our study, 55% respondents had >2 children which indicates that multiparity may be a related risk for premalignancy of the cervix.In the present study highest percentage had experienced menarche at the age of 13 years.Among 180 menstruating subjects, 33% had irregular menstruation.Among subjects with regular menstrual history, 80 (44.4%) had 4-5 days cycle and 140 (77.7%)had average menstrual flow.
In our study there were no smokers among the study subjects, therefore we could not assess the risk of smoking on cervical premalignancy.In this study we found that 15% cases had multiple sexual partners.Among the study subjects 60% were hormonal contraceptive users which is higher than the nationwide data (53.8%).This indicates that the use of contraceptives is higher in the CIN cases.
Regarding age of first coitus, 76.5% experienced coitus before 18 years.Sayeeda S 12 found that more than 80% had experienced first coitus before 19 years.Only 2.5% had family history of cancer in this study.
In this study, most common presentations w e re excessive vaginal discharge, backache, dysuria and dyspareunia.All these were non-specific, which indicated the need for screening test to diagnose CIN.Forty percent subjects had no symptoms or signs.By speculum examination of 200 cases, 172 (86%) had normal appearance of cervix.
In this study, colposcopically 85% had CIN and invasive lesions, while 15% had normal or inflammatory lesions.Colposcopically directed punch biopsy revealed 81% cases showed positive lesions and 19% had no lesions or CIN.
As all of the cases were VIA positive, the sensitivity and specificity of VIA could not be calculated.But considering CDB as a gold standard, the sensitivity and specificity of colposcopy were 92.59% and 47.36% respectively.Among 200 cases, 85% were positive by colposcopy.In CDB 81% had positive finding.Therefore, it stands that 19% was false positive VIA test in comparison with CDB.The false negative could not be calculated as all the cases were VIA positive.
The study concludes that VIA and colposcopy are the important methods in the evaluation of cervical premalignancy.VIA may be an important tool for screening cervical cancer in low resource settings as it is a simple method, easy to perform and costeffective.VIA may be associated with a referral procedure for further methods.Cervical cancer is a priority concern for the WHO program on cancer control.WHO recommends and emphasizes on programs for early detection with a systematic approach and that can be well-integrated into the existing health system.

Table III
TableIVshows the clinical features of the study subjects.Forty percent of the cases had no symptoms at all.Dirty brown or white excessive vaginal discharge was the complaint of more than 50% of the cases.Dyspareunia, backache, dysuria, postcoital bleeding, abnormal intermenstrual b l eeding and heavy irregular vaginal bleeding were in 20%, 15%, 10%, 10%, 7.5% and 2.5% cases respectively.

Table I :
Menstrual history of the study subjects

Table III :
Risk factors of cervical cancer among study subjects (n=200)

Table IV :
Clinical features of study subjects (n=200)

Table VII :
Diagnostic efficacy of colposcopy