Comparison between Visual Inspection of Cervix and Cytology Based Screening Procedures in Bangladesh

  • Nessa, Ashrafun (Gyne-oncology Unit, Bangabandhu Sheikh Mujib Medical University) ;
  • Nahar, Khadiza Nurun (Department of Obstetrics and Gynecology, Bangabandhu Sheikh Mujib Medical University) ;
  • Begum, Shirin Akhter (Department of Obstetrics and Gynecology, Bangabandhu Sheikh Mujib Medical University) ;
  • Anwary, Shahin Ara (Department of Obstetrics and Gynecology, Bangabandhu Sheikh Mujib Medical University) ;
  • Hossain, Fawzia (Department of Obstetrics and Gynecology, Bangabandhu Sheikh Mujib Medical University) ;
  • Nahar, Khairun (Department of Obstetrics and Gynecology, Bangabandhu Sheikh Mujib Medical University)
  • Published : 2013.12.31


Background: Cervical cancer continues to be a major problem in Bangladesh with approximately 18,000 new cases annually of which over 10,000 women die from it. Visual inspection of the cervix after 3-5% acetic acid (VIA) application is a simple and easy to learn method for cervical cancer screening, although cytology-based screening is more often applied in developed countries where it has successfully reduced the prevalence of cervical cancer. Objective: To compare the efficacy of VIA and cytology-based primary methods for cervical cancer screening in Bangladesh. Materials and Methods: This hospital based comparative study was conducted at the VIA centre and Colposcopy Clinic of Bangabandhu Sheikh Mujib Medical University (BSMMU) from October 2008 to October 2010. Results: Among 650 women, 74 (11.4%) were VIA+ve and 8 (1.2%) had abnormalities in their Pap smear reports. During colposcopy, 38 (7.7%) women had different grades of CIN and 4 (0.6%) had cervical cancer. The gold standard histology findings proved 20 women had CIN I, 14 had CIN II/II and 4 had cervical cancer. Among the 38 histology diagnosed abnormalities, VIA test could identify 30 abnormalities including two cervical cancers. However, Pap smear could detect only 8 cases of histological abnormalities (2 low grade and 6 had high grade lesion) and it missed all the cervical cancer cases. The sensitivity and specificity of VIA were 88.9% and 52.1%. The positive predictive value (PPV) and negative predictive value (NPV) were 41.0%, and 92.6% respectively. Moreover, the sensitivity, specificity, PPV and NPV of Pap smear were 33.3%, 95.8%, 75.0% and 79.3%, respectively. Conclusions: VIA test should be used as the primary screening tool even with its low sensitivity and specificity in low resource countries like Bangladesh. False positive results may be greater, but overtreatment can be minimized by colposcopy evaluation of the VIA positive women.


  1. Ahmed T, Ashrafunnessa, Rahman J (2008). Development of a Visual Inspection Programme for Cervical Cancer Prevention in Bangladesh. Elsevier Reproductive Health Matters, 16, 78-85.
  2. Akhter PS, Uddin MM, Sharma SK (1998). Patterns of malignant neoplasm: A three year study Bangladesh. Med J, 27, 29-32.
  3. Akinola OI, Fabamwo AO, Oshodi YA, et al (2007). Efficacy of visual inspection of the cervix using acetic acid in cervical cancer screening: a comparison with cervical cytology. J Obstet Gynaecol, 27, 703-5.
  4. Albert SO, Oguntayo OA Samaila MOA (2012). Comparative study of visual inspection of the cervix using acetic acid (VIA) and Papanicolaou (Pap) smear for cervical cancer screening. Ecancermedicalscience, 6, 262.
  5. Ansink AC, Tolhurst R, Haque R, et al (2008). Cervical cancer in Bangladesh: community perceptions of cervical cancer and cervical cancer screening. Trans R Soc Trop Hyg, 102, 499-505.
  6. Basu P, Nessa A, Majid M, et al (2010). Evaluation of the National Cervical Cancer Screening Programme of Bangladesh and the formulation of quality assurance guidelines. J Fam Plann Reprod Hlth Care, 36, 131-4.
  7. Dhaubhadel P, Vaidya A, Choudhary P (2008). Early detection of precursors of cervical cancer with cervical cytology and visual inspection of cervix with acetic acid. J Nepal Med Assoc, 47, 71-6.
  8. Ferlay J, Shin HR, Bray F, et al (2010). GLOBOCAN 2008: cancer incidence and mortality worldwide. IARC Cancer Base No. 10 Lyon, France: IARC Press.
  9. Ghaemmaghami F, Behtash N, Gilani MM, et al (2003). Visual inspection with acetic acid as a feasible screening test for cervical neoplasia in Iran. Int J Gynecol Cancer 14, 465-69.
  10. Goel A, Gandhi G, Batra S, et al (2005). Visual inspection of the cervix with acetic acid for cervical intraepithelial lesions. Int J Gynaecol Obstet, 88, 25-30.
  11. Jeronimo J, Morales O, Horna J, et al (2005). Visual inspection with acetic acid for cervical cancer screening outside of low-resource settings. Pan Am J public Health, 17, 1-4.
  12. Nessa A, Rashid MH, Ferdous NE Chowdhury A (2013). Screening for and management of high-grade cervical intraepithelial neoplasia in Bangladesh: A cross-sectional study comparing two protocols. J Obstet Gynaecol Res, 39, 564-71.
  13. Nessa A, Hussain MA, Rashid MH, et al (2013). Role of print and audiovisual media in cervical cancer prevention in Bangladesh. Asian Pac J Cancer Prev, 14, 3131-7.
  14. Nessa A, Hussain MA, Rahman JN, et al (2010). Screening for cervical neoplasia in Bangladesh using visual inspection with acetic acid. Int J Gynaecol Obstet, 111, 115-8.
  15. Ngelangel CA, Limson GM, Cordero CP, et al (2003). Aceticacid guided visual inspection vs. cytology-based screening for cervical cancer in the Philippines. Int J Gynaecol Obstet, 83, 141-50.
  16. Rahman A (2009). Visual inspection aided with acetic acid: a feasible approach for cervical cancer screening in Bangladesh. Presented at the 12th Annual Scientific Conference (ASCON), Dhaka, Bangladesh.
  17. Sankaranarayana R, Esmy Po, Rajkumar R, et al (2007). Effect of visual screening on cervical cancer incidence and mortality in Tamil Nadu, India: a cluster-randomised trial. Lancet, 370, 398-406.
  18. Sankaranarayana R, Gaffikin, Jacob M, et al (2005). A critical assesment of screening methods for cervical neoplasia. Int J Gynaecol Obstet, 89, 4-12.
  19. Sankaranarayana R, Nessa A, Esmy PO, Dangou JM (2011). Visual inspection methods for cervical cancer prevention. Best Pract Res Clin Obstet Gynaecol, 26, 221-32
  20. Sankaranarayana R, Thata S Esmy Po, et al (2008). Cervical cancer: screening and therapeutic perspectives. Med Princ Pract, 17, 351-64.
  21. Sankaranarayana R, Wesly R, Somanathan T, et al (1998). Visual inspection of the ulerine cervix after the application of acetic acid in the detection of cervical carcinoma and its precursors. Cancer, 83, 2150-6.<2150::AID-CNCR13>3.0.CO;2-0
  22. Sankaranarayanan R, Budukh AM, Rajkumar R (2001). Effective screening programmes for cervical cancer in low- and middleincome developing countries. Bull World Health Organ, 79, 954-62.
  23. Sellors JW, Sankaranarayanan R (2003). Colposcopy and Treatment on Cervical Intraepithelial Neoplasia: A Beginners' Manual. Lyon, France: IARC Press.
  24. Singh V, Sehgal A, Parashari A, et al (2001). Early detection of cervical cancer through acetic acid application an aided visual inspection. Singapore Med J, 42, 351-54.

Cited by

  1. Incidental Finding of Abnormal Cervical Pathology in Hysterectomy Specimens after Normal Preoperative Papanicolaou Smears in Thammasat University Hospital vol.15, pp.14, 2014,
  2. Type-specific Prevalence of Human Papillomavirus by Cervical Cytology among Women in Brasov, Romania vol.15, pp.16, 2014,
  3. A Systematic Review of Economic Aspects of Cervical Cancer Screening Strategies Worldwide: Discrepancy between Economic Analysis and Policymaking vol.15, pp.19, 2014,
  4. Cervical Cancer Trends in Mexico: Incidence, Mortality and Research Output vol.15, pp.20, 2014,
  5. Cervical Screening Using Visual Inspection with Acetic Acid (VIA) and Treatment with Cryotherapy in Fiji vol.15, pp.24, 2015,
  6. Accuracy of Visual Inspection with Acetic acid in Detecting High-Grade Cervical Intraepithelial Neoplasia in Pre- and Post-Menopausal Thai Women with Minor Cervical Cytological Abnormalities vol.16, pp.6, 2015,
  7. Cost-Effectiveness of Different Cervical Screening Strategies in Islamic Republic of Iran: A Middle-Income Country with a Low Incidence Rate of Cervical Cancer vol.11, pp.6, 2016,