Pocket colposcope: could it improve attendance and increase access to cervical cancer screening programmes?

KEYWORDS:

• Cervical cancer screening
• low resource settings
• POCkeT colposcope
• speculum free cervical screening
• task shifting

1. Introduction

Papanicolaou smear-based cervical cancer screening programs have been successful in the developed world to reduce the burden of cervical cancer [1]. However, in low-resource settings, it is not a feasible option due to paucity of trained cytopathologists, difficulties in following up of screen positive women, absence of quality assurance measures, and poor healthcare infrastructure. Other barriers to cervical cancer screening in low-resource settings include lack of accessible, high-quality services, high cost, and the need for multiple visits [2].

The World Health Organization has recommended visual inspection with acetic acid (VIA) as an alternative to cytology-based screening in low-resource settings [3]. VIA has been most widely investigated and accepted as a potential alternative to cytology in low-resource settings [4]. VIA has been shown to be affordable, feasible, with a sensitivity ranging from 67% to 90% and results are available in the same sitting, hence is an accurate tool for implementation in limited resource settings. However, VIA has limitations in terms of low specificity, requirement of extensive training, and retraining of the health care providers, being a subjective test and a challenge in quality control.

To address these challenges, many devices have been developed and are being tested widely to increase specificity, to acquire digital images of the cervix with or without magnification which can assist and complement subjective visual interpretation and potentially improve the performance of VIA.

Quality assurance of any screening procedure requires a robust system of program management and coordination, paying attention not only to communication and technical aspects but also to qualification of personnel, especially when the screening test is subjective, as is the case in VIA.

Developing low-cost, point of care, high-impact screening technologies that can reduce the incidence of cervical cancer is the need of the hour. In this commentary, we elucidate one such device where we see its potential in increasing the access to cervical cancer screening and improving the attendance of women attending the screening program.

2. POCKeT colposcope

POCkeT colposcope is the point-of-care tampon, low-cost, intravaginal, optical cervical imaging device developed for cervical cancer screening in low-resource settings (Figure 1). This device can be plugged into a cell phone, tablet, or computer, which provides power; therefore, it does not directly require electricity from a wall outlet or power adapter that enables it to be used in remote rural areas, where most of the population may not have access to electricity. POCkeT colposcope is very light, weighs only 1 pound and primarily a 5-megapixel camera as well as white- and green-light emitting diodes on the tip of the probe. Because of the low-cost of these components, it has an anticipated price of US $500. Images from the cervix are collected with the tip of the probe approximately 35 mm from the cervical os.

Figure 1. POCkeT colposcope (reproduced with permission from Wolters Kluwer Health, Inc).

The various studies published on POCkeT colposcope so far are summarized in the Table 1 along with the objectives and conclusion of each study.

Table 1. Summary of studies published on POCkeT colposcope till date.

Article	Year	Objective	Conclusion
Lam T et al [5]	2015	To compare the field of view, resolution and contrast, compared with a standard-of-care colposcope	The images captured by POCkeT colposcope was found suitable for cervical lesion analysis
Mueller J et al [6]	2017	To evaluate the performance of POCkeT colposcope with a standard-of-care colposcope.	POCkeT colposcope was comparable to a standard-of-care colposcope
Asiedu MN et al [7]	2017	To demonstrate the feasibility of a tampon-sized inserter and the POCkeT colposcope, a miniature pen sized-colposcope for comfortable, speculum-free and potentially self-colposcopy	The use of an inserter and miniature-imaging device for cervical image capture of women with synergistic HPV and Pap smear sample collection was feasible.

The limitations of the studies conducted so far with this device are (i) small number of patients and physician readers to validate the device, (ii) small number of biopsies acquired during diagnostic colposcopic examinations, and (iii) use of static colposcopic images instead of dynamic evaluation for comparison.

3. Future perspectives

The success of a cervical cancer screening program depends mainly on the high participation rates. In our opinion, POCkeT colposcope not only would facilitate in increasing the attendance of the screening program but will also improve the access to cervical cancer screening program by the following:

3.1. Task shifting to the community health workers (CHWs)

The acute shortage of doctors and nurses in low- and middle-income countries restricts the ability to manage non-communicable diseases and evokes the need for task sharing of cancer screening services with CHWs. CHWs are the first port of call for any health-related demands of deprived sections of the population, especially women and children, who find it difficult to access advanced health services. In a randomized trial in Mumbai India, trained public health workers with limited education and experience in working in health programs, were effective in doing cervical cancer screening by VIA [8]. There was a significant 31% reduction in cervical cancer mortality over 12 years in this study. However, in the public health settings, mass training of CHWs in cervical cancer screening using VIA is a huge challenge. The performance of naked eye VIA as a cervical cancer screening tool at the community level is poor and the interpretation of this test remains subjective as quality is affected by intrapersonal limitations [9]. Such limitations translate into high false positivity rates that are likely to create panic among the women and inevitably lead to high overtreatment rates. By providing an efficient and practical quality control system, the POCkeT colposcope-based approach evades the main issues that limit the naked eye VIA’s efficacy. The use of an image-based system like POCkeT colposcope may represent an important step toward the improvement of bare eye-based visual inspection screening techniques.

3.2. Empowering the health care provider in the community to carry out screening using the device which can capture the images of the cervix and export it to a remote specialist

POCkeT colposcope eliminates the need for a full pelvic exam with its tampon-like form that enables insertion into the vagina for cervical image capture. By reducing the training level required for use, this will empower CHWs to improve screening and early detection of cervical abnormalities at the primary health center and subcenter level, the closest health care facility one can reach. The images captured during the screening will allow the clinician to review it and decide on the management and would eventually lead to strict quality assurance of the program.

3.3. Speculum-free cervical screening

The latest prototype of the POCkeT colposcope allows a more women friendly alternative to the standard speculum, which would enable comfortable, speculum-free cervical screening [7]. We see this as a huge advantage, since the main resistance to cervical cancer screening in the community is due to the fear and discomfort of speculum insertion by the health care provider [10]. This is generally considered as a painful procedure by the women. In fact, the authors claim that this device would eventually lead to self-screening including cervical image capture by women, either in their homes or in clinics, with minimal guidance by health care providers.

With the growing disparity of cancer prevention and management services between the low-resource and high-income countries, there is an urgent need for scientists, bioengineers, and clinicians to translate the novel cancer care technologies into innovative, resource-appropriate tools, and leverage the ongoing technology development to both build on successes and address challenges in the field.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties. Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.