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Cervical cancer is the second leading cause of cancer-related mortality in women living in low- and middle-income countries in sub-Saharan countries. The WHO launched a global elimination strategy in 2020 involving vaccination, screening, and treatment of pre-cancerous lesions. WHO guidelines recommend primary screening using a human papillomavirus (HPV) test, followed by triage to identify HPV-positive women at risk of developing cervical cancer (Figure 1). Several triage approaches like HPV16/18 genotyping or visual inspection with acetic acid have been evaluated in these contexts, with low positive predictive value leading to overtreatment and unnecessary referrals.
Cytology sampling for triage of human papillomavirus-positive women at the screening center in Bafoussam, West Cameroon.
High-income countries are progressively transitioning from cytology-based screening to primary HPV screening with cytology triage of HPV-positive women. Cytology triage, however, remains a challenge in low- and middle-income countries due to a lack of skilled cytopathologists and infrastructure. We have therefore developed a point-of-care telecytology platform in Bafoussam, West Cameroon, that uses a portable slide scanner allowing the upload of digitized slides to a secure cloud for real-time remote diagnosis.
Before implementing this new triage approach, this study aimed to validate the feasibility of a simplified manual liquid-based cytology preparation method, digitalization, and upload of glass slides for remote cytologic diagnosis in a Sub-Saharan African context. The procedure followed three steps (figure 2): (1) slide preparation with modified Papanicolaou stain equivalent to liquid-based cytology; (2) scanning of the cytology slide using the Ocus 40 scanner; (3) uploading of the digital image to a secure cloud.
Telecytology procedure.
The technical setup included a centrifuge, racks, small laboratory equipment, pre-treated slides, gradient liquid, stains, ethanol, distilled water, and xylol. A database tracked participant identification, slide quality, and cytological diagnosis. On-site setup for slide digitization with the Ocus 40 scanner was conducted (Figure 3), and methods for rapid transfer to a secure cloud were explored. Internet instability was a major concern during setup, as telecytology relies on a dependable network. No absolute solution has been found to overcome this limitation.
Scan of the slides at the laboratory in Bafoussam, West Cameroon.
Four laboratory technicians were trained in manual cytology slide preparation (following the BD Surepath manual), scanning, and uploading methods. Training involved preparing 129 cytological slides. All cases met satisfactory standards for slide cellularity, with 109 (87.5%) achieving optimal or acceptable stain quality. Technicians achieved proficiency after six attempts on average. The ease-of-use rating was 4.9/5, and mean preparation and upload time was 35 min.
Procedure costs were previously calculated, with an initial investment of $32 063 and an operational cost of $6.24 per HPV-positive woman for slide preparation without analysis.
The prevalence of high-grade cervical lesions (ASC-H—atypical squamous cells, HSIL cannot be excluded—and HSIL—high-grade squamous intra-epithelial lesions) was 11.0% (12 out of 109 cases with available cytological diagnosis). Despite some challenges, telecytology offers significant benefits for cervical cancer screening, including accessibility, simplicity, efficiency, and cost-effectiveness. Our results indicate that the platform produces slides with sufficient quality for remote cytological diagnosis. It has the potential to improve triage of HPV-positive women and streamlines the screening process with minimal resources. Ongoing studies will evaluate and compare pathologists’ diagnostic performance on glass slides versus telecytology in Cameroon.
Ethics statements
Patient consent for publication
Ethics approval
This study involves human participants and was approved by Cameroonian National ethical committee for research on human health N°2024/01/1621/CE/CNERSH/SP. Participants gave informed consent to participate in the study before taking part.
Acknowledgments
The authors thank Holly Clarke for her previous work, it greatly contributed to this one. They also thank Edith Kayo, Maxime Tebeu, Diane Kambou and Marthe Sidje for their work as laboratory technicians, and for being passionate students, and Maria Munoz for the set-up and teaching of the procedure. They thank Jessica Sormani for her administrative work and help in the project set-up. Finally, they thank both screening center teams in Dschang – Bruno Kenfack, Gilles Tankeu, Alida Moukam, Sophie Lemoupa, Esther Abatsong, Benitte Limofack, Marcelline Akon, Johovani Mefire – and in Bafoussam – Jean-Marie Alima, Jovany Fouogue, Loïc Djommo, Yvonne Nokam, Françoise Yemelong, Sedrick Noupoue, Virginie Yakam.
Footnotes
Contributors PP, PV, AW and EdW contributed to the planning, conduct and reporting of the work described in the article, whereas GE-O contributed to its planning and conduct, and MM contributed to its reporting. EdW vouches for the content of this article.
Funding This article is funded by 'Fondation de la Régie Bory and Fondation privée des Hôpitaux universitaires de Genève'.
Competing interests None declared.
Provenance and peer review Commissioned; internally peer reviewed.