Prevalence of cervical cancer and role of screening programmes by PAP smears

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1 Original Article Prevalence of cervical cancer and role of screening programmes by PAP smears Shashidhar M R 1*, Shikha Jayasheelan 2 1 Assistant Professor, 2 PG. Student, Department of Pathology, Yenepoya medical college, Mangalore, Karnataka, INDIA. shash.mr@gmail.com Abstract Background: Among the Indian women cervical cancer is the most common genital tract cancer. It is estimated that in India 126,000 new cases of cervical cancer occur annually. Pap test not only plays a crucial role in detection of cervical cancer and its precursor lesions, but also aids in the diagnosis of infective and inflammatory conditions including the identification of causative organism, hormone related benign epithelial changes and changes due to therapeutic agents. Objective: to study the role of Pap smear in detecting premalignant and malignant lesions as well as non-neoplastic lesions of cervix and to determine the prevalence of various lesions Results: Out of 308 cases majority of the cases were benign comprising Negative for intraepithelial neoplasia (NILM) of about 294 (95%) cases followed by ASCUS 5 (1.62%) cases and 2 (0.64%) cases each of squamous cell carcinoma and LSIL Conclusions: Pap smear testing is a very useful, simple, economical and safe tool to detect preinvasive cervical epithelial lesions. Hence on a routine basis, every woman above the age of 30 must be subjected to cervical screening and this must be continued even in post-menopausal period. Key Words: PAP, cervical cancer, screening, Bethesda. * Address for Correspondence: Dr. Shashidhar M R, Assistant Professor, Department of Pathology, Yenepoya medical college, Mangalore, Karnataka, INDIA. shash.mr@gmail.com Received Date: 13/12/2016 Revised Date: 24/01/2017 Accepted Date: 15/02/2017 Quick Response Code: Access this article online Website: DOI: 17 February 2017 INTRODUCTION Cervical cancer is very common in developing countries. India accounts for 1/5th of the burden of cervical cancer. 1 According to WHO 80% deaths from cervical cancer were from developing countries. effective screening programmes in developed countries has reduced the incidence of cervical cancer 2 Among the Indian women cervical cancer is the most common genital tract cancer. It is estimated that in India 126,000 new cases of cervical cancer occur annually. 3 Unlike most other malignancies, cancer of cervix is readily preventable as it is easy to detect and treat its precursor lesions. 4 Cervical cancers in their early stage of development, are treatable as the cancer cells are confined to the surface of the cervix and have not spread into the deeper tissues. Once the tumor cells metastasize to other parts of the body the disease becomes more difficult to treat. 5 Screening programmes have claimed to reduce the incidence and mortality due to cervical cancer significantly, for which sensitization of women is required through community based approach. 6 The Papanicolaou (Pap) smear was introduced in 1941 and became the standard screening test for cervical cancer and premalignant lesions 7. A drastic reduction has been observed in the incidence and mortality due to invasive cervical cancer worldwide. 8 This is because the Pap test detects cervical epithelial cell abnormalities which represent a spectrum of intraeptithelial lesions, from mild-to-severe dysplasia to invasive cancer and facilitates early diagnosis. 9 Pap test not only plays a crucial role in detection of cervical cancer and its precursor lesions, but also aids in the diagnosis of infective and inflammatory conditions including the identification of causative organism, hormone related benign epithelial changes and changes due to therapeutic agents. 10 Greater awareness among clinicians regarding this test is required to carry out screening for cancer of cervix among women in both 11 rural and urban areas in India The simplicity, effectiveness and versatility of Pap test have made it an How to site this article: Shashidhar M R, Shikha Jayasheelan. Prevalence of cervical cancer and role of screening programmes by PAP smears. MedPulse International Journal of Pathology. February 2017; 1(2): (accessed 21 February 2017).

2 MedPulse International Journal of Pathology, Print ISSN: , Volume 1, Issue 2, February 2017 pp integral part of routine clinical examination and large chunk of workload in gynecological and pathological practice is due to this test 12 Pap smear test is very simple and cost effective test for cervical cancer screening. Pap smear screening has sensitivity of 50-75% and specificity of 98-99%. 2 A PAP test is performed by using a brush or spatula to gently scrape the cellular material from the squamocolumnar junction in the cervix and this is smeared onto a glass slide of about mm. The cells are fixed in methanol, stained and visually examined under a microscope. The test was first suggested by Papanicolaou in 1928 but it took almost 15 years before itwas generally accepted by the medical community 13,14. A monograph in gave a detailed account of how the screening should be conducted and this procedure has since been widely adapted, leading to the remarkable reduction in cervical cancer incidence. MATERIALS AND METHODS In present study results of PAP smears obtained from 308 women were analyzed, which had been examined in cytology section (Department of Pathology, Yenepoya medical college, Mangalore). The age of the women ranged from years. Detailed history including menstrual history, sexual history, obstetric history, marital history and educational history was taken. It was ensured that no local douche, antiseptic cream and no local internal examination was done on day of test. The patient was placed in dorsal lithotomy position and a Cusco s bivalve speculum was introduced through vagina and cervix was visualized. The longer projection of the Ayre s spatula was placed in the cervix near squamocolumnar junction and rotated through 360 degree. For each subject,an average of two smears were collected. The cellular material thus obtained was quickly, but gently smeared on a clean glass slide. The glass slide was then immediately put into the coplin jar containing 100% methanol (fixative) which was then stained by Pap method (RAPID-PAP kit). The cytological interpretation of smears was made according to the New Bethesda System for reporting cervical cytology According to 2014 Bethesda system, lesions are broadly divided into negative for intraepithelial neoplasia and epithelial cell abnormalities includes squamous and glandular cells. The squamous epithelial cell abnormality has been categorized into: 1. atypical squamous cells (ASC) includes a. ASC of undetermined significance (ASC- US) and b. ASC, cannot exclude high grade squamous intraepithelial lesions (ASC-H) and 2. squamous intraepithelial lesion (SIL a. lowgrade squamous intraepithelial lesion (LSIL) and b. high-grade squamous intraepithelial lesion (HSIL). Similarly, glandular cell abnormalities were categorized into atypical endocervical cells not otherwise specified, atypical endometrial cell not otherwise specified and atypical glandular cell not otherwise specified. Frank invasive malignancy was termed as squamous cell carcinoma Those with LSIL and HSIL were counselled and were advised to undergo colposcopic examination and biopsy for histopathological examination. RESULTS A total of 308 cases were analyzed during the above mentioned period. The age of the women ranged from 19 to 78 years with an average age of 48.5 years. Most of the women were in age group of years (Table1). Irregular bleeding per vagina, leucorrhea, backache, abdominal pain, burning micturition and vulval pruritus were the common presenting symptoms. Out of 308 cases majority of the cases were benign comprising Negative for intraepithelial neoplasia (NILM) of about 294(95%) cases followed by ASCUS 5(1.62%) cases and 2 (0.64%) cases each of squamous cell carcinoma and LSIL. Table 2 shows 7 (2.27%) cases which were unsatisfactory for evaluation. The main causes for inadequacy were inadequate squamous component or obscuring inflammation. Majority of the epithelial abnormalities were seen in the age group between years (table 3) Table 1: Age-wise distribution of total number of patients Age Number of cases Percentage Total Table 2: Cervicovaginal cytology interpretation/results by the Bethesda System (2014) Interpretation Number of cases and percentage Negative for intraepithelial neoplasia (NILM) 294(95%) ASCUS 5(1.62%) LSIL 2(0.64%) Squamous cell carcinoma 2(0.64%) Unsatisfactory 7(2.27%) Total 308(100%) Copyright 2017, Medpulse Publishing Corporation, MedPulse International Journal of Pathology, Volume 1, Issue 2 February 2017

3 Shashidhar M R, Shikha Jayasheelan Table 3: Cervical epithelial abnormalities in relation to age Age group / Squamous cel ASCUS LSIL HSIL lesions carcinoma The distribution of NILM belonging to various categories shown in the table 4 Table 4: Distribution of NILM cases Interpretation Number of casesand percentage Normal 151(51.36%) Inflammatory smear (non specific ) 78(26.53%) Bacterial vaginosis 13(4.42%) Atrophic smears 46(15.64%) Candida albicans 1(0.34%) Reactive atypia 2(0.68%) Trichomonas vaginalis 1(0.34%) Total 294(100%) DISCUSSIONS According to National Cancer Registry Program of India, cancers of uterine cervix and breast are the leading malignancies seen in females of India. There should be an effective mass screening program aimed at specific age group for detecting precancerous condition before they progress to invasive cancers. 16 It is a well-known fact that the burden of cervical cancer has been reduced dramatically after the introduction of screening programmes. 17 Prevention of cervical cancer can be primary or secondary. Primary prevention modalities include changes in sexual behavior and Human Papilloma Virus (HPV) vaccination. Secondary prevention of cervical cancer includes visual inspection of cervix, cervicoscopy, HPV testing and cytology. Pap smear test is a secondary preventive method aimed at identification of premalignant and malignant lesions, which may need follow-up and/or treatment 18 Table 5: Comparison of benign lesions findings of Pap smear cytology with other studies Authors No of cases Inadequate Normal Atrophic Inflammatory Beinton et al (1986) Mital et al (1989) Chauhan et al (1990) Spinilla et al (1997) (postmenopausal) Tabrizi et al (1999) (p) Thomas et al (2000) 24 85(p) Sherwani et al (2007) Vaghela et al Present study In the present study Table 5 shows 2.27% of inadequate sampling, which is lower than the other studies done by Tabrizi et al, Thomas et al and Vaghela et al. this may due to proper training of personnel and proper technique. Incidence of atrophic changes was lower in present study compare to study done by Spinilla et al which included only postmenopausal group but greater than study done by Sherwani et al. Inflammatory smears comprised of 26.53% which comparable to study done Tabrizi et al. Normal cytomorphology was observed in %which is comparable to most of the studies. Pap smear is an integral part of the comprehensive health care of women. Besides being a tool of cancer diagnosis, it is used for the identification of infections such as trichomonas, herpes and HPV as well as for the classification of the hormonal pattern. Smears with inflammatory changes were seen mainly in women in the reproductive age group. NILM included non-specific inflammation (table 4), atrophy, trichomoniasis, candidal infection, bacterial vaginosis and herpes simplex viral infection 18 Table 6: Comparision of epithelial cell abnormalities with other studies Total number of subjects epithelial cell abnormalities ASCUS LSIL HSIL SCC Bal MS Usha Sarma Kamna Gupta Preetha George Sadhana Kothari Geetha Katheit Geethu G nair Present study MedPulse International Journal of Pathology, Print ISSN: , Volume 1, Issue 2, February 2017 Page 34

4 MedPulse International Journal of Pathology, Print ISSN: , Volume 1, Issue 2, February 2017 pp In our study, epithelial cell abnormality was observed in younger age groups compared to study done by Geethu G Nair and Bukhari et al. This fact highlights the need for cytological screening in these groups and older patients and the need to create awareness about cervical cancer for motivating them to attend screening. Pap smear screening can be improved by following ways 1. Women need to be educated about the importance of participation in regular screening programmes as prevention is better than cure. 2. Clinicians must obtain an adequate sample and ensure regular follow up with adequate treatment of the patient. 3. Pathologist play a crucial role in interpretation of cervival smears. 4. Health care systems should provide better infrastructure and finances to conduct screening programmes CONCLUSIONS Pap smear testing is a very useful, simple, economical and safe tool to detect preinvasive cervical epithelial lesions. Hence on a routine basis, every woman above the age of 30 must be subjected to cervical screening and this must be continued even in post-menopausal period. Pap test has been regarded as the gold standard for cervical screening programs. Pap test combined with HPV- DNA testing can help increase the sensitivity of detection of cervical pathology. REFERENCES 1. Desai M. An assessment of community based cancer screening program among Indian women using the Anganwadi workers. J Obstet Gynecol India. 2004; 54: Rani A et al. Int J Reprod Contracept Obstet Gynecol Apr;4(2): Sankaranarayanan R, Nene BM, Dinshaw K, Rajkumar R, Shastri S, Wesley R, et al. 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5 Shashidhar M R, Shikha Jayasheelan 28. Gupta K, Malik NP, Sharma VK, Verma N, Gupta A. Prevalence of cervical dysplasia in western Uttar Pradesh. J Cytol 2013; 30: Preetha George, Sumathy Rao. Cytology of uterine cervix by pap smear: a study from South India. Journal of evolution of Medical and Dental Sciences 2014; 3: Available from Sadhana Kothari, Arpit Gohel, Anupama Dayal, Rupal Shah, Shantibhai Patel. Pap smear - A tool for detection of cervical intraepithelial lesions in health check up schemes: A study of 36,740 cases. Int J Res Med 2014;3:12-5. Available from issue=volume%203,%20issue% Geetha Katheit, Shilpa Tiwari. Cytological pattern and demographic determinants of cervical cytology (Papanicolaou smear) in a tertiary centre of central India. European journal of biomedical and pharmaceutical sciences 2015; 2: Available from Geethu G. Nair et al Cytopathological pattern of cervical pap smears - a study among population of North Malabar in Kerala Indian Journal of Pathology and Oncology, October-December 2016;3(4); Source of Support: None Declared Conflict of Interest: None Declared MedPulse International Journal of Pathology, Print ISSN: , Volume 1, Issue 2, February 2017 Page 36