{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,27]],"date-time":"2026-10-27T03:01:04Z","timestamp":1793070064090,"version":"4.5.0"},"reference-count":16,"publisher":"Wiley","issue":"11","license":[{"start":{"date-parts":[[2024,6,13]],"date-time":"2024-06-13T00:00:00Z","timestamp":1718236800000},"content-version":"vor","delay-in-days":12,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["Cancer Medicine"],"published-print":{"date-parts":[[2024,6]]},"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Objectives<\/jats:title>\n                    <jats:p>Visual inspection with acetic acid (VIA) is a low\u2010cost approach for cervical cancer screening used in most low\u2010 and middle\u2010income countries (LMICs) but, similar to other visual tests, is subjective and requires sustained training and quality assurance. We developed, trained, and validated an artificial\u2010intelligence\u2010based \u201cAutomated Visual Evaluation\u201d (AVE) tool that can be adapted to run on smartphones to assess smartphone\u2010captured images of the cervix and identify precancerous lesions, helping augment VIA performance.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Design<\/jats:title>\n                    <jats:p>Prospective study.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Setting<\/jats:title>\n                    <jats:p>Eight public health facilities in Zambia.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Participants<\/jats:title>\n                    <jats:p>A total of 8204 women aged 25\u201355.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Interventions<\/jats:title>\n                    <jats:p>Cervical images captured on commonly used low\u2010cost smartphone models were matched with key clinical information including human immunodeficiency virus (HIV) and human papillomavirus (HPV) status, plus histopathology analysis (where applicable), to develop and train an AVE algorithm and evaluate its performance for use as a primary screen and triage test for women who are HPV positive.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Main Outcome Measures<\/jats:title>\n                    <jats:p>Area under the receiver operating curve (AUC); sensitivity; specificity.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>As a general population screening tool for cervical precancerous lesions, AVE identified cases of cervical precancerous and cancerous (CIN2+) lesions with high performance (AUC\u2009=\u20090.91, 95% confidence interval [CI]\u2009=\u20090.89\u20130.93), which translates to a sensitivity of 85% (95% CI\u2009=\u200981%\u201390%) and specificity of 86% (95% CI\u2009=\u200984%\u201388%) based on maximizing the Youden's index. This represents a considerable improvement over naked eye VIA, which as per a meta\u2010analysis by the World Health Organization (WHO) has a sensitivity of 66% and specificity of 87%. For women living with HIV, the AUC of AVE was 0.91 (95% CI\u2009=\u20090.88\u20130.93), and among those testing positive for high\u2010risk HPV types, the AUC was 0.87 (95% CI\u2009=\u20090.83\u20130.91).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>These results demonstrate the feasibility of utilizing AVE on images captured using a commonly available smartphone by nurses in a screening program, and support our ongoing efforts for moving to more broadly evaluate AVE for its clinical sensitivity, specificity, feasibility, and acceptability across a wider range of settings. Limitations of this study include potential inflation of performance estimates due to verification bias (as biopsies were only obtained from participants with visible aceto\u2010white cervical lesions) and due to this being an internal validation (the test data, while independent from that used to develop the algorithm was drawn from the same study).<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1002\/cam4.7355","type":"journal-article","created":{"date-parts":[[2024,6,14]],"date-time":"2024-06-14T02:54:57Z","timestamp":1718333697000},"update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":18,"title":["Internal validation of Automated Visual Evaluation (AVE) on smartphone images for cervical cancer screening in a prospective study in Zambia"],"prefix":"10.1002","volume":"13","author":[{"ORCID":"https:\/\/orcid.org\/0009-0004-9560-7709","authenticated-orcid":false,"given":"Liming","family":"Hu","sequence":"first","affiliation":[{"name":"Global Health Labs, Inc.  Bellevue Washington USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mulindi H.","family":"Mwanahamuntu","sequence":"additional","affiliation":[{"name":"University Teaching Hospital  Lusaka Zambia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Vikrant V.","family":"Sahasrabuddhe","sequence":"additional","affiliation":[{"name":"National Cancer Institute, NIH  Bethesda Maryland USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Caroline","family":"Barrett","sequence":"additional","affiliation":[{"name":"Clinton Health Access Initiative (CHAI), Inc.,  Boston Massachusetts USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Matthew P.","family":"Horning","sequence":"additional","affiliation":[{"name":"Global Health Labs, Inc.  Bellevue Washington USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ishan","family":"Shah","sequence":"additional","affiliation":[{"name":"Global Health Labs, Inc.  Bellevue Washington USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Zohreh","family":"Laverriere","sequence":"additional","affiliation":[{"name":"Global Health Labs, Inc.  Bellevue Washington USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Dipayan","family":"Banik","sequence":"additional","affiliation":[{"name":"Global Health Labs, Inc.  Bellevue Washington USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ye","family":"Ji","sequence":"additional","affiliation":[{"name":"Global Health Labs, Inc.  Bellevue Washington USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Aaron Lunda","family":"Shibemba","sequence":"additional","affiliation":[{"name":"University Teaching Hospital  Lusaka Zambia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Samson","family":"Chisele","sequence":"additional","affiliation":[{"name":"University Teaching Hospital  Lusaka Zambia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mukatimui Kalima","family":"Munalula","sequence":"additional","affiliation":[{"name":"University Teaching Hospital  Lusaka Zambia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Friday","family":"Kaunga","sequence":"additional","affiliation":[{"name":"University Teaching Hospital  Lusaka Zambia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Francis","family":"Musonda","sequence":"additional","affiliation":[{"name":"University Teaching Hospital  Lusaka Zambia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Evans","family":"Malyangu","sequence":"additional","affiliation":[{"name":"University Teaching Hospital  Lusaka Zambia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Karen Milch","family":"Hariharan","sequence":"additional","affiliation":[{"name":"Clinton Health Access Initiative (CHAI), Inc.,  Boston Massachusetts USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Groesbeck P.","family":"Parham","sequence":"additional","affiliation":[{"name":"University Teaching Hospital  Lusaka Zambia"},{"name":"University of North Carolina at Chapel Hill  Chapel Hill North Carolina USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"311","published-online":{"date-parts":[[2024,6,13]]},"reference":[{"key":"e_1_2_10_2_1","unstructured":"WHO guideline for screening and treatment of cervical pre\u2010cancer lesions for cervical cancer prevention. Accessed 11 May 2023 https:\/\/www.who.int\/publications\u2010detail\u2010redirect\/9789240030824."},{"key":"e_1_2_10_3_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.vaccine.2006.05.113"},{"key":"e_1_2_10_4_1","volume-title":"WHO Guideline for Screening and Treatment of Cervical Pre\u2010Cancer Lesions for Cervical Cancer Prevention","author":"Web AA","year":"2021"},{"key":"e_1_2_10_5_1","doi-asserted-by":"publisher","DOI":"10.1002\/14651858.CD008587.pub2"},{"key":"e_1_2_10_6_1","doi-asserted-by":"publisher","DOI":"10.1097\/OGX.0000000000000687"},{"key":"e_1_2_10_7_1","doi-asserted-by":"publisher","DOI":"10.1186\/s13027-023-00536-5"},{"key":"e_1_2_10_8_1","doi-asserted-by":"publisher","DOI":"10.1097\/QAI.0000000000000270"},{"key":"e_1_2_10_9_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.ygyno.2008.04.031"},{"key":"e_1_2_10_10_1","doi-asserted-by":"publisher","DOI":"10.1097\/00006254-199109000-00017"},{"key":"e_1_2_10_11_1","doi-asserted-by":"publisher","DOI":"10.1111\/j.1471-0528.1989.tb03380.x"},{"key":"e_1_2_10_12_1","doi-asserted-by":"publisher","DOI":"10.1136\/bmj.h5527"},{"key":"e_1_2_10_13_1","doi-asserted-by":"publisher","DOI":"10.1109\/EMBC44109.2020.9175863"},{"key":"e_1_2_10_14_1","doi-asserted-by":"publisher","DOI":"10.1109\/TPAMI.2018.2858826"},{"key":"e_1_2_10_15_1","unstructured":"Global strategy to accelerate the elimination of cervical cancer as a public health problem.World Health Organization;2020. Licence: CC BY\u2010NC\u2010SA 3.0 IGO."},{"key":"e_1_2_10_16_1","doi-asserted-by":"publisher","DOI":"10.1002\/ijc.33879"},{"key":"e_1_2_10_17_1","doi-asserted-by":"publisher","DOI":"10.1002\/ijc.22991"}],"container-title":["Cancer Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/onlinelibrary.wiley.com\/doi\/pdf\/10.1002\/cam4.7355","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2024,6,28]],"date-time":"2024-06-28T08:20:05Z","timestamp":1719562805000},"score":1,"resource":{"primary":{"URL":"https:\/\/onlinelibrary.wiley.com\/doi\/10.1002\/cam4.7355"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2024,6]]},"references-count":16,"journal-issue":{"issue":"11","published-print":{"date-parts":[[2024,6]]}},"alternative-id":["10.1002\/cam4.7355"],"URL":"https:\/\/doi.org\/10.1002\/cam4.7355","archive":["Portico"],"relation":{"has-preprint":[{"id-type":"doi","id":"10.1101\/2023.07.19.23292888","asserted-by":"object"}]},"ISSN":["2045-7634","2045-7634"],"issn-type":[{"value":"2045-7634","type":"print"},{"value":"2045-7634","type":"electronic"}],"subject":[],"published":{"date-parts":[[2024,6]]},"assertion":[{"value":"2023-10-05","order":0,"name":"received","label":"Received","group":{"name":"publication_history","label":"Publication History"}},{"value":"2024-05-26","order":1,"name":"accepted","label":"Accepted","group":{"name":"publication_history","label":"Publication History"}},{"value":"2024-06-13","order":2,"name":"published","label":"Published","group":{"name":"publication_history","label":"Publication History"}}],"article-number":"e7355"}}