title: Comparative study of four candidate strategies to detect cervical cancer in different health care settings.
abstract: OBJECTIVE
  Considering the differing but potentially supplementary properties of visual inspection of the cervix with acetic acid (VIA) and the cytological examination (CYTO) of cervical smears for the screening of cervical cancers, we examined the performance of these two tests and their combinations for the screening of cervical cancer in different health care settings.
  
  
  METHODS
  In this cross-sectional diagnostic test performance evaluation study of 4235 female subjects in the reproductive age group, we assessed the screening performance of four strategies: VIA alone, CYTO alone, VIA and CYTO combined in a parallel fashion, and VIA and CYTO combined in tandem. Subjects were recruited from three settings: Hospital, Urban Community and Rural Community. Colposcopy was used as the reference standard. Screening performance was assessed using sensitivity, specificity, post-test probabilities and likelihood ratios (LR), diagnostic odds, area under receiver operating characteristic curve and LR chi(2).
  
  
  RESULTS
  Both VIA and CYTO when used alone had a low sensitivity but high specificity, especially in the Rural Community setting. A combination of the results of VIA and CYTO improved the diagnostic accuracy but the strategy using a parallel combination of VIA and CYTO was the most accurate. In general, all screening strategies using VIA and CYTO showed a modest screening performance.
  
  
  CONCLUSIONS
  In the settings of varying levels of health care and low resources, caution is needed for a generalized use of VIA for cervical cancer screening. Further evaluation of the cost-effective ways of combining VIA and CYTO is needed in these circumstances.
authors: Department of Pathology, Government Medical College, Nagpur, India.
authors: Meherbano M
authors: MM
authors: Kamal
authors: Rekha U
authors: RU
authors: Sapkal
authors: Chhaya S
authors: CS
authors: Sarodey
authors: Maitreyee M
authors: MM
authors: Munshi
authors: Yamini D
authors: YD
authors: Alsi
authors: Mrudul A
authors: MA
authors: Chande
authors: Sneha R
authors: SR
authors: Hingway
authors: Seema
authors: S
authors: Dandige
authors: Utpala S
authors: US
authors: Kane
authors: Ragini
authors: R
authors: Kshirsagar
authors: Madhvi
authors: M
authors: Tangsale
authors: Sanjay
authors: S
authors: Zodpey
authors: Archana B
authors: AB
authors: Patel
authors: Manju
authors: M
authors: Mamtani
authors: Hemant
authors: H
authors: Kulkarni
mesh_terms: D019342:Acetic Acid; D000328:Adult; D003127:Colposcopy; D003430:Cross-Sectional Studies; D005260:Female; D006761:Hospitals; D006801:Humans; D008403:Mass Screening / Q000379:methods; D008875:Middle Aged; D012424:Rural Population; D012680:Sensitivity and Specificity; D014505:Urban Population; D002583:Uterine Cervical Neoplasms / Q000175:diagnosis*; D014626:Vaginal Smears
chemical_list: D019342:Acetic Acid