Effect of VIA screening by primary health workers: randomized controlled study in Mumbai, India

Abstract

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.

Figure 1.

Flow diagram of the trial. MSWs = medical social workers; PHWs = primary health workers; TMH = Tata Memorial Hospital; VIA = visual inspection with acetic acid.

Figure 2.

Cumulative incidence curve for cervix cancer. Cumulative incidence of cervical cancer in the screening and control groups after 12 years of follow-up. The screening group recruited 75360 women aged 35 to 64 years and had an annual attrition of 2.2%, whereas the control group recruited 76178 women also aged 35 to 64 years and had an annual attrition of 2.3%.

Figure 3.

Cumulative mortality curve for cervix cancer. Cumulative mortality from cervical cancer in the screening and control groups after 12 years of follow-up. The screening group recruited 75360 women aged 35 to 64 years and had an annual attrition of 2.2%, whereas the control group recruited 76178 women also aged 35 to 64 years and had an annual attrition of 2.3%.