In 2013, at the ASCO Annual Meeting Plenary Session, it was both surprising and encouraging in the era of personalized medicine for cancer care to hear about a simple low-tech intervention delivered by women in the community that cut the rate of death from cervical cancer in India by about one-third.¹ The intervention, a simple visual inspection after acetic acid (vinegar) is applied to the cervix with a cotton swab, could prevent about 22,000 deaths from cervical cancer in India each year and close to 72,000 deaths each year in the developing world.

Jyoti D. Patel, MD

At the 2013 ASCO Annual Meeting, Jyoti D. Patel, MD, spoke at a press conference: “Today’s results show that progress can happen at both ends of the technology spectrum—from cutting-edge drugs to the simple use of vinegar to detect cervical cancer. Using primary health-care workers and a simple technique saved lives. Congratulations!” Dr. Patel is Associate Professor of Medicine at Robert H. Lurie Comprehensive Cancer Center of Northwestern University in Chicago. “This study has tremendous implications for women around the world, because cervical cancer affects the most disadvantaged women in every society,” she added.

Education Is Key to Screening

“Cervical cancer is the number one cause of cancer-related death in India and in most parts of the developing world. But in the developed world, the incidence has declined due to screening. There is no national cancer screening program in India, and Pap screening is not feasible because of an inadequate infrastructure, high cost, and other factors,” explained lead author Surendra S. Shastri, MBBS, MD, DPh, DHA, Head of the Department of Preventive Oncology at Tata Memorial Centre in Mumbai, India.

Surendra S. Shastri, MBBS, MD, DPh, DHA

The study included more than 150,000 women from 20 poverty-stricken clusters in Maharashtra, a state in western India. Aged 35 to 64 years and with no history of cancer, the women were randomly assigned to undergo screening by visual inspection with application of acetic acid to the cervix (n = 75,360) or no screening (n = 76,178). The screening technique was performed by women in the community who had at least a 10th grade education and good communication skills.

It takes 1 minute to obtain results from the screening test. After vinegar is applied to the cervix, if white areas appear in or near the transformation zone on the endocervix and/or ectocervix, the result is considered positive; if not, it is negative. The paramedical community workers were trained to perform the technique over a 4-week session.

Both groups received cancer education and biennial monitoring for cervical cancer; the screening group also received four rounds of biennial visual inspection with acetic acid screening delivered by the primary health workers. In the screening group, women with positive results were referred to the Tata Memorial Hospital for confirmation of diagnosis, whereas in the control group, women with signs of cervical cancer were directed to the Tata Memorial Hospital or other private facilities for confirmation of diagnosis. Confirmed cases of cervical intraepithelial neoplasia and invasive cervical cancer were treated at no cost at Tata Memorial Hospital or other private facilities.

“Before education, these slum communities were naive in terms of screening for any kind of health condition. We had to pass through several levels of community values to gain acceptance for our program. This included talking to religious, community, and political leaders. Once the program was accepted, communities provided places for health education and a clinic to ensure a sense of ownership among the communities,” he told listeners.

The rate of screening participation was 89%. “This is huge for India,” Dr. Shastri said. In the control group, 91% participated in the education. A total of 86% of the screening group completed treatment, compared with 72% of the control group.

Screening Reduced Death Rates

The incidence of invasive cervical cancer was similar in the two groups: 26.7 per 100,000 in the screening group and 27.5 per 100,000 among controls. Dr. Shastri pointed out these results showed that screening did not lead to overdiagnosis.

Cervical cancer–specific death rates were reduced by 31% with screening (P = .003): 11.1 per 100,000 in the screening group and 16.2 per 100,000 in controls. There was also a 7% reduction in all-cause mortality in the screening group, although this difference was not statistically significant. Five percent of women in the screening group were randomly screened by an expert, and in those cases, the results confirmed those obtained by the trained primary health workers.

“This screening program is widely implementable in the developing world and gives immediate results, which is important in rural areas, where women might have to travel hours to see a doctor,” Dr. Shastri said. In the area where the study was conducted, primary health workers were the only ones available to deliver the screening test.

The authors of this study plan to train primary health workers to provide visual inspection with acetic acid screening every 24 months to all women aged 35 to 64 in the state where the trial was conducted. The Indian government is also working to implement the screening technique throughout the country and plans to partner with other countries in the developing world to offer training resources. 

Disclosure: Dr. Shastri and Dr. Patel reported no potential conflicts of interest.

Reference

1. Shastri SS, Mittra I, Mishra G, et al: Effect of visual inspection with acetic acid screening by primary health workers on cervical cancer mortality: A cluster randomized controlled trial in Mumbai, India. 2013 ASCO Annual Meeting. Abstract 2. Presented June 2, 2013.