[Use of human papilloma virus testing in primary cervical cancer screening in rural Madagascar]. / Intérêt du test HPV dans le dépistage primaire du cancer du col en milieu rural à Madagascar.

BACKGROUND: Testing for high-risk human papilloma virus (HR-HPV) is an effective approach to the prevention of cervical cancer. This study in the Atsinanana area of Madagascar aimed to compare the management of women screened by visual inspection after coloration with acetic acid (VIA) and the management of women screened by HPV with VIA as a triage test. METHOD: During the last two screening campaigns, the first patients (between 28 and 120 women par center) were sampled using a dry swab, just before the acetic acid application, to test 14 genotypes of HR-HPV using Roche Diagnostics Cobas® Test. We compared current management practices based on primary VIA to those that would have been implemented if the clinician had followed the recommendations of the World Health Organization for HPV-based primary screening. We used a regression Poisson model with random effect and robust variance. RESULTS: Among the 250 screened-women, 28 (11.2%) had acidophilic lesions of the uterine cervix or suspected lesions of invasive cancer (IVA +). The HPV test was positive in 62 cases (24.8%). The HPV-based screening strategy would have reduced by 52% the number of women needing thermo-coagulation treatment: 24 women (9.6%) with primary VIA-based screening vs. 13 women (5.2%) with primary HPV-based screening; RR: 0.52 and 95%CI: 0.27-1.02. The diagnosis of severe dysplastic lesion or invasive cancer would not have changed. CONCLUSION: Primary HPV-based screening is a strategy that could be useful for low-resource countries like Madagascar. It would reduce the rate of false positives and unnecessary treatments compared to the current strategy based on primary IVA. The questions of the feasibility and cost-benefit of this strategy should be further explored.

[Cervical cancer screening in rural Madagascar: Feasibility, coverage and incidence]. / Dépistage du cancer du col utérin en milieu rural à Madagascar : faisabilité, couverture et incidence.

OBJECTIVES: To assess the implementation of a cervical cancer screening strategy in rural Madagascar. MATERIALS AND METHODS: A mobile unit, equipped with a cold-coagulator, visited every six months the main health care centers in the Atsinanana area between 2013 and 2015. Cervical cancer screening was based on visual inspection with acetic acid (VIA). The lesions suggestive of intraepithelial neoplasia and limited to the cervix were coagulated on the same day. Non-eligible patients for immediate treatment were referred for appropriate investigations. We assessed the feasibility and the coverage of the screening strategy and estimated the incidence of cervical cancer in the targeted population. RESULTS: One thousand five hundred and sixty-nine (18%) of 8959 women aged between 25 and 65 years old were screened. Three hundred and fifty-seven (23%) were VIA positive and 322 (21%) were eligible for immediate treatment. No serious adverse effects were observed among patients treated on the same day. Among the 35 patients not eligible for immediate treatment and referred to the hospital, 16 (46%) were lost to follow up. CONCLUSION: When a cervical cancer screening by HPV or cytology is not possible, VIA remains a feasible and acceptable option in a disadvantaged environment. The effectiveness of this approach is still limited by the problems of access to care for patients who are not eligible for immediate treatment.