Screening for cervical neoplasia in
Bangladesh using visual
inspection with acetic acid
Chairperson:
Dr. Gopal Chandra Das
Assistant Professor
Department of Obs & Gynae, MMC
Speaker:
Dr. Khurshida Jahan
MS Obs & Gynae (Thesis part), MMC
Auther:
Nessa A, Hussain MA, Rahman JN, Rashid MH,
Muwonge R, Sankaranarayanan R.
Department of Obstetrics & Gynecology, Bangabandhu Sheikh
Mujib Medical University, Dhaka, Bangladesh.
Source:
International Journal of Gynaecology & Obstetrics. 111(2010) 115-118.
Introduction
 Cervical
cancer constitutes 25% of all
cancer cases in women and accounts
for 13000 new cases and 8000 deaths
annually in Bangladesh. More than
80% of patients diagnosed with this
eminently preventable cancer present
in clinically advanced, inoperable
stages.
 The
aim of the present paper was to
briefly describe the organization and
functioning of the VIA screening
program and discuss the early results,
strengths and limitations of the
pioneering effort in cervical cancer
prevention in Bangladesh.
Objective:
 To
report the organization and early
results of a visual inspection with acetic
acid (VIA) screening program for
cervical cancer prevention in
Bangladesh.
Patients and methods

The VIA screening program is provided through
the existing healthcare infrastructure in
Bangladesh.

The target population for VIA screening is
apparently healthy, ambulant, married women aged
30 years and above attending the healthcare
facilities at MCWCs, DHs, MCHs, BSMMU,
UHFWCs, and UHCs.

It was an opportunistic screening program. The
screening algorithm involved a single visit for
screen-negative women and 2-3 visits for screenpositive women,

After counseling and informed consent, a
speculum examination was performed for direct
visualization of the cervix and vagina to identify
the squamocolumnar junction (SCJ),
inflammation, polyps, leukoplakia, and growth.
Freshly prepared 5% dilute acetic acid was applied
to the cervix.

Care was taken to avoid any bleeding and
results were reported 1 minute after
application under 100-watt illumination.
VIA test was considered positive when a
definite, well-defined acetowhitening was
observed in the transformation zone in
close proximity with the SCJ or when a
growth turned acetowhite; when in doubt
the test was repeated.

All VIA-positive women were referred with a
pink referral card to the colposcopy clinics at
BSMMU or nearby medical college hospitals.
Women with negative VIA were given a blue
card and advised to come back after 3 years.
A manual register is kept at each VIA
screening center that provides the number of
women screened, tested positive, and tested
negative.

Colposcopy was performed by the trained
colposcopist when the screen-positive women
reported at the colposcopy clinics at medical
college hospitals or BSMMU. All women with
suspected CIN and cancer had colposcopydirected cervical biopsy and the specimens were
given to the women or their attendants to submit
to the histopathology department. The
colposcopic findings were documented in a form.

Women with normal histology and CIN 1 reports were
advised to return for follow-up after 6-12 months. Women
with CIN 1 who wanted immediate treatment or who were
unlikely to report for follow-up and those above 35 years
were treated with cryotherapy or LEEP. Women with
histologically confirmed CIN 2 or 3 lesions were treated
with LEEP or cryotherapy and were advised to return for
follow-up after 6 months. Women with cervical cancer
were referred to cancer treatment facilities for further
investigations and treatment.

The final diagnosis was based on the histopathology or
colposcopy if no or an inadequate biopsy sample was
taken.
Results

From January 1, 2005, to June 30, 2008, VIA
screening was provided for 104 098 women
in 44 districts in Bangladesh. The average
number of women screened in most
districts ranged from 800-4000 women.
Table 1: Number of women screened
& those tested positive
Year of screening Number screened Screen positive (%)
2005
11693
548 (4.7)
2006
21609
925(4.3)
2007
40785
1918(4.7)
2008 until June
30011
1622(5.4)
Total
104098
5013(4.8)
 Of
the women screened, 5013 (4.8%)
were positive on VIA and were referred
to colposcopy clinics at BSMMU or
nearby medical college hospitals.
 Overall,
4371 (87.2%) of screen positive
women underwent colposcopy.
Table 2: Distribution of women attending different
colposcopy clinics.
Institutes with colposcopy clinics
No. (%) of women
Bangabandhu Sheikh Mujib Medical University (BSMMU)
2188 (43.6)
Chittagong Medical"College Hospital (CMCH)
747 (14.9)
Rajshahi Medical College Hospital (RjMCH)
442 (8.8)
Mymensingh Medical College Hospital (MMCH)
341 (6.8)
Ktmlna Medical College Hospital (KMCH)
277 (5.5)
Sylhet MAG Osmani Medical College Hospital (SMAGOMCH)
210 (4.2)
Dhaka Medical College Hospital (DMCH)
132 (2.6)
Rangpur Medical College Hospital (RMCH)
34 (0.7)
Women who did not attend
Total
642 (12.8)
5013 (100.0)

Total women underwent colposcopy – 4371

Women attended at BSMMU (VIA +ve cases) – 2188

Normal colposcopic findings – 1044 (47.7%)

Colposcopic abnormalities

Suggestive of CIN or cancer
=1144
 CIN
I
= 682
 CIN
II
= 149
 CIN
III
= 29
 Invasive
= 134
 Unsatisfactory
= 150

Histopathology results of cases with
colposcopic abnormalities
 CINI
= 369
 CIN
II
= 127
 CIN
III
= 30
 Invasive
cancer
= 123

Of the 4371 women who underwent colposcopy,
2188 attended the colposcopy clinic at BSMMU.
The results of colposcopy and histology are given
in Table 3. No colposcopic abnormalities were
detected in 1044 (47.7%) women, whereas
directed biopsies in 1144; women showed
colposcopic abnormalities suggestive of CIN or
cancer. On histology, 369 women were diagnosed
with CIN 1, 127 with CIN 2, 30 with CIN 3, and
123 with invasive cancer.

VIA repeated by gynecologists in 2188
women before they underwent colposcopy
was positive in 1060 and negative in 1128
women; the final diagnosis among these 1128
VIA-negative women was as. follows: no
lesion (n = 1091); CIN 1 (n = 22); CIN 2-3 (n
= 10); and invasive cancer (n = 5).

The sensitivity, specificity, and positive
predictive value of VIA to detect CIN 2 and
3 lesions after excluding the 123 invasive
cancer cases in this selected sample of
women were 93.6%, 58.3%, and 15.6%,
respectively (Table 4).

Forty-one women (11%) with CIN 1 and 80
women (50%) with CIN 2-3 lesions received
treatment with LEEP (n = 105), cryotherapy
(n = 6), or hysterectomy (n= 10) at BSMMU.
Table 3 Accuracy of visual screening with acetic acid to
detect CIN 2-3 lesions among 2065 women attending
colposcopy services at BSMMU.
VIA result
Women detected
with CIN 2-3 lesions
Women with normal
cervix or CIN 1 lesions
Total
Positive
147
795
942
Negative
10
1113
1123
Total
157
1908
2065
Sensitivity: 93.6% (95% CI, 88.6-96.9); Specificity: 58.3% (95% CI,
56.1-60.6); Positive predictive value: 15.6% (95% CI, 13.3-18.1);
Negative predictive value: 99.1% (95% CI, 98.4-99.6).
Discussion

Among the cancers, cervical cancer accounts for
almost one fifth of cases in women. The
cervical cancer burden is closer to that of
maternal deaths (13 000 deaths) in Bangladesh.
Currently, 32 million women are aged between
30 and 60 years and less than 0.4% are screened
annually with a Pap smear. It is not feasible to
introduce cytology screening for cervical cancer
control in Bangladesh given the resource

The VIA test positivity of around 5% in this
program was at the lower range of test positivity
reported in other VIA studies in Asia and Africa.

On repeat VIA performed before colposcopy, a
little more than half of the women were scored
as negative, which indicates the wide variability
between the test providers due to the subjective
interpretation of the test.

If we extrapolate this finding to the entire study,
the test-positive rates are likely to be even lower
than 5%.

Treatment coverage of women with high-grade
cervical cancer precursors is inadequate: half of
such women received treatment at the BSMMU
colposcopy clinic.

The treatment rates can be improved if
cryotherapy or LEEP are offered immediately
following colposcopy at the first visit instead of
receiving treatment after histopathology
confirmation of punch biopsy specimens at the
second visit.

Moreover, the current VIA-based program
would facilitate the development of screening,
diagnosis, and treatment infrastructure in health
services, improve awareness of cervical cancer
prevention among the population, and enable
incorporation of new developments such as the
more accurate, objective & affordable HPV
testing technologies when these technologies are
commercially available & affordable for wider
use in public health services.
CONCLUSION:

A VIA-based program would facilitate the
development of screening, diagnosis, and
treatment of cervical neoplasia and improve
awareness of cervical cancer prevention in
Bangladesh.
Approximate rates of spontaneous regression,
persistence & progression of CIN
CINI
CINII
CINIII

Regression to normal
60%
40%
30%

Persistence
30%
35%
48%

Progression to CINIII
10%
20%
-

Progress to carcinoma
<1%
5%
22%
VIA & Colposcopy in MMCH 2010

Total VIA done
VIA –ve
 VIA +ve


Total colposcopy done
Normal
 CINI
 CINII
 CINIII
 Unsatisfactory
 Invasive

- 3214
- 3139
- 75
- 433
- 200
- 172
- 22
- 08
- 11
- 20
Histopathology results of cases with
colposcopic abnormalities in MMCH

CIN I
92

CIN II
45

CIN III
15

Invasive carcinoma
15
Squamous epithelium
Columnar epithelium
Colpoccopy – Abnormal Findings