Comparison Between Pap Smear and Via As Screening For Cervical Lesions. Received ; Revised ; Accepted

Transcription

1 Research Article Indian J. Pharm. Biol. Res Vol. 1 (3), Sep., 2013 ISSN: Comparison Between Pap Smear and Via As Screening For Cervical Lesions Harshini V 1, Amritha Bhandary 2, Suchithra Thunga 3 * 1 Senior Resident, Employment State Insurance Corporation Medical College Post graduate Institute and Research, Bangalore, India. 2 Professor,A.J Institute of Medical Sciences,Mangalore, India. 3 Professor,Kasturba Medical College,Mangalore, India. Received ; Revised ; Accepted Abstract Introduction: An important reason for higher cervical cancer incidence in developing countries is lack of effective screening programs like pap smear, aimed at detecting precancerous conditions before they progress to invasive cancer. The potential difficulties in implementing cervical cytology based screening in low-resource settings have prompted the investigation of accuracy of alternative low technology tests such as Visual inspection with acetic acid application [VIA], Visual inspection with acetic acid application with magnification [VIAM], visual inspection on Lugol s Iodine application [VILI] in early detection of cervical neoplasia.in our study we compared pap smear with VIA to study the accurarcy of VIA as it is simpler and easier technique to be used as screening in low resource settings. Aim: This is a hospital based descriptive, prospective study to evaluate validity of pap smear and VIA techniques as screening tests in identifying cervical lesions. Materials And Methods: After general and systemic examination as a routine,visual local pelvic examination including visualisation of cervix and vagina per speculum and the findings are documented in the proforma.then VIA and pap smear are done in that order, if any of these tests are positive then cervical biopsy will be taken and further advise to the subject is given. Results: A total of 313 women were involved in the study. The sensitivity of pap smear is 54.5% specificity is 98.9% while that of VIA 95.4% and 97.9%respectively. We found that VIA accuracy was comparatively more than that of pap smear. Conclusion: In low resource settings, usefulness of VIA is more than that of pap smear. We suggest to perform VIA in all the women inspite of having pap smear facility to improve detection rate of cervical lesions and provide better patient councelling and treatment. Keywords: Pap smear, Cervix cancer, Visual inspection on acetic acid application [VIA]... 1.Introduction According to National Cancer Registry Program of India, cancers of the uterine cervix and of the breast are the leading malignancies seen in Indian women[1]. In view of the well-defined natural history and long detectable preclinical phase, the cancer of uterine cervix gets priority in terms of control program through mass screening[2]. An important reason for higher cervical cancer incidence in developing countries is lack of effective screening programs aimed at detecting precancerous conditions before they progress to invasive cancer. The pap smear technique introduced by Dr.George N.Papanicolaou,is the basis for current resurgence of diagnostic cytology.pap test has been successful in decreasing the incidence of cervical cancer by 79% and the mortality by 70% since The Pap test is a cytological test designed to detect abnormal cervical cells from cervical transformation zone. Collection of Pap smear is relatively *Corresponding Author: Dr.V.Harshini, Senior Resident,Employment State Insurance Corporation Medical College Post graduate Institute and Research, Bangalore,India Id: vharshini84@gmail.com; Mobile No

2 easy and painless and can be done by trained paramedical workers. It can detect most of the cancers in the in-situ stage or precursor stage. A strong relation is observed between initiating of screening and reduction in mortality from cancer of cervix from different approaches[3,4].in addition to other resource constraints, deficiencies in record keeping in cytology laboratories and cancer registries make the administrative monitoring and evaluation activities difficult, if not impossible. There is a need to look at alternate practicable options for developing countries.the potential difficulties in implementing cervical cytology based screening in lowresource settings have prompted the investigation of accuracy of alternative low technology tests such as VIA,VIAM,VILI in early detection of cervical neoplasia. Visual inspection with acetic acid application (VIA) involves swabbing the cervix with 3-5% acetic acid solution prior to visual examination. VIA is a simple and inexpensive test, which can be provided by trained paramedical personnel (such as midwives, nurses and other health workers) with a short training. Its accuracy at detecting cervical neoplasia has been extensively studied and found to be satisfactory [5,6,7]. Many aspects of VIA make it an attractive approach for use in lowresource settings. It is a low-tech approach with minimum reliance upon infrastructure for performance. Results of the procedure are available immediately for initiating treatment at the same visit. Application of 5% Acetic acid is thought to cause swelling of the epithelial tissue,columnar and any abnormal squamous epithelial area in particular. It causes a reversible coagulation or precipitation of the nuclear proteins and cytokeratins.thus, the effect of acetic acid depends upon the amount of nuclear proteins and cytokeratins present in the epithelium. When acetic acid is applied to normal squamous epithelium, little coagulation occurs in the superficial cell layer, as this is sparsely nucleated. Though the deeper cells contain more nuclear protein, the acetic acid may not penetrate sufficiently and, hence, the resulting precipitation is not sufficient to obliterate the colour of the underlying stroma. Areas of CIN undergo maximal coagulation due to their higher content of nuclear protein and prevent light from passing through the epithelium. As a result, the subepithelial vessel pattern is obliterated and less easy to see and the epithelium appears white. This reaction is termed acetowhitening, and produces a noticeable effect compared with the normal pinkish colour of the surrounding normal squamous epithelium of the cervix, an effect that is commonly visible to the naked eye. With low-grade CIN, the acetic acid must penetrate into the lower one-third of the epithelium (where most of the abnormal cells with high nuclear density are located). Hence, the appearance of the whiteness is delayed and less intense due to the smaller amount of nuclear protein compared to areas with high-grade CIN or preclinical invasive cancer. Areas of high-grade CIN and invasive cancer turn densely white and opaque immediately after application of acetic acid, due to their higher concentration of abnormal nuclear protein and the presence of large numbers of dysplastic cells in the superficial layers of the epithelium. 2.Aims & Objective Available online on 56

3 I. Aim This is a hospital based descriptive, prospective study to evaluate validity of pap smear and VIA techniques as screening tests in identifying cervical lesions. II. Objective To evaluate various cervical lesions in our hospital based study. i. Inclusion Criteria Woman suffering with any symptoms as mentioned in proforma. Woman with previous history of STDs,prior abnormal pap smears or early marriage (<14 yr age). Woman who had already been treated for cervical cancer with no obvious lesions. ii. Exclusion Criteria Pregnant woman, woman during post natal period {upto 3 months}, Previous normal pap smear in last 2 yrs. Woman with evident growth in the cervix during examination. 3.Materials and Methods In this descriptive study women visiting, satisfying the inclusion criteria are first interviewed as per the question format mentioned in the proforma, then the informed consent is taken in the local/english language. After general and systemic examination as a routine, visual local pelvic examination including visualisation of cervix and vagina per speculum and the findings are documented in the proforma. Then VIA and pap smear are done in that order, if any of these tests are positive then cervical biopsy will be taken at the suspected area for the diagnostic purpose and further advise to the subject is given accordingly. The woman is invited to lie down in a modified lithotomy position on a couch with leg rests or knee crutches or stirrups. After proper positioning of the woman, observe if there is any vaginal discharge. Observe the external genitalia and perineal region for any signs of excoriations, oedema, vesicles, papules, sores, ulceration and warts.afterwards, gently introduce a sterile vaginal speculum which has been immersed in warm water and open the blades of the speculum to view the cervix. Adjust the light source so that there is adequate light in the vagina and on the cervix. As the speculum is gently opened and the lips are fixed, the cervix comes into view. Observe the size and shape of the cervix. Identify the external os, columnar epithelium (red in colour), squamous epithelium (pink) and the squamocolumnar junction. Proceed to identify the transformation zone, the upper limit of which is formed by the squamocolumnar junction.look for ectropion, cervical polyp, nabothian cysts, healed laceration of the cervical lips, leukoplakia, condylomata and signs of cervicitis. i. Method of Via Gently, but firmly, apply 5% acetic acid using a cotton swab soaked in acetic acid. The secretions should be gently wiped off. After removing the swab, carefully look at the cervix to see whether any white lesions appear, particularly in the transformation zone close to the squamocolumnar junction, or dense, non-removable acetowhite areas in the columnar epithelium. The results one minute after application of acetic acid should be reported. Note how rapidly the acetowhite lesion appears and then disappears. ii. Method of Pap Smear After placing speculum in the vagina, cervix is exposed. Ayers spatula is applied to the cervix and rotated in Available online on 57

4 30degree to abrade the surface slightly and to pick up cells from SCJ area of cervix os. An endo cervical swab is used to pick up cells from the endo cervix.these 2 specimens are smeared on glass slide and placed in preservative - Methanol to prevent air drying and sent to dept of pathology for reporting. iii. Method of Cervical Biopsy: Using cervical biopsy forceps multiple samples are collected from areas of cervix where dysphasia or neoplasia are suspected or VIA positive areas and specimen is placed in preservative formaldehyde and sent to department of pathology, for reporting. iv. Reporting PAP SMEAR: Bethesda 2001 system is followed {annexure} v. Via: Is considered positive if Distinct well defined,dense areas with regular or irregular margins close to or abutting transformation zone or close to external os if squamocolumnar junction is not visible. Acetowhite areas in columnar epithelium. Condyloma and leukoplakia close to SCJ. 4.Results A total of 313 women were involved in the study. The age groups of the women participated in the study, are depicted in the Table 1,wherein a maximum of 129 [41.21%] are between years of age.233 [74.44%] women belonged from low socio economic status while 80 [25.5%] were of upper middle class.in our study [Table 2a,2b], the sensitivity of pap smear is 54.5% specificity is 98.9% while that of VIA 95.4% and 97.9%respectively.positive predictive value of pap smear and VIA are 80% and 77.7%,also negative predictive values are 96.6% and 99.6% respectively. We found that VIA accuracy[97.7%] was comparatively more than that of pap smear[95.8%].the advantage of VIA is that it is less time taking, does not require transportation of sample or pathologist to report as the reporting of pap smears improve with experience of pathologists. In low resource settings, VIA seems to be effective mode of screening technique. Table 1: Shows Age Distrbution Age Number Percentage > Total 313 Table 2a: Shows Comparison of pap smear and VIA Pap smear VIA True positive True negative False positive 3 6 False negative 10 1 Total Table 2b: Shows Comparison of pap smear and VIA PAP VIA SMEAR Sensitivity Specificity Positive predictive value Negative predictive value Accuracy Discussion In a developing country like India, the awareness about screening techniques are yet to reach significant enough to Available online on 58

5 reduce the incidence of preventing carcinomas like cervical carcinomas. Hence when there is an opportunity to examine or screen a woman, choosing appropriate technique of screening is very important because By the time most patients appear to the hospitals the cancer has already in advanced stages. VIA has proven to have potential value compared to pap smear as an effective screening method in less developed countries in several studies. According to our results, we can effectively screen women through VIA. The VIA has better negative predictive value than that of the Pap smear and specificity is comparable to that of cytology or Pap smear. Due to high negative predictive value, when the test result is negative, the woman can be reassured that she is not likely to have a neoplastic cervical lesion. The accuracy of VIA is also higher than that of pap smear. VIA is proposed as a credible alternative to Pap smear in resource-challenged settings in a study by Akinola et al, compared the efficacy of visual inspection of the cervix using acetic acid (VIA) with the Pap smear method.the sensitivity of VIA was 100%, while that of Pap smear was 85.7%. The negative predictive value of VIA was 100%, while the positive predictive value was 20%. The sensitivity of VIA equals the reported rates for Pap smear [8]. The study by Basu et al, evaluated the performance of VIA, magnified visual inspection after application of acetic acid (VIAM), and cytology in the detection of high-grade cervical cancer precursor lesions in Kolkata (Calcutta) and suburbs in eastern India, concurrently screened 5881 women aged years with VIA, VIAM, and conventional cervical cytology. The sensitivities of VIA and VIAM to detect CIN 2-3 lesions were 55.7% and 60.7%, respectively; the specificities were 82.1% and 83.2%, respectively. The sensitivity and specificity of cytology were 29.5% and 92.3%, respectively. All the tests were associated with negative predictive values above 98%. VIA and VIAM had significantly higher sensitivity than cytology in our study; the specificity of cytology was higher than that of VIA and VIAM[9]. In our study, 2 cases reported by pap smear as inflammatory smear were VIA positive and on cervical biopsy were proven to be CIN I and CIN II. 6.Conclusion: The specificity, sensitivity and accuracy of VIA is more than that of pap smear. In low resource settings, usefulness of VIA is more than that of pap smear and the bias between pathologist and examiner/gynaecologist can be reduced by VIA. We suggest to perform VIA in all the women inspite of having pap smear facility to improve detection rate of cervical lesions and provide better patient councelling and treatment. Conflict of interest statement: We declare that we have no conflict of interest. Acknowledgements We thank foremost all the patients who had participated in the study, Kasturba Medical College and Lady Goschen Hospital for all their support throughout. We specially thank department of pathology, Nursing staff and every person who had extended their support for this study. References 1. National Cancer Registry Program. Annual Report. ICMR: New Delhi; Available online on 59

6 2. Koss LG, Greenebaum. Precancerous lesions. In : Bourke GF, editor. The epidemiology of cancer. Charles Press: Philadelphia; p Eddy DM. Screening for cervical cancer. Ann Intern Med 1990;113: Celentano DD, delissovoy G. Assessment of cervical cancer screening and followup programs. Public Health Rev 1989;17: Bhargava VL, Verma K, Sharma R, Batra S, Anandalakshmy PN. A hospital-based study on the use of paramedical personnel for clinical downstaging of cancer cervix. Indian J Med Res 1993;98: Gaffikin L, Ahmed S, Chen YQ, McGrath JM, Blumenthal PD. Risk factors as the basis for triage in low-resource cervical cancer screening programs. Int J Gynaecol Obstet 2003;80: Belinson JL, Pretorius RG, Zhang WH, Wu LY, Qiao YL, Elson P. Cervical cancer screening by simple visual inspection after acetic acid. Obstet Gynecol 2001;98: Akinola OI, Fabamwo AO, Oshodi YA, Banjo AA, Odusanya O, Gbadegesin A, Tayo A. J Obstet Gynaecol. 2007;27(7): Basu PS, Sankaranarayanan R, Mandal R, Roy C, Das P, Choudhury D, Bhattacharya D, Chatterjee R, Dutta K, Barik S, Tsu V, Chakrabarti RN, Siddiqi M; Calcutta Cervical Cancer Early Detection Group. Int J Gynecol Cancer ;13(5): Cite this article as: Harshini V, Amritha Bhandary, Suchithra Thunga. Comparison Between Pap Smear and Via As Screening For Cervical Lesions. Indian J. Pharm. Biol. Res. 2013; 1(3): All 2013 are reserved by Indian Journal of Pharmaceutical and Biological Research. Available online on 60