Intended for healthcare professionals


Screening with acetic acid could prevent 22 000 deaths from cervical cancer in India every year

BMJ 2013; 346 doi: (Published 17 June 2013) Cite this as: BMJ 2013;346:f3935
  1. Meera Kay
  1. 1Bangalore

Women who were screened by primary health workers who used visual inspection with acetic acid were less likely to die of cervical cancer, a large Indian study has found.

The research, which looked at the effectiveness of acetic acid screening by primary health workers in reducing cervical cancer mortality, found that the method could actively reduce cervical cancer mortality by nearly one third. The results were presented at the 49th annual meeting of the American Society of Clinical Oncology in Chicago at the beginning of June.

The study involved 150 000 women in India aged 35-64 years who were randomly assigned to screening with acetic acid by primary health workers (75 360 women) or no screening (76 178 women) and were followed for 12 years. Women in the intervention group received four rounds of screening and education on cancer at 24 month intervals between 1998 and 2010. Precancerous or cancerous cells show up as white when the cervix is wiped with diluted acetic acid. Control women received one round of cancer education and were advised to report any signs or symptoms of cervical cancer. All participants were offered free treatment if cervical cancer was diagnosed.

The study found that the incidence of invasive cervical cancer was 26.7 cases per 100 000 population (95% confidence interval 23.4 to 30.7) in the screening group and 27.5 per 100 000 (23.7 to 32.1) in the control group. Compliance with treatment for invasive cancer was 86% in the screening group and 72% in the control group.

The screening group showed a 31% lower cervical cancer mortality (rate ratio 0.69 (0.54 to 0.88)). The study also reported a (non-significant) lower all cause mortality in the screening group (0.93 (0.79 to 1.10)).

The authors estimated that acetic acid screening carried out by primary health workers could prevent 22 000 deaths from cervical cancer in India every year and 72 600 deaths in resource poor countries annually.

“We had 67 and 98 cervical cancer deaths in the screening and control groups, respectively,” said Surendra Srinivas Shastri, the study’s lead investigator. “We calculated the mortality reduction in India and developing countries by calculating 31% of the projected deaths from cervical cancer in 2010, using the prediction tool in GLOBOCAN 2008.”

In India large scale cervical smear testing or human papillomavirus DNA testing is not currently possible because of lack of resources, laboratory infrastructure, and medical professionals.

Cervical cancer is the most common cancer among women in developing countries and is the leading cause of death from cancer in Indian women. Since cytology based screening is not easy to implement in India, there is a need to evolve simpler alternatives, said Shastri.

Rani Bhat, consultant gynaecologist and oncologist at HealthCare Global Hospital in Bangalore, the largest private provider of cancer treatment in India, said, “Vinegar screening does pick up early cervical cancer lesions, and by doing so these women can have early treatment and decrease the mortality by 31% in low resource countries. Since this a simple test and can be easily performed, more awareness should be created among women to come forward and undergo screening.”

The authors said that on the basis of their results health officials in Maharashtra state, where the trial was conducted, are preparing to train primary healthcare workers to provide acetic acid screening to all women aged 35-64 years in the state every two years, the same as in the trial.

In addition, the authors said that the Indian government was working to implement the screening countrywide and had plans to reach out to other low to moderate income countries to inform them of these results and offer training resources.

The study was supported in part by the US National Institutes of Health and the Women’s Cancer Initiative.


Cite this as: BMJ 2013;346:f3935

View Abstract