Pocket colposcope: New hope for India's teeming cervical cancer population

It's a cheap screening device that's gaining acceptance over the more intrusive speculum for its ability to capture cancerous and pre-cancerous conditions using high-quality pictures of the cervix

Cervical cancer is preventable, but more women in India die from it than in any other country. According to the National Institute of Cancer Prevention and Research (NICPR), at least 96,322 new cervical cancer cases are detected and 60,078 deaths are reported every year. Experts believe the numbers could be many times over, as cancer screening and detection is abysmally low in India and developing countries. 

Dr Nimmi Ramanujan, professor of biomedical engineering at Duke University, directs the Global Women’s health Technologies at the Pratt School of Engineering and Duke Global Health Institute. Recently, she was in India to talk about a technology she has developed called the pocket colposcope, and to dwell on an ongoing study being conducted in India in partnership with noted gynecologic oncologist, Dr Neerja Bhatla of the All-India Institute of Medical Sciences (AIIMS).

The inspiration for the pocket colposcope, a new screening device that is gaining acceptance, resulted from a visit to Moshi, Tanzania. The director of the Kilimanjaro Christian Medical Center reproductive screening clinic pointed out that one of biggest barriers to cervical cancer screening is the use of speculum. Women who enter the screening cascade for the first time are usually not familiar with this procedure and are intimidated by the idea of having a cold metal object inside their bodies. This barrier was ultimately what led to the conceptualisation of the pocket colposcope.

How the pocket colposcope works

What is fundamentally different about the pocket colposcope, compared to a standard clinical colposcope is that rather than looking at the cervix from outside the body, through the speculum, the pocket colposcope can be inserted through the speculum to provide a close-up view of the cervix to take a picture. When the colposcope is close to the cervix, the quality of pictures obtained rival that of the best colposcopes on the market, but at a fraction of the cost and size (a fifth or a tenth, depending on the kind of colposcope you buy). There are two versions of the pocket colposcope – one with a 5-mega pixel camera that can be used to obtain images via insertion through a speculum and one with a 2-mega pixel camera that is more slender and can be inserted into a tampon-like introducer called the Calla scope, to enable speculum-free visualisation of the cervix.

Historically, the colposcope has not been the gold standard for screening of cervical cancer; rather it guides biopsy following a positive pap smear screen. It is used to visualise lesions, which are then biopsied and evaluated by a pathologist to confirm disease prior to treatment. That being said, in low resource communities, there is not sufficient funding or infrastructure to perform pap smears, buy colposcopes, or process biopsies. So in those communities, providers often visualise the cervix with the naked eye or a camera, and use their experience to determine whether a patient needs treatment or not. 

In this instance, having a device like a colposcope is particularly important, as a high-quality image provides the basis for a more accurate interpretation in the absence of a biopsy. The digital images can be processed with automated decision-making algorithms, making effective point-of-care colposcopy and diagnosis possible in the hands of community health providers. 

In a high-income setting, it can be used as a standard colposcope during a procedure in a hospital or a specialty clinic, bringing affordable screening to more providers. It is very intuitive to use, like a digital camera and, typically, a one-hour training over skype on the use of the technology is sufficient for providers to independently use the device on patients.

The ultimate goal is to bring this technology to the community health setting so it can be used to triage patients at the sites where they live, before referring them to a hospital. 

Currently, a session which involves screening using a colposcope costs Rs 35,000. Says Dr Sabhyata Gupta, Director, Gynaecology and Onco Gynaecology, “The pocket colposcope will be an excellent device to use as the current product is bulky.” 

The pocket colposcope is easy to use and needs minimal maintenance. In the US, it has been priced at $1,000. Pricing for the developing world is still being worked on, as access was the raison d'être for developing the product.

Duke is in discussions with potential partners for scale up in India. 

What is the Human papillomavirus? 

• Human papillomavirus (HPV) is a group of pathogens that are extremely common worldwide.
• There are more than 100 types of HPV, of which at least 14 are cancer-causing (also known as high-risk type). Vaccines are available to protect against four strains of the virus, and are generally administered to females between the ages of nine and 26.
• HPV is mainly transmitted through sexual contact and most people get infected shortly after the onset of sexual activity.
• Cervical cancer is caused by sexually acquired infection with certain types of HPV.
• Two HPV types (16 and 18) cause 70 per cent of cervical cancers and pre-cancerous cervical lesions.
• There is also evidence linking HPV with cancers of the anus, vulva, vagina, penis and oropharynx.
• Cervical cancer is the second most common cancer in women living in less developed regions with an estimated 570,000 new cases in 2018 (84 per cent of the new cases worldwide).
• In 2018, approximately 311,000 women died from cervical cancer, with more than 85 per cent of these deaths occurring in low- and middle-income countries.
• Comprehensive cervical cancer control includes primary prevention (vaccination against HPV), secondary prevention (screening and treatment of pre-cancerous lesions), tertiary prevention (diagnosis and treatment of invasive cervical cancer) and palliative care.
• Vaccines that protect against HPV 16 and 18 are recommended by WHO and have been approved for use in many countries.
• Screening and treatment of pre-cancer lesions in women of 30 years and more is a cost-effective way to prevent cervical cancer.
• Clinical trials and post-marketing surveillance have shown that HPV vaccines are very safe and very effective in preventing infections with HPV infections.
• Cervical cancer can be cured if diagnosed at an early stage.

Source: World Health Organization