Performance of visual inspection of the cervix with acetic acid (VIA) for triage of HPV screen-positive women : results from the ESTAMPA study
Correspondence: Armando Baena, Early Detection, Prevention & Infections Branch, International Agency for Research on Cancer, 150 Cours Albert Thomas, 69372 Lyon CEDEX 08, France. Email: baenaa@iarc.who.int
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| Format: | article |
| Language: | English |
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2022
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| Online Access: | https://doi.org/10.1002/ijc.34384 http://hdl.handle.net/20.500.14066/4517 |
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| _version_ | 1870612068445454336 |
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| author | Baena, Armando |
| author2 | Mesher, David Salgado, Yuly Martínez, Sandra Villalba, Griselda Raquel Amarilla, María Luisa Salgado, Brenda Flores, Bettsy Bellido Fuentes, Yenny Álvarez Larraondo, Manuel Valls, Joan Lora, Oscar Virreira Prout, Gonzalo Figueroa, Jacqueline Turcios, Elmer Soilan, Ana María Ortega, Marina Celis, Marcela González, Mauricio Venegas, Gino Terán, Carolina Ferrera, Annabelle Mendoza Torres, Laura Patricia Kasamatsu, Elena Satiko Murillo, Raúl Wiesner, Carolina Broutet, Nathalie Luciani, Silvana Herrero, Rolando Almonte, Maribel ESTAMPA Study Group |
| author2_role | author author author author author author author author author author author author author author author author author author author author author author author author author author author author author author |
| author_browse | Almonte, Maribel Amarilla, María Luisa Baena, Armando Bellido Fuentes, Yenny Broutet, Nathalie Celis, Marcela ESTAMPA Study Group Ferrera, Annabelle Figueroa, Jacqueline Flores, Bettsy González, Mauricio Herrero, Rolando Kasamatsu, Elena Satiko Lora, Oscar Luciani, Silvana Martínez, Sandra Mendoza Torres, Laura Patricia Mesher, David Murillo, Raúl Ortega, Marina Salgado, Brenda Salgado, Yuly Soilan, Ana María Terán, Carolina Turcios, Elmer Valls, Joan Venegas, Gino Villalba, Griselda Raquel Virreira Prout, Gonzalo Wiesner, Carolina Álvarez Larraondo, Manuel |
| author_facet | Baena, Armando Mesher, David Salgado, Yuly Martínez, Sandra Villalba, Griselda Raquel Amarilla, María Luisa Salgado, Brenda Flores, Bettsy Bellido Fuentes, Yenny Álvarez Larraondo, Manuel Valls, Joan Lora, Oscar Virreira Prout, Gonzalo Figueroa, Jacqueline Turcios, Elmer Soilan, Ana María Ortega, Marina Celis, Marcela González, Mauricio Venegas, Gino Terán, Carolina Ferrera, Annabelle Mendoza Torres, Laura Patricia Kasamatsu, Elena Satiko Murillo, Raúl Wiesner, Carolina Broutet, Nathalie Luciani, Silvana Herrero, Rolando Almonte, Maribel ESTAMPA Study Group |
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| dc.contributor.other.es.fl_str_mv | Universidad Nacional de Asunción. Instituto de Investigaciones en Ciencias de la Salud |
| dc.creator.none.fl_str_mv | Baena, Armando Mesher, David Salgado, Yuly Martínez, Sandra Villalba, Griselda Raquel Amarilla, María Luisa Salgado, Brenda Flores, Bettsy Bellido Fuentes, Yenny Álvarez Larraondo, Manuel Valls, Joan Lora, Oscar Virreira Prout, Gonzalo Figueroa, Jacqueline Turcios, Elmer Soilan, Ana María Ortega, Marina Celis, Marcela González, Mauricio Venegas, Gino Terán, Carolina Ferrera, Annabelle Mendoza Torres, Laura Patricia Kasamatsu, Elena Satiko Murillo, Raúl Wiesner, Carolina Broutet, Nathalie Luciani, Silvana Herrero, Rolando Almonte, Maribel ESTAMPA Study Group |
| dc.date.accessioned.none.fl_str_mv | 2025-01-31T19:32:37Z |
| dc.date.available.none.fl_str_mv | 2025-01-31T19:32:37Z |
| dc.date.issued.none.fl_str_mv | 2022-11-30 |
| dc.identifier.citation.en.fl_str_mv | Baena, A., Mesher, D., Salgado, Y., Martínez, S., Villalba, G. R., Amarilla, M. L., Salgado, B., Flores, B., Bellido Fuentes, Y., Álvarez Larraondo, M., Valls, J., Lora, O., Virreira Prout, G., Figueroa, J., Turcios, E., Soilán, A. M., Ortega, M., Celis, M., González, M., … ESTAMPA Study Group. (2023). Performance of visual inspection of the cervix with acetic acid (VIA) for triage of HPV screen-positive women: results from the ESTAMPA study. International Journal of Cancer, 152(8), 1581–1592. https://doi.org/10.1002/ijc.34384 |
| dc.identifier.doi.es.fl_str_mv | 10.1002/ijc.34384 |
| dc.identifier.essn.es.fl_str_mv | 1097-0215 |
| dc.identifier.issn.es.fl_str_mv | 0020-7136 |
| dc.identifier.other.es.fl_str_mv | https://doi.org/10.1002/ijc.34384 |
| dc.identifier.uri.none.fl_str_mv | http://hdl.handle.net/20.500.14066/4517 |
| dc.language.iso.es.fl_str_mv | eng |
| dc.publisher.es.fl_str_mv | WILEY |
| dc.relation.projectCONACYT.es.fl_str_mv | PINV18-256 |
| dc.rights.*.fl_str_mv | Attribution-NonCommercial-NoDerivatives 4.0 Internacional |
| dc.rights.accessRights.es.fl_str_mv | info:eu-repo/semantics/openAccess |
| dc.rights.uri.*.fl_str_mv | http://creativecommons.org/licenses/by-nc-nd/4.0/ |
| dc.subject.classification.es.fl_str_mv | 7. Salud 7.3. Prevención, vigilancia y control de enfermedades transmisibles y no transmisibles |
| dc.subject.mesh.en.fl_str_mv | Acetic acid Colposcopy Cervix uteri Early detection of cancer/methods Uterine cervical dysplasia Pregnancy Papillomavirus infections Uterine cervical neoplasms Mass screening/methods Triage |
| dc.subject.mesh.es.fl_str_mv | Ácido acético Colposcopía Cuello del útero Detección precoz del cáncer/métodos Displasia del cuello del útero Embarazo Infecciones por papillomavirus Neoplasias del cuello uterino Tamizaje masivo Triaje |
| dc.subject.ocde.es.fl_str_mv | 3. Ciencias Médicas y de la Salud 3.3. Ciencias de la Salud (salud pública, medicina social, higiene, enfermería, epidemiología) |
| dc.subject.other.es.fl_str_mv | Ablative treatment eligibility Cervical cancer screening and triage ESTAMPA HPV Visual inspection with acetic acid |
| dc.title.es.fl_str_mv | Performance of visual inspection of the cervix with acetic acid (VIA) for triage of HPV screen-positive women : results from the ESTAMPA study |
| dc.type.es.fl_str_mv | info:eu-repo/semantics/article info:eu-repo/semantics/publishedVersion |
| description | Correspondence: Armando Baena, Early Detection, Prevention & Infections Branch, International Agency for Research on Cancer, 150 Cours Albert Thomas, 69372 Lyon CEDEX 08, France. Email: baenaa@iarc.who.int |
| eu_rights_str_mv | openAccess |
| format | article |
| id | CONACYT_67fdc13a4e950b2a259e444ac456b42c |
| identifier_str_mv | Baena, A., Mesher, D., Salgado, Y., Martínez, S., Villalba, G. R., Amarilla, M. L., Salgado, B., Flores, B., Bellido Fuentes, Y., Álvarez Larraondo, M., Valls, J., Lora, O., Virreira Prout, G., Figueroa, J., Turcios, E., Soilán, A. M., Ortega, M., Celis, M., González, M., … ESTAMPA Study Group. (2023). Performance of visual inspection of the cervix with acetic acid (VIA) for triage of HPV screen-positive women: results from the ESTAMPA study. International Journal of Cancer, 152(8), 1581–1592. https://doi.org/10.1002/ijc.34384 0020-7136 10.1002/ijc.34384 1097-0215 |
| language | eng |
| network_acronym_str | CONACYT |
| network_name_str | Repositorio Institucional CONACYT |
| oai_identifier_str | oai:repositorio.conacyt.gov.py:20.500.14066/4517 |
| publishDate | 2022 |
| publishDateSort | 2022 |
| repository.mail.fl_str_mv | repositorio.institucional@conacyt.gov.py |
| repository.name.fl_str_mv | Repositorio Institucional CONACYT |
| repository_id_str | |
| rights_invalid_str_mv | Attribution-NonCommercial-NoDerivatives 4.0 Internacional http://creativecommons.org/licenses/by-nc-nd/4.0/ |
| spelling | 3dae0585-6d92-484e-967d-a467832d463c600f4143d74-b076-42f8-9070-4d93eba61ad860047209b50-b94f-4430-99a1-8510e25136836004bbb5dfc-fa2b-4efc-ab0c-04d3a98c1d17600204d34b9-5404-4f3f-b886-6383a2ff4794600afde6c7b-7997-444c-9b3d-5c449b7208df60026159ffe-dd5e-46cc-9a37-201197d5bb656003ed524c4-ece3-4992-9d88-9a39ad21708e600e47586a1-937c-4f9f-b188-5a8415a66fc8600f4c4fcd7-7307-4468-813f-ff100fda6b93600474c8735-b39e-4f6d-9d21-3007ba5e38e660032674876-f1a7-4cc0-900e-26101ca087206004a76670e-19d9-4cbf-8077-e3d3f60e21586009950e8fb-df6e-4c5e-9923-862d5cdc62ea600efe20942-6e25-4a34-9493-21f206f9eb01600a71cc85e-536f-4b27-ab97-f0e9b299474b600b9a9239e-adfd-4a79-88c1-629332229bc060097fa4221-e7d8-4a54-89fe-2e1a429e2c6560055894a19-333f-4cdd-a5af-6a7b30e93c68600237b6042-6173-4938-b6a5-c57a7c833b13600367757c6-4b74-4761-8622-86a237c2158d6004a3f9200-fcac-4eaa-920b-10bc412080d56007426000000-0001-6124-124462960099c237e4-f783-4e0c-b081-dffe786bbcfa600332afe94-d5e2-4e94-bcf0-67552dca734e600417f6da3-64ac-495d-85af-915232e255f46005bbd6784-398f-417d-b460-c1a2549a0d686009c5af811-a155-46f3-bb66-ab6ba5daccaa60051f60c85-a8ed-4c91-a0e2-c89f1e086bb760045f19e9c-637e-477a-8120-284b99d80330600Universidad Nacional de Asunción. Instituto de Investigaciones en Ciencias de la Salud2025-01-31T19:32:37Z2025-01-31T19:32:37Z2022-11-30Baena, A., Mesher, D., Salgado, Y., Martínez, S., Villalba, G. R., Amarilla, M. L., Salgado, B., Flores, B., Bellido Fuentes, Y., Álvarez Larraondo, M., Valls, J., Lora, O., Virreira Prout, G., Figueroa, J., Turcios, E., Soilán, A. M., Ortega, M., Celis, M., González, M., … ESTAMPA Study Group. (2023). Performance of visual inspection of the cervix with acetic acid (VIA) for triage of HPV screen-positive women: results from the ESTAMPA study. International Journal of Cancer, 152(8), 1581–1592. https://doi.org/10.1002/ijc.343840020-7136https://doi.org/10.1002/ijc.34384http://hdl.handle.net/20.500.14066/451710.1002/ijc.343841097-0215Correspondence: Armando Baena, Early Detection, Prevention & Infections Branch, International Agency for Research on Cancer, 150 Cours Albert Thomas, 69372 Lyon CEDEX 08, France. Email: baenaa@iarc.who.intVIA is recommended for triage of HPV-positive women attending cervical screening. In the multicentric ESTAMPA study, VIA performance for detection of cervical intraepithelial neoplasia grade 3 or worse (CIN3+) among HPV-positive women was evaluated. Women aged 30-64 years were screened with HPV testing and cytology and referred to colposcopy if either test was positive. At colposcopy visit, study-trained midwives/nurses/GPs performed VIA ahead of colposcopy. VIA was considered positive if acetowhite lesions were observed in or close to the transformation zone. Ablative treatment eligibility was assessed for VIA positives. Performance indicators were estimated. Three thousand one hundred and forty-two HPV-positive women were included. Sensitivity for CIN3+ was 85.9% (95% CI 81.2-89.5) among women <50 years and, although not significant, slightly lower in women 50+ (78.0%, 95% CI 65.9-86.6). Overall specificity was 58.6% (95% CI 56.7-60.5) and was significantly higher among women 50+ (70.3%, 95% CI 66.8-73.5) compared to women <50 (54.3%, 95% CI 52.1-56.5). VIA positivity was lower among women 50+ (35.2%, 95% CI 31.9-38.6) compared to women <50 (53.2, 95% CI 51.1-55.2). Overall eligibility for ablative treatment was 74.5% and did not differ by age. VIA sensitivity, specificity, and positivity, and ablative treatment eligibility varied highly by provider (ranges: 25%-95.4%, 44.9%-94.4%, 8.2%-65.3%, 0%-98.7%, respectively). VIA sensitivity for cervical precancer detection among HPV-positive women performed by trained providers was high with an important reduction in referral rates. However, scaling-up HPV screening triaged by VIA will be challenging due to the high variability of VIA performance and providers' need for training and supervision.Consejo Nacional de Ciencia y TecnologíaPrograma Paraguayo para el Desarrollo de la Ciencia y Tecnología. Proyectos de investigación y desarrolloengWILEYAttribution-NonCommercial-NoDerivatives 4.0 Internacionalhttp://creativecommons.org/licenses/by-nc-nd/4.0/info:eu-repo/semantics/openAccess© 2022 The Authors. International Journal of Cancer published by John Wiley & Sons Ltd on behalf of UICC.7. Salud7.3. Prevención, vigilancia y control de enfermedades transmisibles y no transmisiblesAcetic acidColposcopyCervix uteriEarly detection of cancer/methodsUterine cervical dysplasiaPregnancyPapillomavirus infectionsUterine cervical neoplasmsMass screening/methodsTriageÁcido acéticoColposcopíaCuello del úteroDetección precoz del cáncer/métodosDisplasia del cuello del úteroEmbarazoInfecciones por papillomavirusNeoplasias del cuello uterinoTamizaje masivoTriajeAblative treatment eligibilityCervical cancer screening and triageESTAMPAHPVVisual inspection with acetic acid3. Ciencias Médicas y de la Salud3.3. Ciencias de la Salud (salud pública, medicina social, higiene, enfermería, epidemiología)Performance of visual inspection of the cervix with acetic acid (VIA) for triage of HPV screen-positive women : results from the ESTAMPA studyinfo:eu-repo/semantics/articleinfo:eu-repo/semantics/publishedVersion8International Journal of Cancer15811592PINV18-256152Baena, ArmandoMesher, DavidSalgado, YulyMartínez, SandraVillalba, Griselda RaquelAmarilla, María LuisaSalgado, BrendaFlores, BettsyBellido Fuentes, YennyÁlvarez Larraondo, ManuelValls, JoanLora, OscarVirreira Prout, GonzaloFigueroa, JacquelineTurcios, ElmerSoilan, Ana MaríaOrtega, MarinaCelis, MarcelaGonzález, MauricioVenegas, GinoTerán, CarolinaFerrera, AnnabelleMendoza Torres, Laura PatriciaKasamatsu, Elena SatikoMurillo, RaúlWiesner, CarolinaBroutet, NathalieLuciani, SilvanaHerrero, RolandoAlmonte, MaribelESTAMPA Study GroupORIGINALPerformance of visual inspection of the cervix with acetic acid (VIA) for triage of HPV screen-positive women.pdfPerformance of visual inspection of the cervix with acetic acid (VIA) for triage of HPV screen-positive women.pdfArtículo científicoapplication/pdf959340http://repositorio.conacyt.gov.py/bitstream/20.500.14066/4517/1/Performance%20of%20visual%20inspection%20of%20the%20cervix%20with%20acetic%20acid%20%28VIA%29%20for%20triage%20of%20HPV%20screen-positive%20women.pdf6da07d4c5bb5f2231bfb36f690b863efMD51Appendix S1. 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Supporting Information.pdf.txtAppendix S1. Supporting Information.pdf.txtExtracted texttext/plain5576http://repositorio.conacyt.gov.py/bitstream/20.500.14066/4517/7/Appendix%20S1.%20Supporting%20Information.pdf.txtdc4c57acea7245778135e18a7657ec28MD5720.500.14066/4517oai:repositorio.conacyt.gov.py:20.500.14066/45172026-02-12 19:30:39.249Repositorio Institucional CONACYTrepositorio.institucional@conacyt.gov.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 |
| spellingShingle | Performance of visual inspection of the cervix with acetic acid (VIA) for triage of HPV screen-positive women : results from the ESTAMPA study Baena, Armando 7. Salud 7.3. Prevención, vigilancia y control de enfermedades transmisibles y no transmisibles Acetic acid Colposcopy Cervix uteri Early detection of cancer/methods Uterine cervical dysplasia Pregnancy Papillomavirus infections Uterine cervical neoplasms Mass screening/methods Triage Ácido acético Colposcopía Cuello del útero Detección precoz del cáncer/métodos Displasia del cuello del útero Embarazo Infecciones por papillomavirus Neoplasias del cuello uterino Tamizaje masivo Triaje Ablative treatment eligibility Cervical cancer screening and triage ESTAMPA HPV Visual inspection with acetic acid 3. Ciencias Médicas y de la Salud 3.3. Ciencias de la Salud (salud pública, medicina social, higiene, enfermería, epidemiología) |
| status_str | publishedVersion |
| title | Performance of visual inspection of the cervix with acetic acid (VIA) for triage of HPV screen-positive women : results from the ESTAMPA study |
| title_full | Performance of visual inspection of the cervix with acetic acid (VIA) for triage of HPV screen-positive women : results from the ESTAMPA study |
| title_fullStr | Performance of visual inspection of the cervix with acetic acid (VIA) for triage of HPV screen-positive women : results from the ESTAMPA study |
| title_full_unstemmed | Performance of visual inspection of the cervix with acetic acid (VIA) for triage of HPV screen-positive women : results from the ESTAMPA study |
| title_short | Performance of visual inspection of the cervix with acetic acid (VIA) for triage of HPV screen-positive women : results from the ESTAMPA study |
| title_sort | Performance of visual inspection of the cervix with acetic acid (VIA) for triage of HPV screen-positive women : results from the ESTAMPA study |
| topic | 7. Salud 7.3. Prevención, vigilancia y control de enfermedades transmisibles y no transmisibles Acetic acid Colposcopy Cervix uteri Early detection of cancer/methods Uterine cervical dysplasia Pregnancy Papillomavirus infections Uterine cervical neoplasms Mass screening/methods Triage Ácido acético Colposcopía Cuello del útero Detección precoz del cáncer/métodos Displasia del cuello del útero Embarazo Infecciones por papillomavirus Neoplasias del cuello uterino Tamizaje masivo Triaje Ablative treatment eligibility Cervical cancer screening and triage ESTAMPA HPV Visual inspection with acetic acid 3. Ciencias Médicas y de la Salud 3.3. Ciencias de la Salud (salud pública, medicina social, higiene, enfermería, epidemiología) |
| url | https://doi.org/10.1002/ijc.34384 http://hdl.handle.net/20.500.14066/4517 |