The surprising contribution of vinegar test to the fight against cervical cancer
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Cervical cancer is one of the top killers of women in many parts of the world, yet it can be detected with a simple household item. Health organisations are working on spreading the screening technique.
Cervical cancer is one of the world’s deadliest and most easily preventable diseases. If caught in the early or precancerous stages, cervical cancer is extremely treatable. While systematic screening is the norm in the developed world, where women get regular Pap smears, that’s not the case in low- and middle-income countries, where 90 percent of deaths from the disease occur. In those places, a low-cost test using vinegar saves lives.
The technique is known as VIA (Visual Inspection with Acetic Acid) and involves using a cotton swab to paint a woman’s cervix with vinegar, which causes pre-cancerous spots to turn white. Since the results are immediate, the spots can be instantly treated, usually by being frozen off using a technique called cryotherapy. The entire process can be done without expensive medical equipment and can be carried out by midwives, eliminating the need for a doctor or nurse or, as is the case with Pap smears, a laboratory. Dr. Leslee Jaeger, an OB/GYN who regularly volunteers in Haiti, said the cost of the instruments needed for VIA is less than $1 per patient.
Treament pioneered in India
“If you take a large population of women and you do VIA and you treat everybody with a suspicious lesion, the incidence of cancer in a population will go down,” said David Walmer, Associate Professor at Duke Global Health Institute and the founder of Haiti Sans Cervical Cancer, a consortium working to fight the disease in Haiti. Cervical cancer is one of the leading causes of death in Haiti.
VIA isn’t new the technique was pioneered in India in the 1980s and is now used in Latin America, the Caribbean and Africa but there are still plenty of women around the globe who are not being screened. Part of the problem is access, said Mikal Finkelstein, Medical Director of CapraCare, a non-profit group providing medical care in Haiti.
“These women, they’re not seeing doctors at all, they’re not getting medical care,” Finkelstein said. “Just getting the women in to see somebody to be screened is the major roadblock in my mind… We have the capacity to see hundreds, probably thousands, more women than we do a year and we just can’t get them to come in.”
What’s more, “a pelvic exam is not friendly,” said Dr. Somesh Kumar, senior director of new initiatives and innovations at Jhpiego, an international health non-profit affiliated with Johns Hopkins University. Kumar pointed out that even in high-income countries, women who feel healthy are reluctant to subject themselves to pelvic exams.
Another downside of VIA, experts say, is that it is not very sensitive. While providers can miss lesions, the bigger issue is false-positive results, which means women are getting treated who don’t need to. Nonetheless, this is preferable to leaving women untreated, Finkelstein contends. “For a disease like this, it’s okay to over-diagnose,” she said. “I would rather treat lesions than may not turn into cancer than miss the cancerous ones.”
“It is better than doing nothing,” concurred Dr. Nathalie Broutet, a medical officer at the World Health Organization and a leading expert on the elimination of cervical cancer.
HPV more cost effective in long-run?
Cervical cancer is caused by the HPV virus, so many healthcare organisations now prioritise HPV testing, which is far more accurate than VIA although also more expensive, putting it out of reach for many women in low- and middle-income countries. Still, HPV testing may be more cost efficient in the long-run, proponents say, because women who test negative don’t need cervical screening since they are not at risk of developing the disease and don’t need to be retested for at least another five years, as cervical cancer develops slowly. What’s more, women can collect their own samples with a simple vaginal swab, eliminating the need for a medical professional to conduct the test.
That also makes the test more accessible to a wider population. Some countries have provided drop boxes in which women can deposit samples they have taken themselves. In Peru, community workers went into street markets and passed out testing kits to women, who would quickly take their own samples behind market stalls, Finkelstein said.
“HPV-DNA screening is the most efficacious and should be advocated as the first choice for cervical screening globally,” Dr. Surendranath Shastri, professor at the MD Anderson Cancer Center, said in by email. “However, in resource-constrained settings a vinegar test that performs second best should be advocated,” continued Shastri, who is a pioneer in VIA and one of the world’s primary experts in cervical cancer screening and prevention.
The preferred approach is initial HPV testing followed by screening for those who test positive followed by cryotherapy or ablation treatment for early-stage lesions, said Broutet, stressing that no screening should be done without a treatment plan for those who test positive. “Don’t screen if you don’t treat,” she said. “Then you just waste your time.” Cancerous legions that are more developed, or have spread beyond the cervix, require more involved treatment.
Another major advance in the prevention of cervical cancer has been the development of an HPV vaccine, which is 99 percent effective and could eventually wipe out the disease. While the cost is still prohibitive in many parts of the world, healthcare organisations and governments are beginning to work together to bring down the cost of the vaccine, though Kumar says the effort needs to be better coordinated to be effective.
The use of the vaccine is growing globally, though some healthcare providers worry that in some countries money is being shifted from treatment programmes to vaccination programmes. “It feels like it’s a choice,” Finkelstein said.
"If it is, it’s a false choice", said Kumar. “It has to be a combination,” he said. “It cannot be either or. Vaccines will protect tomorrow’s women, today’s girls, but you have an entire cohort of women that you cannot leave to die.”
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