Research Article: Determinants of Cervical Cancer Screening Accuracy for Visual Inspection with Acetic Acid (VIA) and Lugol’s Iodine (VILI) Performed by Nurse and Physician

Date Published: January 20, 2017

Publisher: Public Library of Science

Author(s): Amidu O. Raifu, Mariam El-Zein, Ghislain Sangwa-Lugoma, Agnihotram Ramanakumar, Stephen D. Walter, Eduardo L. Franco, Marcia Edilaine Lopes Consolaro.


Visual inspection with acetic acid (VIA) and Lugol’s iodine (VILI) are used to screen women for cervical cancer in low-resource settings. Little is known about correlates of their diagnostic accuracy by healthcare provider. We examined determinants of VIA and VILI screening accuracy by examiner in a cross-sectional screening study of 1528 women aged 30 years or older in a suburb of Kinshasa, Democratic Republic of Congo.

We used a logistic regression model for sensitivity and specificity to estimate the diagnostic accuracy of VIA and VILI, independently performed by nurse and physician, as a function of sociodemographic and reproductive health characteristics.

Nurses rated tests as positive more often than physicians (36.3% vs 30.2% for VIA, 26.2% vs 25.2% for VILI). Women’s age was the most important determinant of performance. It was inversely associated with sensitivity (nurse’s VIA: p<0.001, nurse’s VILI: p = 0.018, physician’s VIA: p = 0.005, physician’s VILI: p = 0.006) but positively associated with specificity (all four combinations: p<0.001). Increasing parity adversely affected sensitivity and specificity, but the effects on sensitivity were significant for nurses only. The screening performance of physician’s assessment was significantly better than the nurse’s (difference in sensitivity: VIA = 13%, VILI = 16%; difference in specificity: VIA = 6%, VILI = 1%). Age and parity influence the performance of visual tests for cervical cancer screening. Proper training of local healthcare providers in the conduct of these tests should take into account these factors for improved performance of VIA and VILI in detecting cervical precancerous lesions among women in limited-resource settings.

Partial Text

Cervical cancer is the third most common cancer diagnosed among women worldwide and ranks seventh among all causes of death, with an estimated 529,000 new cases and 275,000 deaths in 2008 [1,2]. Nearly 85% of cases occur in developing countries, mostly in Eastern Africa, Melanesia, Southern Africa, and Middle Africa [1]. Cervical cancer is a preventable disease if precancerous lesions are detected early through effective screening programs, but establishment and successful implementation of the latter is challenging in low-income countries. For cervical cancer screening to be successful in resource-limited settings, the screening test, diagnosis, and treatment must either be provided on-site or in clinics accessible to the majority of women at risk. In search of simple, cost-effective screening methods for cervical cancer prevention in low-resource settings, visual inspection with acetic acid (VIA) and visual inspection with Lugol’s iodine (VILI) have been considered as alternative, less technically complex tests to conventional cytology. However, their diagnostic accuracy in detecting high-grade precursor lesions and invasive cervical cancer varies across studies. VIA sensitivity and specificity ranged from 55% to 96% and from 49% to 98%, respectively, whereas VILI sensitivity and specificity ranged from 44% to 98% and from 75% to 91%, respectively [3–7].

The mean age of participants was 42.7 years (range: 30–85 years). Among the 1528 women enrolled, nurses reported a positive VIA for 555 (36.3%) and a positive VILI for 401 (26.2%), whereas VIA and VILI positivity according to the physician’s assessment were recorded for 462 (30.2%) and 385 (25.2%) women, respectively. Table 1 shows the distribution of VIA and VILI positivity, independently performed by nurse and physician, according to selected sociodemographic, sexual behavior, and clinical variables. The proportions of VIA and VILI positivity were lower for physician-assessed compared to nurse-administered tests across most non-clinical characteristics.

The diagnostic accuracy of VIA and VILI tests performed by nurse and physician were significantly related to being younger, having high parity, pre-menopausal status, HPV positivity, and cytology with an ASC-US cut-off status. Our results suggest that improved training of healthcare providers (prior to their being deployed as screeners) to take these determinants into account will enhance the performance of VIA and VILI in detecting cervical precancerous lesions among women in low-resource settings. To improve their diagnostic accuracy, more training of the nurse on case definition and interpretation of definite aceto-white cervical epithelium of VIA test is also warranted.