Usability of a smartphone-compatible, confocal micro-endoscope for cervical cancer screening in resource-limited settings

Abstract

Background: More efficient methods to detect and treat precancerous lesions of the cervix at a single visit, such as low-cost confocal microscopy, could improve early diagnosis and hence outcomes. We piloted a prototype smartphone-compatible confocal micro-endoscope (SCME) among women presenting to a public cervical cancer screening clinic in Kampala, Uganda. We describe the piloting of the SCME device at an urban clinic used by lower cadre staff.

Methods: We screened women aged 18 and 60 years, who presented for cervical cancer screening at the Kawempe National Referral Hospital Kampala, and evaluated the experience of their providers (nurses). Nurses received a 2-day training by the study doctors on how to use the SCME, which was added to the standard Visual Inspection with Acetic acid (VIA)-based cervical cancer screening. The SCME was used to take colposcopy images before and after VIA at positions 12 and 6 O'clock if VIA negative, and on precancer-suspicious lesions if VIA positive. We used questionnaires to assess the women's experiences after screening, and the experience of the nurses who operated the SCME.

Results: Between November 2021 and July 2022, we screened 291 women with a median age of 36 years and 65.7% were HIV positive. Of the women screened, 146 were eligible for VIA, 123 were screened with the SCME, and we obtained confocal images from 103 women. Of those screened with the SCME, 60% found it comfortable and 81% were willing to screen again with it. Confocal images from 79% of the women showed distinguishable cellular features, while images from the remaining 21% were challenging to analyze. Nurses reported a mean score of 85% regarding the SCME's usefulness to their work, 71% regarding their satisfaction and willingness to use it again, 63% in terms of ease of use, and 57% concerning the ease of learning how to operate the SCME.

Conclusion: Our findings demonstrate the feasibility of using the SCME by lower cadre staff in low-resource settings to aid diagnosis of precancerous lesions. However, more work is needed to make it easier for providers to learn how to operate the SCME and capture high-quality confocal images.

Keywords: Cervical cancer; Confocal microscopy; Mobile health; Nurses; Task shifting; User experience.

Fig. 1

Photos of the smartphone colposcope and SCME device used in clinic (A, B) and a representative smartphone colposcopy image showing SCME placed on the cervix (C)

Fig. 2

Representative SCME images (A, D) and their manually-segmented images (B, E) and automatically-segmented images (C, F) for an image with low cell density (A, B, C) and high cell density (D, E, F)

Fig. 3

Study flow diagram. *We invited all women who were interested to consent for the study, and gave them the option to withdraw from the study at any time. All the women accepted to participate and gave written consent. However, one woman later declined to have a speculum exam and did not continue with the subsequent study procedures

Fig. 4

Representative confocal endoscopy (A-D), histologic (E, F), and smartphone colposcopic (G, H) of benign (A, C,E, G) and HSIL (B, D,F, H) tissues

Fig. 5

Morphometric parameters of cell nuclei visualized in confocal images of benign/LSIL and HSIL tissues