Assessment of Current Cervical Cancer Screening Practice and Responses to a Novel Screening Device, Transvaginal Digital Colposcopy, Among Gynecologists in Hyderabad, India

Background: India has the highest burden of cervical cancer mortality, globally, with 67,477 deaths in 2012. A novel device, the transvaginal digital colposcope (TVDC), or a small handheld colposcope, could potentially improve quality of care and address barriers to cervical cancer screening, by reducing patient discomfort and aiding practitioners in screening. Studies which validate India-WHO guidelines for cervical cancer screening report wide ranges of sensitivity and specificity for techniques currently used in low-resource settings, all of which are contingent on numerous factors from patient awareness to receptivity to user training, suggesting that the context is paramount to improving cervical cancer detection. To that end, assessment of the healthcare and physician environment in terms of practice and reaction to the new device is essential prior to device implementation in order to anticipate benefits or negative consequences of device use.

Methods: A survey was developed to explore experiences, practice, and approaches to cervical cancer screening based on a new technology, and administered to 15 gynecologists in various clinical settings in Hyderabad, India. First, participants answered questions about past and current practices for cervical cancer screening, diagnosis, and treatment procedures. Next, physicians assessed images from a clinical trial involving imaging of cervix by the TVDC and with standard colposcopy. To check physician interpretation of images from the clinical trial, biopsy or histologic confirmation was used for positive results, while colposcopy was used as the reference standard for negative results.

Results: Colposcopy and magnification for visualization of the cervix were preferred by all physicians, in spite of low frequency of in-house use or referrals for the procedure. Accuracy among physicians interpreting TVDC images ranged from 25%-100%, while accuracy with colposcopy images ranged from 38%-100%. Sensitivity for TVDC images and corresponding colposcopy images was 72% and 91% respectively, while specificity was 54% and 38% respectively. Physicians were more likely to report suspicion for cancer in positive cases with a false negative rate with TVDC images and corresponding colposcopy images at 19% and 0%. Images with the new device were either considered comparable to or were preferred to colposcopy images, but disagreement in interpretation between TVDC and colposcopy for the same patient ranged from 13%-63%.

Conclusion: This study shows how observation-based cervical cancer screening or diagnostic techniques, without preceding, adjunct screening or diagnostic tests, may have low specificity in disease detection. However, a new technology TVDC may be appropriate for this type of setting. Further research into patient attitudes, physician motivation, physician experience with colposcopy and clinical decision-making is required prior to implementation if gains in reduction of cervical cancer incidence and deaths are to be realized.