In India, vinegar test proves vital in global cervical cancer fight

MUMBAI // A simple vinegar test slashed cervical cancer death rates by a third in a remarkable study of 150,000 women in the slums of India, where the disease is the leading cause of cancer deaths of women.

Doctors reported the results yesterday during a cancer conference in the United States.

Experts described the outcome as "amazing" and said the quick, cheap test could save tens of thousands of lives each year in developing countries by spotting the early signs of cancer, allowing treatment before it is too late. India has nearly one-third of the world's cases of cervical cancer - more than 140,000 each year.

Usha Devi, one of the women who took part in the study, said it saved her life.

"Many women refused to get screened," she said. "Some of them died of cancer later. Now I feel everyone should get tested. I got my life back because of these tests."

Pap smears and tests for HPV - a virus that causes most cervical cancers - have slashed the numbers of cases and deaths in the US but poor countries can't afford those screening tools.

The new study tried a test that costs little and can be carried out by people with just two weeks of training and no need for expensive lab equipment. They simply swab the cervix with diluted vinegar, which can make abnormal cells briefly change colour.

This low-tech visual exam cut the cervical cancer death rate by 31 per cent, the study found. It could prevent 22,000 deaths in India and 72,600 worldwide each year, researchers estimate.

"That's amazing. That's remarkable," said Dr Ted Trimble of the National Cancer Institute in the US, the main sponsor of the study. "It's a very exciting result."

Ms Devi's story is not an unusual one. Despite having given birth to four children, she had never had a gynaecological exam. She had been bleeding heavily for several years, hoping patience and prayers would fix things.

"Everyone said it would go away, and every time I thought about going to the doctor there was either no money or something else would come up," she said, sitting in a room that serves as bedroom, kitchen, bathroom and living room for her family.

One day she found a card from health workers attempting to convince women to join the study. Ms Devi is in her late 40s and, like many of the country's poor, does not know her date of birth. She learnt she had advanced cervical cancer. The study paid for surgery to remove her uterus and cervix.

The research effort was led by Dr Surendra Shastri of Tata Memorial Hospital in Mumbai.

"It's just not possible to provide Pap smear screening in developing countries. We don't have that kind of money," Dr Shastri said.

There was also the lack of staff and equipment to consider, so a simpler method had to be found

Starting in 1998, researchers enrolled 75,360 women to receive the vinegar test every two years. Another 76,178 women were chosen for a control, or comparison group that just got cancer education at the start of the study and vouchers for a free Pap test - if they could get to the hospital to have one. Women in either group found to have cancer were offered free treatment at the hospital.

Despite the offer of quick and free cancer screening, it proved a hard sell in a deeply conservative country where women are subservient and need permission from husbands, fathers or others for even routine decisions. Social workers were sent into the slums to win people over.

"We went to every single house in the neighbourhood assigned to us, introducing ourselves and asking them to come to health talks," said Vaishnavi Bhagat, a social worker.

"They used to come out of curiosity, listen to the talk. But when we asked them to get screened they would totally refuse. The women were both scared and shy."

One woman who did agree to testing jumped up from the table when she was examined with a speculum. "She started screaming that we had stolen her kidney," Ms Bhagat said.

Another health worker was beaten by people in the neighbourhood when women realised they would have to disrobe to be screened.

"Sometimes just the idea of getting tested for cancer scared them. They would start crying even before being tested," said Urmila Hadkar, a health worker.

But screening worked. The quality of screening by health workers was comparable to that of an expert gynecologist, researchers reported.

The study was planned for 16 years but results at 12 years showed lives were saved with the screening, so independent monitors advised offering it to the women in the comparison group.

An ethics controversy developed during the study. The US Office for Human Research Protections faulted researchers for not adequately informing participants in the comparison group about Pap tests for screening. A letter from the agency in March indicated officials seemed to accept many of the remedies study leaders had implemented.

Others defended the study. Dr Trimble, who visited the project in India, said the ethics were looked at carefully and were felt to be sound.

Dr Sandra Swain, a cancer specialist at Medstar Washington Hospital Centre, also defended the research. She is president of the American Society of Clinical Oncology and the research results were presented at that group's meeting in Chicago yesterday. "There really was no wrongdoing there," she said.

Dr Swain said that, as they have no screening anyway, there is no standard of care.

Officials in India already are making plans to expand vinegar testing.

Mammograms for breast cancer screening are also beyond the resources of many poor countries and the India study has been testing breast exams by health workers as an alternative.

Dr Trimble said that preliminary results suggest breast cancers are being found at an earlier stage but it was too soon to know if that will save lives because not enough women have died yet to compare the groups.

More progress against cervical cancer may come from last month's announcement that two companies will drastically lower prices on HPV vaccines for poor countries. Pilot projects will begin in Asia and Africa, with the campaign aiming to vaccinate more than 30 million girls in more than 40 countries by 2020.

* Associated Press