title: Smartphone Use for Cervical Cancer Screening in Low-Resource Countries: A Pilot Study Conducted in Madagascar.
abstract: BACKGROUND
  Visual inspection of the cervix after application of 5% acetic acid (VIA) is a screening technique for cervical cancer used widely in low and middle-income countries (LMIC). To improve VIA screening performance, digital images after acid acetic application (D-VIA) are taken. The aim of this study was to evaluate the use of a smartphone for on- and off-site D-VIA diagnosis.
  
  
  METHODS
  Women aged 30-65 years, living in the city of Ambanja, Madagascar, were recruited through a cervical cancer screening campaign. Each performed a human papillomavirus (HPV) self-sample as a primary screen. Women testing positive for HPV were referred for VIA followed by D-VIA, cervical biopsy and endocervical curettage according to routine protocol. In addition, the same day, the D-VIA was emailed to a tertiary care center for immediate assessment. Results were scored as either D-VIA normal or D-VIA abnormal, requiring immediate therapy or referral to a tertiary center. Each of the three off-site physicians were blinded to the result reported by the one on-site physician and each gave their individual assessment followed by a consensus diagnosis. Statistical analyses were conducted using STATA software.
  
  
  RESULTS
  Of the 332 women recruited, 137 (41.2%) were HPV-positive and recalled for VIA triage; compliance with this invitation was 69.3% (n = 95). Cervical intraepithelial neoplasia was detected in 17.7% and 21.7% of digital images by on-site and off-site physicians, respectively. The on-site physician had a sensitivity of 66.7% (95%CI: 30.0-90.3) and a specificity of 85.7% (95%CI: 76.7-91.6); the off-site physician consensus sensitivity was 66.7% (95%CI: 30.0-90.3) with a specificity of 82.3% (95%CI: 72.4-89.1).
  
  
  CONCLUSIONS
  This pilot study supports the use of telemedicine for off-site diagnosis of cervical intraepithelial neoplasia, with diagnostic performance similar to those achieved on-site. Further studies need to determine if smartphones can improve cervical cancer screening efficiency in LMIC.
authors.affiliation: Department of Gynecology and Obstetrics, Geneva University Hospitals, Geneva, Switzerland.
authors.forename: Rosa
authors.initials: R
authors.lastname: Catarino
authors.affiliation: Geneva Foundation for Medical Education and Research, Geneva, Switzerland.
authors.forename: Pierre
authors.initials: P
authors.lastname: Vassilakos
authors.affiliation: Saint-Damien Health-Care Center, Ambanja, Madagascar.
authors.forename: Stefano
authors.initials: S
authors.lastname: Scaringella
authors.affiliation: Department of Gynecology and Obstetrics, Geneva University Hospitals, Geneva, Switzerland.
authors.forename: Manuela
authors.initials: M
authors.lastname: Undurraga-Malinverno
authors.affiliation: Department of Gynecology and Obstetrics, Geneva University Hospitals, Geneva, Switzerland.
authors.forename: Ulrike
authors.initials: U
authors.lastname: Meyer-Hamme
authors.affiliation: Department of Gynecology and Obstetrics, Geneva University Hospitals, Geneva, Switzerland.
authors.forename: Dominique
authors.initials: D
authors.lastname: Ricard-Gauthier
authors.affiliation: Department of Gynecology and Obstetrics, Geneva University Hospitals, Geneva, Switzerland.
authors.forename: Juan Carlos
authors.initials: JC
authors.lastname: Matute
authors.affiliation: Department of Gynecology and Obstetrics, Geneva University Hospitals, Geneva, Switzerland.
authors.forename: Patrick
authors.initials: P
authors.lastname: Petignat
mesh_terms: D019342:Acetic Acid / Q000008:administration & dosage; D000328:Adult; D001706:Biopsy / Q000379:methods; D002584:Cervix Uteri / Q000473:pathology / Q000821:virology; D003127:Colposcopy / Q000379:methods; D055088:Early Detection of Cancer / Q000295:instrumentation* / Q000379:methods; D005260:Female; D006801:Humans; D008270:Madagascar; D008403:Mass Screening / Q000295:instrumentation / Q000379:methods; D008875:Middle Aged; D027383:Papillomaviridae / Q000472:pathogenicity; D030361:Papillomavirus Infections / Q000175:diagnosis / Q000473:pathology; D010865:Pilot Projects; D012680:Sensitivity and Specificity; D000068997:Smartphone; D002583:Uterine Cervical Neoplasms / Q000175:diagnosis* / Q000473:pathology* / Q000821:virology; D014626:Vaginal Smears / Q000379:methods; D002578:Uterine Cervical Dysplasia / Q000175:diagnosis / Q000473:pathology / Q000821:virology
chemical_list: D019342:Acetic Acid