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Disparities in the incidence and mortality due to cervical cancer between developed and developing countries continue to persist due to suboptimal health care systems in low- to middle-income countries (LMICs) that are unable to implement organized programs for screening which lack the technical, infrastructure and financial resources for adequate coverage and access to quality assured cervical cancer screening services that further reduce their effectiveness. The challenges in introducing quality cytology screening in LMICs led to the evaluation of alternative screening approaches such as visual inspection with acetic acid (VIA) and human papillomavirus (HPV) testing-based screening. Large-scale clinical trials have generated sufficient evidence of efficacy of HPV-based screening for the introduction as the primary technology in cervical cancer screening. Being more objective, automated with better sensitivity than cytology requiring fewer rounds of screening and opportunity for self-sampling, HPV testing is thus poised to be more cost-effective in providing opportunity for wider coverage, making it ideal for incorporating into primary screening programs of LMIC settings that could help reduce regional disparities. But its optimal implementation in public health programmatic settings in LMIC still faces barriers due to high operating cost and logistic challenges. This review summarizes and presents evidence for HPV primary screening leading to higher program efficiency in cervical cancer screening programs. Policy measures and strategies to overcome the resource limitations and weaknesses in health care service delivery in low resource settings need to be assessed and streamlined to leverage the initial high program costs with that of the long term potential benefits for HPV DNA testing to reach its full potential in reducing cervical cancer incidence and mortality.

Cervical cancer is highly preventable and can be easily treated if detected at early stages. However there is disproportionate high burden of cervical cancer incidence and mortality in low-middle income (LMIC) country settings that lack organized screening and prevention programs. Robust evidence for prevention and screening of cervical cancer is currently available. However there are barriers for country specific adoption and implementation. These pose unique challenges such as organizing prevention and screening services delivery through the current health infrastructure, access to screening facilities, follow-up management and adequate linkages for confirmatory diagnosis and subsequent treatment. Overall cervical cancer screening rates and cancer screening among women still remains suboptimal in many LMIC's. Considering the complexities involved in organization, service uptake and delivery of population based cervical cancer prevention and screening programs, this article aims to provide evidence based appropriate, affordable and effective standardized cervical cancer prevention and screening guidelines that are operationally feasible to help adopt best practices for uniform adaptation and implementation leveraging with the existing public health care settings. Cost-effective strategies and tools to reduce cervical cancer burden worldwide to mitigate the existing disparities in cervical cancer burden between low-resourced and high-resourced settings are needed. The current cervical cancer prevention and screening guidelines are drawn from the most robust evidence generated from the randomised trials and cross-sectional studies undertaken in the socioeconomic, cultural and health systems context of varied geographic settings and therefore conform towards applicability for wide-scale, sustainable and uniform implementation of population based cervical cancer screening and prevention program.

Purpose of Review: Cervical cancer still remains the fourth most common cancer, affecting women worldwide with large geographic variations in cervical cancer incidence and mortality rates. There exist vast disparities in cervix cancer control and prevention efforts globally. The present review addresses the current developments in cervical cancer prevention and control across both high-income countries and low-middle income countries and attempts to identify new strategies that might help address the gaps in cervical cancer care disparities globally., Recent Findings: Paradigms for cervix cancer screening are changing in high-resource settings from cytology-based screening to adoption of molecular screening and cotesting to achieve program effectiveness. Low-middle income countries with larger burden of cervical cancer continue to face financial and logistic limitations to make both cervix cancer screening and human papillomavirus vaccine available to their populations. Alternative low-cost screening technologies, operationally feasible implementation strategies, reduction of cost of procurement and delivery approaches for human papillomavirus vaccine need assessment to decrease cancer care disparities., Summary: Efforts directed toward cervix cancer prevention and early detection for improvements in cervical cancer outcomes of incidence and mortality have to be proportionately matched by access to acceptable standards of cancer care.

Background: Cervical cancer is the leading cause of cancer mortality among women in India. Because Pap smear screening is not feasible in India, we need to develop effective alternatives., Methods: A cluster-randomized controlled study was initiated in 1998 in Mumbai, India, to investigate the efficacy of visual inspection with acetic acid (VIA) performed by primary health workers in reducing cervical cancer mortality. Four rounds of cancer education and VIA screening were conducted at 24-month intervals in the screening group, whereas cancer education was offered once at entry to the control group. The study was planned for 16 years to include four screening rounds followed by four monitoring rounds. We present results after 12 years of follow-up. Poisson regression method was used to calculate the rate ratios (RRs); two-sided χ(2) was used to calculate the probability., Results: We recruited 75360 women from 10 clusters in the screening group and 76178 women from 10 comparable clusters in the control group. In the screening group, we achieved 89% participation for screening and 79.4% compliance for diagnosis confirmation. The incidence of invasive cervical cancer was 26.74 per 100000 (95% confidence interval [CI] = 23.41 to 30.74) in the screening group and 27.49 per 100000 (95% CI = 23.66 to 32.09) in the control group. Compliance to treatment for invasive cancer was 86.3% in the screening group and 72.3% in the control group. The screening group showed a statistically significant 31% reduction in cervical cancer mortality (RR = 0.69; 95% CI = 0.54 to 0.88; P = .003)., Conclusions: VIA screening by primary health workers statistically significantly reduced cervical cancer mortality. Our study demonstrates the efficacy of an easily implementable strategy that could prevent 22000 cervical cancer deaths in India and 72600 deaths in resource-poor countries annually.

Background and Objectives: Preventable cancers like cancers of cervix, breast and oral cavity claim more than 142,500 lives of Indian women annually. Mobile cancer screening may help in early detection and successful treatment in vulnerable populations., Methods: This is a community based mobile cancer screening program in co-ordination with various non-governmental organizations. Participants included 182 women from low socio-economic background residing in Mumbai. Around twenty five consenting women were screened in each of the eight camps conducted. Health education programme (HEP) was given before screening. Tests included clinical breast examination (CBE) for breast , visual inspection with 5% acetic acid (VIA), visual inspection with lugols iodine (VILI) followed by colposcopic examination for cervix and oral visual examination (OVE) for oral cavity. Women requiring further diagnostic tests were referred to the nodal hospital. A satisfaction survey was carried out at the end of the examination., Results: Out of 182 women screened, 179 received health education. More than 90% of the participants were satisfied with the various aspects of screening. Majority (90%) of them found the mobile screening facility more convenient and accessible than static site screening. The variables age and income were found to be significantly associated with the overall satisfaction of the participants. The satisfaction level regarding information given during HEP was moderate (74%) compared to other factors., Interpretation and Conclusion: The overall acceptance and satisfaction levels were encouraging with the mobile cancer screening programme. Such a facility can act as an important tool in cancer prevention and control in low socio-economic women.

Cervix and Breast cancers are the most common cancers among women worldwide and extract a large toll in developing countries. In May 1998, supported by a grant from the NCI (US), the Tata Memorial Hospital, Mumbai, India, started a cluster-randomized, controlled, screening-trial for cervix and breast cancer using trained primary health workers to provide health-education, visual-inspection of cervix (with 4% acetic acid-VIA) and clinical breast examination (CBE) in the screening arm, and only health education in the control arm. Four rounds of screening at 2-year intervals will be followed by 8 years of monitoring for incidence and mortality from cervix and breast cancers. The methodology and interim results after three rounds of screening are presented here. Good randomization was achieved between the screening (n = 75360) and control arms (n = 76178). In the screening arm we see: High screening participation rates; Low attrition; Good compliance to diagnostic confirmation; Significant downstaging; Excellent treatment completion rate; Improving case fatality ratios. The ever-screened and never-screened participants in the screening arm show significant differences with reference to the variables religion, language, age, education, occupation, income and health-seeking behavior for gynecological and breast-related complaints. During the same period, in the control arm we see excellent participation rate for health education; Low attrition and a good number of symptomatic referrals for both cervix and breast.

Objectives: The study aims to investigate the efficacy of screening by low-cost technology in down-staging and reduction of mortality due to breast and cervix cancer., Methods: The present trial is a community-based, cluster randomised controlled cohort study on screening for breast and cervix cancers (clinical breast examination and visual inspection of the cervix after application of 4% acetic acid). Univariate and multivariate logistic regression analyses are conducted to identify the predictors of compliance to referral among screen-positive women and to treatment among cancer cases., Results: The compliance to diagnostic investigations is 73% among screen-positive women referred for breast cancer and 79% among women referred for cervix cancer. Younger women, women working in service or being self-employed, school level-educated women, mother tongue Marathi, participation in screening in all 3 rounds and women referred as screen positive for cervix cancer had higher compliance to diagnostic investigations. The compliance to treatment completion is higher in women diagnosed with breast cancer, at 95%, compared to 86% for cervix cancers and 81% for cervix pre-cancers., Conclusions: Good compliance rates along with a proper system of referral, further investigations, confirmation of diagnosis and treatment as demonstrated in this trial are crucial for successful screening programmes., ((c) 2008 S. Karger AG, Basel)

Objectives: This study aims to investigate the efficacy of screening by low-cost technology in down-staging and reducing mortality due to breast and cervix cancer., Methods: The present trial is a community-based, cluster randomised controlled cohort study on screening for breast and cervix cancers (clinical breast examination and visual inspection of the cervix after application of 4% acetic acid). Univariate and multivariate logistic regression analyses are conducted to identify the predictors of participation in screening., Results: The average compliance is 71.43 and 64.93% for breast and cervix cancer screening, respectively, with the highest compliance in round 1. At the end of 3 screening rounds, 94 and 84% of the eligible women were screened at least once for breast and cervix cancer, respectively. Younger women, women from other than Hindu and Muslim communities, school level-educated women, women belonging to lower-income families, Marathi-speaking women, married women and women who had previously consulted for any breast or gynaecological complaints had higher compliance to participation in screening., Conclusions: Good compliance rates to screening have been demonstrated in the trial, reflecting acceptance of the study by the society, which has implications while translating the trial into a programme., ((c) 2008 S. Karger AG, Basel)

Background: The objective of the study is to comparatively evaluate performance of human papillomavirus (HPV) hybrid capture 2 (HC2) and cytology as triage tests among visual inspection after application of 3-5% acetic acid (VIA) screen positive women, thus aiming to reduce the referral burden. Methods: The community-based cross sectional cervical cancer screening with VIA was conducted among women aged between 30 and 65, residing in selected low socio-economic areas of Mumbai, India, during October 2010-March 2017. After obtaining informed consent, delivering health education and collecting socio-demographic data, participants were offered VIA screening by trained primary health workers. The VIA screen positive women underwent cytology, HPV HC2 and diagnostic colposcopy at nodal hospital. Women with positive colposcopy underwent cervical biopsies. Results: 231 VIA positive women underwent cytology and HPV HC2 test, followed by colposcopy. Cervical biopsies were obtained in 83 cases. The sensitivity and specificity in detecting ≥ CIN 2 were 77.8 and 92.3 for HC2 and 66.7 and 98.2 for cytology. The false positivity and negativity rates were 7.7 and 22.2 for HC2 and 1.8 and 33.3 for cytology. Conclusions: HPV HC2 reduces referrals to larger extent and misses fewer cases compared to cytology, thus appearing a better triage test among VIA positive women. [ABSTRACT FROM AUTHOR]