A comparison of cervical cancer screening methods: pap smear, liquid based cytology and VIA VILI

Abinaya Maathuri Jeyakumar, Swarnalatha Mohanapu


Background: There are multiple screening methods available for screening cervical cancer with their advantages and disadvantages, researches that compare the sensitivity, specificity, positive and negative predictive values of these tests in a low-cost setting specific to a geographical area is lacking and has to be enhanced. The objective of this study was to determine and compare the agreement, sensitivity, specificity and predictive values of conventional Pap smear cytology, liquid-based cytology and VIA/VILI with cervix biopsy.

Methods: This cross sectional study was conducted on women of >35 years of age. Pap smear specimen was collected followed by Liquid Base Cytology (LBC) using cytobrush specimen after which visual inspection with 5% acetic acid (VIA) and visual inspection with Lugol’s Iodine (VILI) procedure was carried out and followed by cervix biopsy. All methods were analyzed for accuracy.

Results: Sensitivity was lowest for PAP smear (39.1%, 95% CI 19.18% to 59.1%), followed by VIA VILI (95.7%, 95% CI 87.32% to 100%), and highest for LBC (100.0%). The negative predictive value was lowest for PAP smear (87.4%, 95% CI 81.21% to 93.6%), followed by VIA VILI (99.0%, 95% CI 96.99% to 100.0%) and highest for LBC (100%). The overall diagnostic accuracy was lowest for PAP smear (88.3%) followed by VIA/VILLI (99.2%) and highest for LBC (100%).

Conclusions: Treatment decisions based on findings of the PAP smear have to be taken with caution, considering the lower sensitivity. Wherever resources are available more accurate screening methods like liquid-based cytology must be used.


Liquid-based cytology, Pap smear, Visual inspection with 5% acetic acid, Visual inspection with Lugol’s iodine

Full Text:



Arbyn M, Raifu AO, Weiderpass E, Bray F, Anttila A. Trends of cervical cancer mortality in the member states of the European Union. European J Canc. 2009;45(15):2640-8.

Bosch FX, Lorincz A, Muñoz N, Meijer CJ, Shah KV. The causal relation between human papillomavirus and cervical cancer. J Clinic Pathol. 2002;55(4):244-65.

Schiffman M, Castle PE, Jeronimo J, Rodriguez AC, Wacholder S. Human papillomavirus and cervical cancer. Lancet. 2007;370(9590):890-907.

Dillner J. The serological response to papillomaviruses. In seminars in cancer biology. Academic Press.1999; 9(6): 423-30.

Solomon D, Davey D, Kurman R, Moriarty A, O'connor D, Prey M, et al. The 2001 Bethesda System: terminology for reporting results of cervical cytology. JAMA. 2002;287(16):2114-9.

Arbyn M, Anttila A, Jordan J, Ronco G, Schenck U, Segnan N, et al. European guidelines for quality assurance in cervical cancer screening-summary document. Annals Oncol. 2010;21(3):448-58.

Sigurdsson K. The Icelandic and Nordic cervical screening programs trends in incidence and mortality rates through 1995. Acta Obstet Gynecol Scand. 1999;78(6):478-85.

Karimi MZ, Akhavan A, Gholami H, Dehghani A, Naghshi M, Mohseni F. Evaluation of cervical cancer risk-factors in women referred to Yazd-Iran hospitals from 2002 to 2009. Asian Pacific J Canc Prevention. 2010;11(2):537-8.

Karabulutlu O. Evaluation of the pap smear test status of Turkish women and related factors. Asian Pacific J Canc Prevent. 2013;14(2):981-6.

Oh HY, Kim MK, Seo SS, Lee JK. Association of combined tobacco smoking and oral contraceptive use with cervical intraepithelial neoplasia 2 or 3 in Korean women. J Epidemiol. 2016;26(1):22-9.

Munk AC, Gudlaugsson E, Malpica A, Fiane B, Løvslett KI, Kruse AJ, et al. Consistent condom use increases the regression rate of cervical intraepithelial neoplasia 2-3. PloS One. 2012;7(9):e45114.

Whitehouse KC, Montealegre JR, Follen M, Scheurer ME, Aagaard K. Sociodemographic factors associated with pap test adherence and cervical dysplasia in surgically sterilized women. J Reprod Infert. 2014;15(2):94.

Tayyeb R, Khawaja NP, Malik N. Comparison of visual inspection of cervix and Pap smear for cervical cancer screening. J Coll Physic Surg-Pak. 2003;13(4):201-3.

Shastri SS, Dinshaw K, Amin G, Goswami S, Patil S, Chinoy R, et al. Concurrent evaluation of visual, cytological and HPV testing as screening methods for the early detection of cervical neoplasia in Mumbai, India. Bull World Health Organization. 2005;83:186-94.

Hegde D, Shetty H, Shetty PK, Rai S. Diagnostic value of acetic acid comparing with conventional Pap smear in the detection of colposcopic biopsy proved CIN. J Cancer Res Ther. 2011;7(4):454-8.

Albert SO, Oguntayo OA, Samaila MO. Comparative study of visual inspection of the cervix using acetic acid (VIA) and Papanicolaou (Pap) smears for cervical cancer screening. Ecancer Med Sci.2012;6.

Qiao L, Li B, Long M, Wang X, Wang A, Zhang G. Accuracy of visual inspection with acetic acid and with Lugol's iodine for cervical cancer screening: Meta‐analysis. J Obstetr Gynaecol Res. 2015;41(9):1313-25.

Consul S, Agrawal A, Sharma H, Bansal A, Gutch M, Jain N, et al. Comparative study of effectiveness of Pap smear versus visual inspection with acetic acid and visual inspection with Lugol's iodine for mass screening of premalignant and malignant lesion of cervix. Indian J Med Paediatr Oncol. 2012;33(3):161-5.

Cox JT. Liquid-based cytology: evaluation of effectiveness, cost-effectiveness, and application to present practice. J National Comprehensive Canc Network. 2004;2(6):597-611.

Hussein T, Desai M, Tomlinson A, Kitchener HC. The comparative diagnostic accuracy of conventional and liquid‐based cytology in a colposcopic setting. BJOG: Int J Obstet Gynaecol. 2005;112(11):1542-6.

Cochand‐Priollet B, Cartier I, de Cremoux P, Le Galès C, Ziol M, Molinié V, et al. Cost‐effectiveness of liquid‐based cytology with or without hybrid‐capture II HPV test compared with conventional Pap smears: a study by the French society of clinical cytology. Diagnostic Cytopathol. 2005;33(5):338-43.

Ronco G, Segnan N, Giorgi-Rossi P, Zappa M, Casadei GP, Carozzi F, et al. Human papillomavirus testing and liquid-based cytology: results at recruitment from the new technologies for cervical cancer randomized controlled trial. J National Canc Inst. 2006;98(11):765-4.

Arbyn M, Bergeron C, Klinkhamer P, Martin-Hirsch P, Siebers AG, Bulten J. Liquid compared with conventional cervical cytology: a systematic review and meta-analysis. Obstet Gynecol. 2008;111(1):167.

Sykes PH, Harker DY, Miller A, Whitehead M, Neal H, Wells JE, et al. A randomised comparison of Sure Path liquid‐based cytology and conventional smear cytology in a colposcopy clinic setting. BJOG: Int J Obstet Gynaecol. 2008;115(11):1375-81.

Siebers AG, Klinkhamer PJ, Arbyn M, Raifu AO, Massuger LF, Bulten J. Cytologic detection of cervical abnormalities using liquid-based compared with conventional cytology: a randomized controlled trial. Obstet Gynecol. 2008;112(6):1327-34.

Chen C, Yang Z, Li Z, Li L. Accuracy of several cervical screening strategies for early detection of cervical cancer: a meta-analysis. Int J Gynecol Cancer. 2012 Jul 1;22(6):908-21.