Cervical leukoplakia in Ghana: Unveiling diagnostic challenges and informing low-resource screening strategies

Background Visual Inspection with Acetic acid (VIA) is widely used for detecting cervical (pre)cancer in resource-limited settings due to its simplicity and cost-effectiveness. However, the finding of cervical leukoplakia, poses diagnostic challenges. Methods This retrospective observational study evaluated the prevalence, associated risk factors, and referral outcomes of cervical leukoplakia among 13,861 women previously screened for cervical cancer in Ghana between June 2016 and May 2024. Screening approaches included VIA alone, mobile colposcopy alone, or VIA/mobile colposcopy combined with other tests (HPV DNA testing and/or cytology). Results Among 120 women (0.9%) with leukoplakia, 112 (93.3%) did not have acetowhitening on VIA/mobile colposcopy, and 21 (17.5%) received LEEP. The histopathology results ranged from no Cervical Intraepithelial Neoplasia (CIN) (15) to CIN I (2), CIN II (1), and CIN III (3). High-risk HPV positivity (aOR: 30.27; 95% CI: 3.56–257.37) and HIV infection (aOR: 8.27; 95% CI: 1.18–57.69) were associated with higher odds of leukoplakia in VIA-screened women. Conclusion Leukoplakia can be clinically important without coexistence with acetowhitening. The association of leukoplakia with hrHPV and HIV, coupled with a high referral default and logistical barriers to biopsy and histopathology, calls for simplified management protocols and point-of-care triage tools for cervical screening in low-resource settings.