Mobile High-Resolution Microendoscopy (mHRME) for the Detection of Cervical Dysplasia in El Salvador
Conditions: Cervical Cancer
Sponsor: William Marsh Rice University

 
 
 
 
 
Protocol 2015-0620 
 
 
 
 
 
 
 
 
 
 
 
November 12, 2018 
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Mobile High-Resolution Microendoscopy (mHRME) for the Detection of
Cervical Dysplasia in El Salvador
 
 
 
Principal Investigators:
 
Mauricio Maza, MD
Basic Health International (BHI), El Salvador
 
Miriam Cremer, MD
Department of Obstetrics & Gynecology, University of Pittsburgh
Basic Health International (BHI), El Salvador
 
Rebecca Richards-Kortum, PhD 
Department of Bioengineering, Rice University
 
Kathleen M. Schmeler, MD
Department of Gynecologic Oncology & Reproductive Medicine, MDACC
 
Phil Castle, PhD
Albert Einstein College of Medicine (AECOM)
 
 
 
Collaborators:
 
 
Mark Stoler, MD
Department of Pathology, University of Virginia

 
 
 
 
 
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1.1 Objectives:
 
1. To evaluate the performance of mobile high-resolution microendoscopy (mHRME) compared 
with HPV DNA testing alone and HPV testing followed by VIA in San Salvador, El Salvador.
2. To evaluate the feasibility and usability of the mHRME system in a rural setting in El Salvador.
3. To assess the performance of n e w  t e c h n o l o g i e s  f o r HPV DN Aand oncoprotein and 
compare their p e r f o r m a n c e in patients with and without cervical precancer and cancer.
Introduction:
Cervical cancer is still the most common type of cancer and the second leading cause of cancer-related 
deaths among women in developing countries, due to the lack of appropriate screening programs. There 
are economic, political, and logistic barriers for the implementation of mass vaccination programs, 
especially in Low-and-Middle-Income-Countries (LMIC). Furthermore, currently available vaccines do 
not bring protection against all types of high-risk HPV strains and are not effective in curing already 
existing infections. Therefore, cervical cancer screenings will continue to be necessary for years to come. 
One of the ways to screen for cervical cancer is through visual inspection with acetic acid (VIA). The 
VIA’s sensitivity in the detection of cervical dysplasia and cancer is similar to that of a colposcopy, but 
with less specificity. The low specificity of this test can translate into false positives, leading to 
overtreatment of benign conditions, which not only increases the programs’ cost, but causes unnecessary 
concern for the patients. These reasons highlight the need to have diagnostic methods with increased 
specificity that allow the identification of patients requiring intervention. This is particularly relevant in 
developing countries, where colposcopy-guided biopsies and histopathological testing are not readily 
available. The mHRME imaging system is a low-cost method that allows for the evaluation of epithelial 
cells in situ, thus eliminating the need for cervical biopsies. This study intends to validate the performance 
characteristics of HRME as a diagnostic tool.
 
 
 
2.0 Background and Significance
 
Early Detection:
For a while, cervical cancer was considered the leading cause of cancer-related deaths among women in 
the United States. However, its prevalence and death rate have decreased by approximately 70% over the 
last 40 years. This reduction is greatly linked to the implementation of the Papanicolaou test in 1941, 
which promoted increased efforts in the detection of precancerous lesions (1). Cervical cancer is still the 
most common type of cancer and the second leading cause of cancer-related deaths among women in
developing countries, due to the lack of appropriate screening programs (2). Today, it is a known fact that 
almost all cases of cervical cancer are caused by high-risk strains of the Human Papilloma Virus (HPV) 
(3). Despite the development of preventive vaccines, in use since 2006 (4, 5), administration rates for said 
vaccine remain very low, with less than 50% of minors being vaccinated in the United States of America 
(6, 7). There are economic, political, and logistic barriers to the implementation of mass vaccination 
programs, especially in Low-and-Middle-Income-Countries (LMIC). Furthermore, currently available 
vaccines do not bring protection against all types of high-risk HPV strains and are not effective in curing 
already existing infections. Therefore, cervical cancer screenings will continue to be necessary for years 
to come.
 

 
 
 
 
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Cervical Cancer Screening and Prevention in LMICs:
Current approaches when it comes to cervical cancer screening in developing countries include cervical 
cytology and HPV detection testing. Patients with abnormal results undergo a colposcopy during which 
biopsies of the areas that are considered abnormal are taken. If significant lesions with the potential of 
developing into cancer are found, a cryotherapy or a cone biopsy (LEEP) is performed. These methods 
are effective; however, they are also very costly and require appropriate infrastructure and qualified 
personnel. Furthermore, the patient has to be seen in three different occasions, including one visit to be 
informed about the test results. This is why alternative solutions are highly needed, especially in 
developing countries. A visual inspection with acetic acid (VIA) is an option. During this test, the acetic 
acid is applied to the cervical epithelium, and upon the identification of any acetowhite areas, indicative 
of precancerous lesions, a cryotherapy or a cone biopsy (LEEP) can be performed during the same visit 
(“See and Treat”). The VIA’s sensitivity in the detection of cervical dysplasia and cancer is similar to that
of a colposcopy but with less specificity (8-12). The low specificity of this test can translate into false 
positives, leading to overtreatment of benign conditions, which not only increases the programs’ cost, but 
causes unnecessary concern for the patients. A similar “See and Treat” protocol in higher-income regions 
has been implemented in the Netherlands, where patients undergo a cone biopsy (LEEP) immediately 
after a colposcopy has identified high-risk lesions. Even in cases where a colposcopy was performed, an 
overtreatment rate of 18.1% was observed (13). This highlights the need to have diagnostic methods with 
increased specificity that allow the identification of patients requiring intervention. This is particularly 
relevant in developing countries, where colposcopy-guided biopsies and histopathological testing are not 
readily available.
HRME Imaging:
The mHRME imaging system is a low-
cost method that allows for the evaluation 
of epithelial cells in situ, thus eliminating 
the need for cervical biopsies. A topical 
contrast marker called Proflavine is 
applied to the cervix in the same way that 
the acetic acid is applied during VIA and 
colposcopy procedures. The tip of a small 
optic fiber probe is placed on the cervix 
and the presence of proflavine-stained 
fluorescent cells is transmitted to the 
HRME system and to a computer monitor 
or 
tablet 
(Fig. 
1). 
Some 
of 
the 
morphological features usually assessed 
by 
pathologists, 
such 
as 
nuclear 
clustering, 
pleomorphism, 
and 
the 
nuclear-cytoplasmic (N:C) ratio can be 
evaluated live, in real time. An imaging analysis software is then used to quantify the nuclear morphology 
parameters and calculate the N:C ratio. This approach allows for real-time detection of high-grade 
precancerous lesions without the need for a biopsy. Moreover, the lesions can be treated during that same 
visit either with cryotherapy or with a cone biopsy (LEEP), if necessary. The HRME system is portable, 
resistant, and battery-operated. Its cost is around $2,500 if the device is used with a computer.
Fig. 1 (a) HRME system; (b) Proflavine application; (c) Fiber optic 
probe, (d) Real-time, high-resolution image on a computer; (c) 
Colposcopic image of a lesion located at 5:00 o’clock; (d) Resulting 
HRME-created image. Histopathological diagnosis was normal, 
consistent with the HRME image, showing small homogeneously-
distributed nuclei; (g) Colposcopic image of a lesion located at 1:00 
o’clock; (f) Resulting HRME-created image. The diagnosis for this site 
was CIN 3, consistent with the HRME image, showing

 
 
 
 
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A more inexpensive system that uses a smartphone 
(mHRME) has been developed recently (Fig. 2). The
phone model used was a Samsung Galaxy Note 3, with 
a 2.3 GHz processor, 3 GB RAM, and a 12-MP camera. 
An optic adaptor is placed on the phone. The system 
measures 150mm x 60mm x 80mm. The 4.9-micron 
resolution is appropriate for the maximum resolution 
allowed by the fiber optic used. The optic performance 
of the mHRME is equivalent to that of the HRME 
system. Production costs of mHRME systems are 
estimated to be under $500 if around 10,000 units are 
manufactured.
HPV E7 Assay:
The presence of HPV DNA is associated with an increased risk of cervical cancer. Nevertheless, said 
presence alone does not imply the existence of a persistent or precancerous lesion. In fact, most HPV 
infections are cleared by the immune system. In low-grade lesions, the HPV DNA exists as an 
extrachromosomal episome. However, in high-grade and cancer lesions, the viral genomes are often found 
in the chromosome of the host cell (14), resulting in a non-regulated expression of the E6 and E7 viral genes, 
prompting the lesion to progress to a cancer. The HPV DNA test cannot discriminate between episomal and 
integrated DNA. Therefore, this method has 
high sensitivity and negative predictive 
value, but low specificity and positive 
predictive 
value 
for 
cervical 
cancer. 
However, the overexpression of viral 
oncoproteins (ex. E6 and E7) is often 
associated with genetic integration and 
represents a high risk of disease progression 
(15). HPV DNA testing renders positive 
results for many patients who do not require 
treatment. 
Screening 
for 
other 
HPV 
biomarkers that have been linked to 
neoplastic progression could improve care 
management for infected women, as it would 
allow the identification of those patients 
with a higher risk of having a precancerous 
or cancerous lesion.
Recently, two ELISA tests reported the presence of E6 proteins in cervical cytology (16, 17). The presence 
of this protein has been more closely correlated to the presence of CIN II than the results obtained with the 
HPV DNA test. An epidemiologic study to identify the presence of HPV E6 oncoprotein, types 16, 18, and 
45 (OncoE6™, Arbor Vita Corporation, Fremont, CA, USA), showed that the detection of E6 has a high 
 
Fig. 2 (a) mHRME system; (b) mHRME-created cervical 
tissue image.

 
 
 
 
 
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specificity (<2% positive), resulting in a higher positive predictive value (30-35%) of precancerous and 
cancerous lesions, in comparison to a positive predictive value of <10% using VIA, HC2, and careHPV (18). 
This method’s sensitivity was about 50%, partly because it only screens for three out of all the virus strains 
responsible for 75% of all cervical cancer cases. Despite these results proving that these tests are efficient at 
detecting the presence of HPV oncoproteins and that these proteins are specific to cancerous and 
precancerous lesions, its use at health care centers is still not ideal, since they require specific infrastructure 
(ex. microtiter plates) (16) and several properly-timed wash and incubation periods (17).
HPV DNA assay
The HPV DNA test has been broadly used in cervical screening protocols due to its high sensitivity and 
negative predictive value. Recent studies show that HPV DNA screening is more effective than the use of a 
cervical cytology test or VIA tests (R Sankaranarayanan et al, 2009), with the number of advance-stage 
cervical cancer cases and cervical cancer deaths dropping down to 50%. Unfortunately, the HPV DNA tests 
that are commercially available are expensive and require a large infrastructure. The Digene HC2 HPV DNA 
test has a cost of $40-$60 per test, takes over 4.5 hours to perform, and must be done at a laboratory equipped 
with an agitator and a plate reader (which cost around $500 and $20,000, respectively) (PE Gravitt et al, 
2011). While it is not commercially available yet, the HPV DNA test, known as careHPV, has a projected 
cost of $5 per test. Despite the great improvement cost-wise when compared to the Digene HC2 test, the 
price of each test remains high for many low-income locations. Moreover, it takes about 2.5 hours to perform 
the careHPV test, in which 90 samples are processed simultaneously; the test also requires an agitator and a 
plate reader.
To address these limitations, we have developed an HPV DNA test with a lateral flow method that can be
produced for less than $2 per test and does not require expensive equipment. Our test uses an RNA 
hybridization probe, complementary to an HPV DNA sample, and will allow the screening of RNA hybrids: 
DNA through a sandwich-ELISA assay using the same two-dimension paper technology described above. 
The test does not require electricity; it relies on capillary reactions and it is disposable. Additionally, it can 
be performed on a one by one basis, without the need to gather different samples. Our test uses specimens 
collected from previously attained Papanicolaou tests using a swab, which have been preserved in a bottle. 
To perform the test, a drop of a denaturizing agent will be added to the bottle to lyse the cells and for DNA 
denaturation purposes. Then, the RNA hybridization probes will hybridize the denatured DNA and the bottle 
contents will be transferred to the sample board. An operator will simply rehydrate the dried-up reactors with 
water and fold the device in half to start the flow. The sample will flow through the testing area, followed by 
the necessary colorimetric reactors. If HPV DNA is present in the patient’s sample, there will be a 
colorimetric change on the test site itself, which is visible without the need of any additional equipment. Our 
lateral flow DNA test will allow for the fast and accessible detection of HPV DNA at the health care center. 
In the following pages, we will assess the performance of this test and if said performance will improve when 
combined with the HRME.
To address these limitations, we have developed a low-cost ELISA test to screen for the presence of the E7 
protein, which can be implemented with a simple, one-step procedure. A new generation, bi-dimensional 
ELISA method with a lateral flow network lies the foundations for multi-step testing with minimal operator 
intervention. With our technology, we have developed a nitrocellulose-based platform which uses capillarity 
to sequentially bring the ELISA reactor to an area where there is no need for the operator’s interaction once 
the test has started. (Fig.3) Due to the absorption properties of nitrocellulose, the test does not require 
electricity. This disposable test is produced using dried reactors in disposable fiberglass patches. To perform 
the test, the operator simply adds the patient’s cervical swab and water to the dry patches, and then folds the 
device in half to start the test. Both the sample and the colorimetric reactors flow to the reaction area at the 
same time. If HPV E7 is present in the patient’s sample, there will be a color change that is easily visible 

 
 
 
 
 
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without the need for additional equipment. This testing device will allow for the detection of HPV E7 at 
health care centers, thus reducing the number of patients that fail to continue their follow-up visits. The 
performance of this test will be evaluated observing if its performance in combination with HRME imaging 
testing renders better results.
 
 
3.0 Preliminary Data
 
A pilot study that evaluated HRME testing was recently carried out with 174 female participants in a rural 
area in China (19). All patients received HPV testing, VIA, colposcopy and HRME imaging. Out of the 69 
women who showed abnormalities in the colposcopy, only 12 (17%) were diagnosed with a high-grade 
lesion after the biopsy. The HRME imaging system correctly classified as “abnormal” all 12 areas (100%) 
having a high-grade lesion, and it correctly classified 38 out of the 57 remaining samples (67%) as 
“normal”. Moreover, when the patients were stratified according to a positive high-risk HPV DNA 
detection test, the HRME system correctly identified 100% of patients with CIN 2 or higher. Out of the 30 
patients with a positive high-risk HPV DNA detection test with no histological evidence of the disease, 
only 6 patients (20%) were misidentified as “abnormal” using the HRME imaging system. These 
preliminary findings suggest that the HRME has an improved specificity when compared to VIA and 
colposcopy testing, potentially leading to a more accurate screening of patients needing treatment, as part
of a “See and Treat” protocol. The study results also suggest that the HRME system can be an effective 
initial diagnostic tool after a positive cervical cytology or an HPV test. Recently, our collaborators 
completed a pilot study at the Barretos Cancer Hospital (BCH) to assess the feasibility of using HRME in 
Brazil (MDACC Protocol 2011-0396). All patients underwent a colposcopy as the standard of care and all 
acetowhite lesions were recorded. HRME images were obtained for each lesion observed by colposcopy. 
Abnormal areas were biopsied and assessed by two independent pathologists, and the results were 
compared to the HRME findings. A total of 79 acetowhite lesions were identified among 46 patients, all of 
which were biopsied. Adequate images were obtained using the HRME for 59 of these lesions (75%). 
Biopsy results showed normal tissue (n=9, 15%), CIN 1 (n=16, 27%), CIN 2 (n=12, 20%), CIN 3 (n=19, 
32%) and invasive tumors (n=3, 5%). The HRME’s positivity percentages were 22% for normal, 31% for 
CIN 1, 83% for CIN 2, 95% for CIN 3, and 100% for cancer. As for the HRME’s sensitivity and specificity 
rates for CIN 2+ verified by biopsy (n=34), the former was 89% and the latter 77%. These results suggest 
that the HRME system can be a precise, low-cost alternative to colposcopies and guided cervical biopsies 
for the diagnosis of cervical dysplasia in low income locations, where the availability of colposcopy and 
pathology services is low.
This research proposal will be developed based on the findings of the two aforementioned studies, in an 
attempt to validate the performance characteristics of HRME testing as a diagnostic tool, following an 
abnormal screening, in a prospective study in El Salvador. The study will be carried out at two different 
sites: Basic Health International and the ICES.
Duration of the Study:
This study will last 5 years, starting in September 2015.

 
 
 
 
 
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Projected Number of Research Subjects:
A total of 3,000 women will take part in this study.
The sample size is based on the following premise: our goal is to determine whether the addition of the 
mHRME to VIA improves the specificity without significantly reducing the sensitivity (non-inferiority 
trial) in this screening population. During our preliminary work (19), we found that the use of HRME did 
not reduce the VIA’s sensitivity; however, we saw a considerable improvement in specificity (VIA + 
HRME = 82% vs. VIA alone = 64%) when compared to the histopathology gold standard. The following 
sample size was estimated using the PASS software (24): a sample size of 45 CIN 2+ cases diagnosed by 
VIA reaches at least 80% power (84%) to ensure a non-inferior proportion (mHRME sensitivity for CIN 
2+ diagnosed by VIA) (P0) of 0.7500, using a one-sided binomial test for non-inferiority. The target 
significance level is 0.0500. The actual significance level attained by this test is 0.0446. These results 
assume that the actual proportion (sensitivity) (PI) is 0.9000. If the mHRME sensitivity for CIN 2+ 
diagnosed by VIA is over 90%, as observed in the preliminary HRME study, the power will be greater. 
Assuming that 1) VIA’s actual sensitivity for all CIN 2+ cases is at least 75% (25); and 2) that the total 
prevalence of CIN 2+ in El Salvador is 2%, a total sample of 3,000 women will need to be screened using 
VIA. Finally, assuming that 10% of women have a positive VIA (n = 300, 255 VIA+ without CIN 2+), a 
2% reduction among women with VIA+ (2% improvement in specificity) would be statistically 
significant (ex., 98% positive, 95% confidence interval = 95%-99%).
4.0 Eligibility Criteria
 
Inclusion Criteria:
1. Women who are between the ages of 30
and 49 years of age
2. All women
must have a negative urine or serum  pregnancy test  prior to any study procedure
(within 7 days)
3. Intact cervix (patients who have undergone previous LEEP, cone and/or cryotherapy are not 
eligible)
4. No history of invasive cervical cancer
5. Able and willing to provide informed consent
 
Exclusion Criteria:
1. Women < 30 years of age or over 49 years of age
2. Women who have undergone a hysterectomy with removal of the cervix
3.Women who have had a previous LEEP, Cold knife cone and/or 
cryotherapy
4. Women who are pregnant or breastfeeding
5. Women with a history of invasive cervical cancer
6. Unable or unwilling to provide informed consent
 
5.0 Research Plan and Methods
This is a prospective cohort study.
Eligibility is open to women 30-49 years old, who are not pregnant, have an intact cervix and no history 
of cervical cancer.
Visit 1:
Patients will enroll at the screening clinic of the Instituto del Cáncer de El Salvador (El Salvador Cancer 
Institute, ICES). An informed consent will be obtained. They will be given a urine pregnancy test; if 

 
 
 
 
 
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negative, two cervical samples will be collected. The first sample will be used to screen for HPV DNA. 
New technologies to screen for oncoproteins and HPV will be applied to the second sample. This sample 
will be stored at a temperature of at least -20°C until it is used. 3-5% acetic acid will also be applied to the 
cervix to perform the VIA. The health care provider will record their impression: positive VIA, (in which 
case they will describe the lesion area), or negative. Images of the cervix will be taken and any personally 
identifiable information removed; these will also be stored in the REDCap database.
 
    Visit 2:
All participants will return for their results within three to four months. All women with a positive VIA or 
HPV test will undergo additional evaluation. In addition, 10% of women in the double negative group 
(VIA-/HPV-) will be randomly selected for evaluation. This evaluation includes: Urine pregnancy test, 
VIA, colposcopy, Lugol’s solution application, and a HRME. 3-5% acetic acid will also be applied to the 
cervix to perform the VIA. The health care provider will record their impression for each of the abnormal 
lesions (positive or negative). Then, the physician will perform the colposcopy and record their impression 
for each of the abnormal lesions (positive or negative). Proflavine and Lugol’s solution (2-5%) will be 
applied to these lesions, and once again the health care provider will record their impression for each of the 
abnormal lesions. Cervical images will be taken. Then, 0.01% proflavine will be topically applied to the 
cervix for 1 minute. Images will be obtained using the mHRME system of a visually normal site and then 
of all lesions identified by VIA, colposcopy, and/or Lugol’s solution. If no lesions are identified by VIA, 
colposcopy, and/or Lugol’s solution, mHRME images will be taken of each quadrant. Samples of abnormal 
areas identified by VIA, colposcopy, Lugol’s solution, and/or mHRME will be collected for biopsy and 
ECC purposes. If the evaluation shows no abnormalities, a random sample will be collected from the 
squamocolumnar junction and an ECC will be performed (only if the patient is HPV positive). This 
diagnostic protocol will be used to prevent the introduction of bias from knowing the screening results. It 
will also avoid potential bias from auto-correlating the visual methods (colposcopy, VIA, Lugol’s solution), 
which could falsely increase the clinical performance (22, 23). Two expert pathologists will review and 
classify the samples. All research results will be unbeknownst to them. They will use the following 
classification system: normal, CIN 1, CIN 2, CIN 3, or cancer, per standard criteria. Any discrepancies will 
be resolved through a new review, until consensus is reached. Women with CIN 2+ will undergo an excision 
or cryotherapy, according to the treatment standard. Patients diagnosed with invasive cancer will be referred 
to gynecology/oncology. The sensitivity and positive predictive value will be calculated for each patient 
with CIN 2 or a more severe diagnosis (CIN 2+), both for VIA alone, and for VIA followed by the mHRME. 
The results will be compared with those of the biopsy, which is the histopathology gold standard. The 
sensitivity and positive predictive value for the HPV DNA alone will also be calculated and compared to 
an HPV test with VIA/mHRME triage, as well as to the histopathological analysis. These results will enable 
us to compare the total number of women that could have received adequate and inadequate treatment based 
on four of the most predominant clinical scenarios: VIA alone, VIA/mHRME triage, HPV test alone, and 
HPV test integrated with VIA/mHRME triage.
 
7.0 Potential Side Effects
 
There are no known risks associated with the mHRME system used in this study. However, there is a remote 
potential for a severe allergic reaction to proflavine, the contrast dye used to obtain the images. Proflavine 
can be flammable at high temperatures. Proflavine is the active ingredient in acriflavine and has been used 
without reported side effects in fluorescent gastrointestinal imaging techniques, according to European, 
Asian, and Australian literature. It is also used as an antibacterial agent. In neonatal care, a triple dye 
consisting of a combination of proflavine hemisulfate and crystal violet is routinely used as a topical 
antibacterial agent on the newborn’s umbilical cord (28), with a recent review of this practice which 

 
 
 
 
 
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classified the agent’s toxicity as rare (29).
The proflavine concentration proposed for our study is lower than that of commercial products, 0.11% 
(Kerr Triple Dye, Vista Pharm). The solution amount required for diagnostic imaging is usually not greater 
than the amount used in neonatal care (0.65 ml per swab). Some research studies in humans using confocal 
laser scanning microscopy for gastrointestinal cancer patients currently use topical acriflavine with a 
concentration of 0.05% (30). We have conducted pilot studies using proflavine and the HRME system in 
174 women in China (19) and 59 patients in Brazil (MDACC Protocol 2011-0396). No allergic reactions 
or side effects have been reported by any of the participants.
 
 
8.0 Data Collection:
 
Study data will be collected and managed with REDCap (Research Electronics Data Capture), a data 
management tool used by MD Anderson [13]. REDCap (www.project-redcap.org) is a secure network tool 
with controlled access designed for data collection in research studies. The tool provides the following 
features: 1) a data-input interface; 2) information auditing capabilities to identify cases of mishandling of 
information; 3) automatic data conversion to statistical analysis packages; 4) import capabilities from 
external resources. When dealing with multi-center studies, REDCap uses access groups to ensure that 
personnel 
from 
one 
institution 
cannot 
access 
the 
data 
from 
other 
facilities. 
REDCap 
(https://redcap.mdanderson.org) operates within a secure server at the MD Anderson Cancer Center's 
Department of Research Information & Technology Services. REDCap’s data system has been evaluated 
by MD Anderson’s Information Security Office to ensure that it is compliant with HIPAA, Texas 202-203
Administrative Codes, The University of Texas; Regulation 165, Federal Regulations mentioned in 21CFR, 
Part 11, and UTMDACC Institutional Regulation #ADM0335. The only people with access to the study’s 
information will be the study chair and research personnel. All confidential information will be removed 
from the database once it is transferred from REDCap for processing purposes. All dates for each patient 
will be randomly replaced by a number between 0 and 364, maintaining the proper distance interval 
between each date.
 
The following is the specific data to be collected:
• Patient’s age
• Ethnicity
• Parity
• History of dysplasia
• VIA and colposcopy findings
• mHRME findings
• Final histopathological findings
• Performed treatment (LEEP, cold knife cone biopsy, cryotherapy)
9.0 Patient Confidentiality
 
All pathology specimens, evaluations forms, reports and other patient records will be identified in a
manner designed to maintain patient confidentiality. Clinical information will not be released without the
written permission of the patient or the patient’s guardian, except as necessary for monitoring by

 
 
 
 
 
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regulatory authorities, or the IRB.
 
The investigators and all employees and co-workers involved with this study shall not disclose or use for 
any purpose, other than performance of the study, any data, records or other unpublished, confidential
information disclosed to those individuals for the purpose of the study. No patient identifiers will be 
used when analyzing the data or reporting the results.
 
For this protocol we will only capture adverse events that are determined by the PI to be definitely
related to the proflavine and/or HRME imaging. Adverse events and serious adverse events related to 
the standard of care colposcopy and cervical biopsies will not be captured as part of the protocol data.
Potential Benefits:
There will be no direct benefits for the participants of this study. Their entire screening, treatment, and 
follow-up process will be the same as if the patient did not participate in this study. The main benefit will 
be contributing to the research of a prevention mechanism of cervical cancer in other women.
 
 
Treatment Alternatives:
Patients will be given the option to receive appropriate treatment if their results come back positive. 
Women with CIN 2+ will undergo an excision or cryotherapy, according to the treatment standard. 
Patients diagnosed with invasive cancer will be referred to gynecology/oncology. Participation in this 
study will not impact the type of treatment given to a patient.
 
 
Study Payments:
Participants will receive no payment for taking part in this study.
 
Costs:
Participation in this study will not result in any additional costs to the participant, other than the amount 
that is normally billed by ICES for the medical care services rendered.
Compensation for Study-related Injuries:
Patients will not receive any compensation in case of injury and there is a minimal risk when participating 
in this study.
 
Voluntary Participation and Withdrawal:
Participation in this study is strictly voluntary. Each patient will decide whether or not to participate in 
this study. A decision not to enroll will not affect their medical care. Participants will be able to withdraw 
their consent at any time during their participation in the study, and their decision will not affect their 
care.
 
Questions/Contact:
Should there be any questions regarding this study, please contact:
Dr. Mauricio Maza, Colonia Las Mercedes Ave. Los Espliegos #5, San Salvador.
Phone: (503) 7854 8873
Conflict of Interest Disclosure:
The study’s Co-chair, Dr. Miriam Cremer, is a founder of Basic Health International, INC. (BHI), a non-
profit organization. BHI is a collaborator in this study. BHI and Dr. Cremer could benefit from positive 
advertising if this research is performed correctly. Neither Dr. Cremer nor Basic Health International have 
financial interests in the mobile high-resolution microendoscopy system. These financial interests are 

 
 
 
 
 
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being monitored and are within the permissible limits established by the local institution and the Conflict 
of Interest Policies. Should there be any questions regarding the Conflict of Interest Policy, ask your 
doctor or call the Cleveland Clinic at (216) 444-2924.
 
 
10.0 References
 
1.
G. N. Papanicolaou, H. F. Traut, The diagnostic value of vaginal smears in carcinoma of the uterus. 1941. 
Arch Pathol Lab Med 121, 211 (Mar, 1997). 
2.
A. Jemal et al., Global cancer statistics. CA Cancer J Clin 61, 69 (Mar-Apr, 2011). 
3.
J. M. Walboomers et al., Human papillomavirus is a necessary cause of invasive cervical cancer worldwide. 
J Pathol 189, 12 (Sep, 1999). 
4.
Quadrivalent vaccine against human papillomavirus to prevent high-grade cervical lesions. N Engl J Med 
356, 1915 (May 10, 2007). 
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