STUDY OF EARLY DETECTION OF CERVICAL CANCER BY PAP S SMEAR IN SELECTED SETTING OF PUDUCHERRY

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1 STUDY OF EARLY DETECTION OF CERVICAL CANCER BY PAP S SMEAR IN SELECTED SETTING OF PUDUCHERRY *Thirumurugan. P, **Premila. E, ***Suresh Kanna. K *Associate Professor, Mother Theresa Post Graduate and Research Institute of Health Sciences, Puducherry, India **Associate Professor, Mother Theresa Post Graduate and Research Institute of Health Sciences, Puducherry, India ***Associate Professor, Bharathiyar College of Engineering & Technology, Karaikal, India ABSTRACT *Corresponding Author Cervical cancer has emerged as a major global public health problem In India and other developing countries cervical cancer is the leading cause of morbidity and mortality. Cancer of cervix is readily preventable, and can be diagnosed at the pre-invasive stage with adequate and repetitive cytological screening with Papanicolaou (Pap) smears. This is a cross sectional study aimed to detect the cervical cancer by PAP s Smear in selected setting of Puducherry. A total of 60 subjects were recruited. A socio demographic profile and Pap smear cytology reports were obtained and data noted in a structured proforma. All the smears were reported as per the 2001 Bethesda system. A total of 60 Pap smears were examined. Maximum number of patients was in the age group of less than 35 years. A total of 56 (93.33%) smears were reported as Negative for Intraepithelial. Lesion or Malignancy, only a few 4 (6.67%) cases reported to have epithelial cell abnormality. The 4 abnormal cases comprised of 2 low grade squamous intraepithelial lesion and 2 high grade squamous intraepithelial lesion. Pap smears play a substantial role in not only detection but also prevention of cervical cancer. Screening programmes can be organised by community health workers for the women in reproductive age for early detection of cervical cancer and reduce morbidity and mortality rate. Keywords: Pap s smear, cervical cancer, cervical cytology Page 156

2 Introduction Cervical cancer has emerged as a major global public health problem and the commonest malignancy found amongst Indian women. Among women, it ranked as the third commonest cancer in developed countries and as the second in developing countries. (Ferlay J et al, 2008) Over 5, 00,000 new cases of invasive cervical cancer are diagnosed annually worldwide (WHO, 2006) It is the most common cancer among women after breast and colorectal cancer in the world, but in India and other developing countries cervical cancer is the leading cause of mortality and morbidity. Women in these countries usually present to the clinic only when they have symptoms, such as pain, discharge, and/or abnormal bleeding. (Patel M et al, 2011) Cervical cancer is a female genital cancer that results from infection with the Human Papilloma Virus (HPV) commonly serotypes 16 and 18. (Bosch, F.X. and Munoz, N, 2002) HPV infection is a sexually transmitted infection spread by skin to skin contact during intercourse. Known risk factors include early age at first intercourse and multiple sexual partners. Fortunately, infection is usually transient and of no clinical consequence, but a minority of patients retain the oncogenic viruses within their genital epithelium which can lead to the development of cervical intraepithelial neoplasia and possible cancer. (Bosch et al, 2006) Papanicolaou cytological testing (Pap smear) permits cervical lesions to be detected before they become cancerous, effectively reducing the incidence of cervical cancer by 75% - 90%. US Department of Health and Human Services (1995) Cancer of cervix is readily preventable, by early detection and appropriate timely treatment of its precursor lesions by simple Pap screening test. Though Pap smear is a routine screening test, the overall sensitivity in detection of high grade squamous intraepithelial lesion (HSIL) is 70-80%. (Maryem A et al, 2011) The role of HPV in development of cervical cancer is proved beyond doubt. If Pap screening is associated with HPV-DNA testing than we can increase the sensitivity. (Patel M et al, 2011) Intensive screening programmes in various countries show a striking reduction in mortality from cancer of cervix. (Ferlay J et al, 2008) In general, in countries where Pap smear screening is routine, it is recommended that females who have had sex should seek regular Pap smear testing. Guidelines on frequency vary from every three to five years. If results are abnormal, and depending on the nature of the abnormality, the test may need to be repeated in six to twelve months. (Saslow et al, 2012) Generally developing countries have lower Pap smear coverage (19%) as compared to developed countries (63%) (Gakidou et al, 2008) The delivery of cervical cancer screening in the country is usually conducted in an opportunistic manner, whereby screening depends on the initiative of the woman and or health care provider. There is currently no mass screening program for the detection of cervical cancer in India. Services are mostly available in Teaching Hospitals and are not adequately utilized. Though many studies have been done on cervical cancer; these studies were carried out among women attending the antenatal/gynaecology clinics. There is thus paucity of work on cervical cancer screening among general women population. Therefore, the aim of this study was to assess the prevalence of cervical cancer among women by using Pap smear for early detection and prevention of cervical cancer in selected setting of Puducherry. Materials and Methods: This was a cross-sectional study carried out in the Mother Theresa Post Graduate and Research Institute of Health Sciences, Puducherry, India during Community camp which was organised by SOMI, Puducherry chapter. A total of 60 women were recruited from the Self-help groups in Thattanchavady, Puducherry by convenient sampling method. Pregnant women, women with active bleeding per vaginum, frank growth on cervix, post-hysterectomy patients, and women who had never been sexually active or had undergone prior treatment for cervical intraepithelial neoplasia (CIN) or cancer cervix were excluded from the study. Ethical approval of the study protocol was obtained from the Ethics Committee of Mother Theresa Post Graduate and Research Institute of Health Sciences, Puducherry. After taking an informed consent from all women included, socio-demographic characteristics like age, educational status, monthly family income, Page 157

3 previous history of pap smear test, age of coitus, number of children and current use of contraceptives were collected using semi structured interview schedule. Pap smears were taken of all participants by health team for cervical screening. Health team comprised of two doctors, 3 nurses and 2 lab technicians. The smears were obtained with the help of Ayer s spatula and cytobrush to collect specimen from the squamocolumnar junction. The cellular material obtained on the spatula and cytobrush was quickly smeared on a clean glass slide. Two smears were prepared for each case. The glass slides were then fixed immediately by immersing them into the coplin jar containing 95% ethyl alcohol. The smears were stained with Papanicolaou stain. After mounting the slides with DPX (Distrene dibutyl pthalate xylene), slides were examined under light microscope and were reported by two pathologists independently according to the 2001 Bethesda system. Results: As shown in the table no.1, majority of the subjects (63.33%) were less than 35 years. Most of the participants (41.67%) had higher secondary education followed by 36.67% had high school level of education. Majority of the subjects (51.67%) had family income of Rs Majority of participants (93.33%) reported never had Pap test and the remaining only 6.67% of them had Pap test previously. Most of the subjects (70%) had coitus between years followed by 20% of them had coitus before 20 years. Majority of the subjects had 2 number of children and only 86.67% of the subjects not using any type of contraceptives currently. Table No. 1. Description of socio-demographic variables of the study subjects Socio demographic Variables Frequency (f) Percentage (%) Age 35 years > 35 years Educational status Primary High school Higher secondary Graduate Monthly Family Income < or more Previous history of Pap smear test Yes No Age of coitus Before 20 years years More than 30 years Number of Children No children 2 < 2 Use of contraceptives currently Yes No % 52% 63.33% 36.67% 13.33% 36.67% 41.67% 8.33% 20.00% 51.67% 28.33% 6.67% 93.33% 20.00% 70.00% 10.00% 5% 70.00% 25% 13.33% 86.67% Page 158

4 Table No. 2 Distribution of subjects according to pap smear interpretation Cytological Findings Frequency (%) Percentage (%) Normal smears % Abnormal Smears % Table No.2 shows the cytological findings broadly classified into normal and abnormal smears. There were only 6.67% of the pap smears (benign cellular changes of inflammation as well as Epithelial Cell Abnormalities), with 56 (93.3%) normal cases. Out of those 4 abnormal smears, 2 were low grade squamous intraepithelial lesion and 2 were high grade squamous intraepithelial lesion. Discussion: In the current study, women from all the age groups were included which is supported a large study done by Luthra et al, 1987 revealed mean ages for mild, moderate and severe dysplasia to be 33.8, 35.2 and 40.2 years. Therefore, screening for cervical carcinoma should start ideally at the onset of sexual activity and all women should be screened at least once by the age of yr. (Sankaranarayanan R, et al, 2004) The occurrence of abnormal smears was 6.67 per cent in our study. This was correlated well with the other previous Indian studies. (Luthra et al, 1987 & Goel A et al. 2005) Conclusion: It has been recognized worldwide, through studies and clinical practices that for early detection of precancerous lesions of cervical cancer the best technique is cytological examination of cervical by Pap smear. This is because an abnormal cervical cytology report show the existence of a precancerous lesion which if left untreated mostly progresses to cancer. Cervical cancer is a potentially preventable cancer. It is preceded by premalignant lesions which may take 5-15 years to progress to invasive cancer. If detected and treated timely, pre-invasive disease has nearly 100 per cent cure rate with simple surgical procedure, while advanced cancers have less than 35 percent survival rates. (Dinshaw KA et al, 2001) It has been estimated that in India, even with a major effort to expand services, it will not be possible to screen even one-fourth of the population once in a lifetime5. Moreover, screening programmes in India are mostly institution based and are restricted to urban centres. Misra JS et al, 2004) As Pap smears play a substantial role in not only detection but also prevention of cervical cancer. Especially if performed yearly for women after the age of 34 years. It is therefore recommended that as part of an organized screening after 34 years of age a yearly Pap smear should be made mandatory as part of the primary health care system. The yearly Pap smear should be performed irrespective of whether any of the before mentioned symptoms exist or not. In case of abnormal but non-cancerous cytology a follow-up Pap smear after six months should be performed. We propose that larger studies are required to estimate the pattern of cervical cytological abnormalities along with detection of common HPV strains in cervical cancer in Indian population, as this knowledge would be useful for prevention of HPV infection either by vaccines or future targeted therapy. Acknowledgement: We owe a great deal of gratitude to the Director, Department of Health and Family Welfare Services, Puducherry and Director, National Rural Health Mission, Puducherry for giving us permission to conduct the study. We extend our gratitude to all the participants of the study for their enthusiasm and cooperation. We are grateful to those who have supported and motivated for the study and publication. Page 159

5 References: 1. Bosch, F.X., Munoz, N., The Viral Etiology of Cervical Cancer. Virus Research, 89. Pp Available from Bosch, F.X., Qiao, Y.L., Castellsague, X., The Epidemiology of Human Papillomavirus Infection and Its Association with Cervical Cancer. International Journal of Gynaecology and Obstetrics, 5. Pp Available from 3. Dinshaw KA., Shastri SS, Screening for cervical cancer in India. Natl Med J India. 14. Pp Ferlay J., Shin HR., Bray F., Forman D., Mathers C., Parkin DM., 2010, Dec. Estimates of worldwide burden of cancer in GLOBOCAN International Journal of Cancer; 127 (12), pp Gakidou E., Nordhagen S., Obermeyer Z, Coverage Of Cervical Cancer Screening In 57 Countries: Low Average Levels And Large Inequalities. Plos Medicine. 5. Pp Goel A., Gandhi G., Batra S., Bhambhani S., Zutshi V., Sachdeva P Visual inspection of the cervix with acetic acid for cervical intraepithelial lesions. Int J Gynaecol Obstet. 88. Pp Luthra UK., Prabhakar AK., Seth P., Agarwal SS., Murthy N.S, Bhatnagar P., et al Natural history of precancerous and early cancerous lesions of the uterine cervix. Acta Cytol. 31. Pp Maryem A., Ghazala M., Arif, H.A., Tamkin K., Smear Pattern and Spectrum of Premalignant and Malignant Cervical Epithelial Lesions in Postmenopausal Indian Women: A Hospital Based Study. Diagnostic Cytopathology. 40(11). Pp , 9. Misra JS., Gupta HP., Das V, Assessing the feasibility of single lifetime PAP smear evaluation between years of age as strategy for cervical cancer control in developing countries from our 32 years of experience of hospital-based routine cytological screening. Diagn Cytopathol. 31. Pp Patel M.M., Pandya A.N., Modi J., Cervical pap smear study and its utility in cancer screening, to specify the strategy for cervical cancer control. National Journal of Community Medicine, 2 (1). 11. Saslow et al American Cancer Society, American Society for Colposcopy and Cervical Pathology, and American Society for Clinical Pathology Screening Guidelines for the Prevention and Early Detection of Cervical Cancer. Journal of Lower Genital Tract Disease. 16(3). Pp Sankaranarayanan R., Chatterji R., Shastri SS., Wesley R.S, Basu. P, Mahe C., et al Accuracy of human papillomavirus testing in primary screening of cervical neoplasia: Results from a multicentre study in India. Int J Cancer Pp US Department of Health and Human Services, The National Breast and Cervical Cancer Early Detection Program. Centers for Disease Control and Prevention, Atlanta. 14. World Health Organization, Comprehensive cervical cancer control: A guide to essential practice. Geneva: WHO; p Page 160