Screening for cervical Screening for cervical neoplasia in Bangladesh neoplasia in Bangladesh
using visual inspection using visual inspection
with acetic acid with acetic acid
Chairperson: Chairperson:Dr. Gopal Chandra Das Dr. Gopal Chandra Das
Assistant Professor Assistant Professor
Department of Obs & Gynae, Department of Obs & Gynae,
MMCMMC
Speaker:
Speaker:
Dr. Khurshida Jahan Dr. Khurshida Jahan
MS Obs & Gynae (Thesis part), MS Obs & Gynae (Thesis part),
MMC MMC
Auther:
Auther:
Nessa
Nessa A A, , HussainHussain MA MA, , RahmanRahman JN JN, , Rashid MH
Rashid MH, , MuwongeMuwonge R R, , Sankaranarayanan
Sankaranarayanan R R..
Department of Obstetrics & Gynecology, Bangabandhu Department of Obstetrics & Gynecology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh.
Sheikh Mujib Medical University, Dhaka, Bangladesh.
Source:
Source:
International Journal of Gynaecology & Obstetrics. 111(2010) 115- International Journal of Gynaecology & Obstetrics. 111(2010) 115-
118.
118.
Introduction Introduction
Cervical cancer constitutes 25% Cervical cancer constitutes 25%
of all cancer cases in women and of all cancer cases in women and
accounts for 13000 new cases accounts for 13000 new cases
and 8000 deaths annually in and 8000 deaths annually in
Bangladesh. More than 80% of Bangladesh. More than 80% of
patients diagnosed with this patients diagnosed with this
eminently preventable cancer eminently preventable cancer
present in clinically advanced, present in clinically advanced,
inoperable stages.
inoperable stages.
The aim of the present paper was The aim of the present paper was to briefly describe the
to briefly describe the
organization and functioning of organization and functioning of the VIA screening program and the VIA screening program and
discuss the early results, discuss the early results,
strengths and limitations of the strengths and limitations of the
pioneering effort in cervical pioneering effort in cervical
cancer prevention in Bangladesh.
cancer prevention in Bangladesh.
Objective:
Objective:
To report the organization and To report the organization and early results of a visual
early results of a visual
inspection with acetic acid inspection with acetic acid
(VIA) screening program for (VIA) screening program for
cervical cancer prevention in cervical cancer prevention in
Bangladesh.
Bangladesh.
Patients and Patients and
methods methods
The VIA screening program is provided The VIA screening program is provided through the existing healthcare
through the existing healthcare infrastructure in Bangladesh.
infrastructure in Bangladesh.
The target population for VIA screening The target population for VIA screening is apparently healthy, ambulant,
is apparently healthy, ambulant,
married women aged 30 years and married women aged 30 years and
above attending the healthcare above attending the healthcare
facilities at MCWCs, DHs, MCHs, facilities at MCWCs, DHs, MCHs,
BSMMU, UHFWCs, and UHCs.
BSMMU, UHFWCs, and UHCs.
It was an opportunistic screening program. It was an opportunistic screening program.
The screening algorithm involved a single The screening algorithm involved a single
visit for screen-negative women and 2-3 visit for screen-negative women and 2-3
visits for screen-positive women, visits for screen-positive women,
After counseling and informed consent, a After counseling and informed consent, a speculum examination was performed for speculum examination was performed for
direct visualization of the cervix and direct visualization of the cervix and
vagina to identify the squamocolumnar vagina to identify the squamocolumnar
junction (SCJ), inflammation, polyps, junction (SCJ), inflammation, polyps,
leukoplakia, and growth. Freshly prepared leukoplakia, and growth. Freshly prepared 5% 5% dilute acetic acid was applied to the dilute acetic acid was applied to the
cervix.
cervix.
Care was taken to avoid any Care was taken to avoid any
bleeding and results were reported 1 bleeding and results were reported 1
minute after application under 100- minute after application under 100-
watt illumina tion. VIA test was watt illumina tion. VIA test was
considered positive when a definite, considered positive when a definite,
well-defined acetowhitening was well-defined acetowhitening was
observed in the transformation zone observed in the transformation zone
in close proximity with the SCJ or in close proximity with the SCJ or
when a growth turned acetowhite;
when a growth turned acetowhite;
when in doubt the test was repeated.
when in doubt the test was repeated.
All VIA-positive women were referred All VIA-positive women were referred with a pink referral card to the
with a pink referral card to the
colposcopy clinics at BSMMU or nearby colposcopy clinics at BSMMU or nearby
medical college hospitals. Women with medical college hospitals. Women with
negative VIA were given a blue card negative VIA were given a blue card
and advised to come back after 3 years.
and advised to come back after 3 years.
A manual register is kept at each VIA A manual register is kept at each VIA
screening center that provides the screening center that provides the
number of women screened, tested number of women screened, tested
positive, and tested negative.
positive, and tested negative.
Colposcopy was performed by the trained Colposcopy was performed by the trained colposcopist when the screen-positive
colposcopist when the screen-positive
women reported at the colposcopy clinics women reported at the colposcopy clinics
at medical college hospitals or BSMMU.
at medical college hospitals or BSMMU.
All women with suspected CIN and All women with suspected CIN and
cancer had colposcopy-directed cervical cancer had colposcopy-directed cervical biopsy and the specimens were given to biopsy and the specimens were given to
the women or their attendants to submit the women or their attendants to submit
to the histopathology department. The to the histopathology department. The
colposcopic findings were documented in colposcopic findings were documented in
a form.
a form.
Women with normal histology and CIN 1 reports Women with normal histology and CIN 1 reports were advised to return for follow-up after 6-12 were advised to return for follow-up after 6-12
months. Women with CIN 1 who wanted months. Women with CIN 1 who wanted
immediate treatment or who were unlikely to immediate treatment or who were unlikely to report for follow-up and those above 35 years report for follow-up and those above 35 years
were treated with cryotherapy or LEEP. Women were treated with cryotherapy or LEEP. Women with histologically confirmed CIN 2 or 3 lesions with histologically confirmed CIN 2 or 3 lesions
were treated with LEEP or cryotherapy and were were treated with LEEP or cryotherapy and were
advised to return for follow-up after 6 months.
advised to return for follow-up after 6 months.
Women with cervical cancer were referred to Women with cervical cancer were referred to
cancer treatment facilities for further cancer treatment facilities for further
investigations and treatment.
investigations and treatment.
The final diagnosis was based on the The final diagnosis was based on the
histopathology or colposcopy if no or an histopathology or colposcopy if no or an
inadequate biopsy sample was taken.
inadequate biopsy sample was taken.
Results Results
From January 1, 2005, to June 30, From January 1, 2005, to June 30, 2008, VIA screening was provided 2008, VIA screening was provided
for 104 098 women in 44 districts in for 104 098 women in 44 districts in
Bangladesh. The average number of Bangladesh. The average number of
women screened in most districts women screened in most districts
ranged from 800-4000 women.
ranged from 800-4000 women.
Table 1: Number of women screened & those tested
positive
Year of screening Number screened Screen positive (%)
2005 11693 548 (4.7)
2006 21609 925(4.3)
2007 40785 1918(4.7)
2008 until June 30011 1622(5.4)
Total 104098 5013(4.8)
Of the women screened, 5013 (4.8%) Of the women screened, 5013 (4.8%) were positive on VIA and were
were positive on VIA and were referred to colposcopy clinics at referred to colposcopy clinics at
BSMMU or nearby medical college BSMMU or nearby medical college
hospitals.
hospitals.
Overall, 4371 (87.2%) of screen Overall, 4371 (87.2%) of screen positive women underwent
positive women underwent colposcopy.
colposcopy.
Table 2: Distribution of women Table 2: Distribution of women
attending different colposcopy clinics.
attending different colposcopy clinics.
Institutes with colposcopy clinics No. (%) of women
Bangabandhu Sheikh Mujib Medical University (BSMMU) 2188 (43.6) Chittagong Medical"College Hospital (CMCH) 747 (14.9) Rajshahi Medical College Hospital (RjMCH) 442 (8.8) Mymensingh Medical College Hospital (MMCH) 341 (6.8)
Ktmlna Medical College Hospital (KMCH) 277 (5.5)
Sylhet MAG Osmani Medical College Hospital (SMAGOMCH) 210 (4.2)
Dhaka Medical College Hospital (DMCH) 132 (2.6)
Rangpur Medical College Hospital (RMCH) 34 (0.7)
Women who did not attend 642 (12.8)
Total 5013 (100.0)
Total women underwent colposcopy – 4371 Total women underwent colposcopy – 4371
Women attended at BSMMU (VIA +ve cases) – Women attended at BSMMU (VIA +ve cases) – 2188
2188
Normal colposcopic findings – 1044 (47.7%) Normal colposcopic findings – 1044 (47.7%)
Colposcopic abnormalities Colposcopic abnormalities
Suggestive of CIN or cancer Suggestive of CIN or cancer =1144 =1144
CIN I CIN I = 682 = 682
CIN IICIN II = 149 = 149
CIN III CIN III = 29 = 29
Invasive Invasive = 134 = 134
Unsatisfactory Unsatisfactory = 150 = 150
Histopathology results of cases Histopathology results of cases with colposcopic abnormalities with colposcopic abnormalities
CINI CINI = 369 = 369
CIN II CIN II = 127 = 127
CIN III CIN III = 30 = 30
Invasive cancer Invasive cancer = 123 = 123
Of the 4371 women who underwent Of the 4371 women who underwent
colposcopy, 2188 attended the colposcopy colposcopy, 2188 attended the colposcopy
clinic at BSMMU. The results of colposcopy clinic at BSMMU. The results of colposcopy
and histology are given in Table 3. No and histology are given in Table 3. No
colposcopic abnormalities were detected in colposcopic abnormalities were detected in
1044 (47.7%) women, whereas directed 1044 (47.7%) women, whereas directed
biopsies in 1144; women showed biopsies in 1144; women showed
colposcopic abnormalities suggestive of CIN colposcopic abnormalities suggestive of CIN
or cancer. On histology, 369 women were or cancer. On histology, 369 women were
diagnosed with CIN 1, 127 with CIN 2, 30 diagnosed with CIN 1, 127 with CIN 2, 30 with CIN 3, and 123 with invasive cancer.
with CIN 3, and 123 with invasive cancer.
VIA repeated by gynecologists in 2188 VIA repeated by gynecologists in 2188 women before they underwent
women before they underwent
colposcopy was positive in 1060 and colposcopy was positive in 1060 and
negative in 1128 women; the final negative in 1128 women; the final
diagnosis among these 1128 VIA- diagnosis among these 1128 VIA-
negative women was as. follows: no negative women was as. follows: no
lesion (n = 1091); CIN 1 (n = 22); CIN lesion (n = 1091); CIN 1 (n = 22); CIN 2-3 (n = 10); and invasive cancer (n = 2-3 (n = 10); and invasive cancer (n = 5). 5).
The sensitivity, specificity, and positive The sensitivity, specificity, and positive predictive value of VIA to detect CIN 2 predictive value of VIA to detect CIN 2
and 3 lesions after excluding the 123 and 3 lesions after excluding the 123 invasive cancer cases in this selected invasive cancer cases in this selected
sample of women were 93.6%, 58.3%, sample of women were 93.6%, 58.3%,
and 15.6%, respectively (Table 4).
and 15.6%, respectively (Table 4).
Forty-one women (11%) with CIN 1 Forty-one women (11%) with CIN 1 and 80 women (50%) with CIN 2-3 and 80 women (50%) with CIN 2-3
lesions received treatment with LEEP lesions received treatment with LEEP
(n = 105), cryotherapy (n = 6), or (n = 105), cryotherapy (n = 6), or hysterectomy (n= 10) at BSMMU.
hysterectomy (n= 10) at BSMMU.
Table 3 Accuracy of visual screening with Table 3 Accuracy of visual screening with acetic acid to detect CIN 2-3 lesions among acetic acid to detect CIN 2-3 lesions among 2065 women attending colposcopy services 2065 women attending colposcopy services
at BSMMU.
at BSMMU.
VIA result Women detected
with CIN 2-3 lesions Women with normal
cervix or CIN 1 lesions Total
Positive 147 795 942
Negative 10 1113 1123
Total 157 1908 2065
Sensitivity: 93.6% (95% CI, 88.6-96.9);
Specificity: 58.3% (95% CI, 56.1-60.6); Positive predictive value: 15.6% (95% CI, 13.3-18.1);
Negative predictive value: 99.1% (95% CI, 98.4- 99.6).
Discussion Discussion
Among the cancers, cervical cancer Among the cancers, cervical cancer
accounts for almost one fifth of cases in accounts for almost one fifth of cases in
women. The cervical cancer burden is closer women. The cervical cancer burden is closer
to that of maternal deaths (13 000 deaths) to that of maternal deaths (13 000 deaths)
in Bangladesh. Currently, 32 million women in Bangladesh. Currently, 32 million women are aged between 30 and 60 years and less are aged between 30 and 60 years and less
than 0.4% are screened annually with a Pap than 0.4% are screened annually with a Pap
smear. It is not feasible to introduce smear. It is not feasible to introduce
cytology screening for cervical cancer cytology screening for cervical cancer
control in Bangladesh given the resource control in Bangladesh given the resource
The VIA test positivity of around 5% in this The VIA test positivity of around 5% in this program was at the lower range of test
program was at the lower range of test
positivity reported in other VIA studies in positivity reported in other VIA studies in
Asia and Africa.
Asia and Africa.
On repeat VIA performed before colposcopy, On repeat VIA performed before colposcopy, a little more than half of the women were
a little more than half of the women were
scored as negative, which indicates the wide scored as negative, which indicates the wide variability between the test providers due to variability between the test providers due to
the subjective interpretation of the test.
the subjective interpretation of the test.
If we extrapolate this finding to the entire If we extrapolate this finding to the entire study, the test-positive rates are likely to be study, the test-positive rates are likely to be
even lower than 5%.
even lower than 5%.
Treatment coverage of women with high-Treatment coverage of women with high- grade cervical cancer precursors is
grade cervical cancer precursors is
inadequate: half of such women received inadequate: half of such women received
treatment at the BSMMU colposcopy clinic.
treatment at the BSMMU colposcopy clinic.
The treatment rates can be improved if The treatment rates can be improved if cryotherapy or LEEP are offered
cryotherapy or LEEP are offered
immediately following colposcopy at the immediately following colposcopy at the first visit instead of receiving treatment first visit instead of receiving treatment
after histopathology confirmation of punch after histopathology confirmation of punch
biopsy specimens at the second visit.
biopsy specimens at the second visit.
Moreover, the current VIA-based program Moreover, the current VIA-based program would facilitate the devel opment of
would facilitate the devel opment of screening, diagnosis, and treatment screening, diagnosis, and treatment
infrastructure in health services, improve infrastructure in health services, improve
awareness of cervical cancer prevention awareness of cervical cancer prevention
among the population, and enable among the population, and enable
incorporation of new developments such incorporation of new developments such
as the more accurate, objective &
as the more accurate, objective &
affordable HPV testing technologies when affordable HPV testing technologies when
these technologies are commercially these technologies are commercially
available & affordable for wider use in available & affordable for wider use in
public health services.
public health services.
CONCLUSION:
CONCLUSION:
A VIA-based program would A VIA-based program would facilitate the development of facilitate the development of
screening, diagnosis, and screening, diagnosis, and
treatment of cervical neoplasia treatment of cervical neoplasia
and improve awareness of cervical and improve awareness of cervical
cancer prevention in Bangladesh.
cancer prevention in Bangladesh.
Approximate rates of spontaneous Approximate rates of spontaneous
regression, persistence &
regression, persistence &
progression of CIN progression of CIN
CINI
CINI CINII CINII CINIII CINIII
Regression to normal Regression to normal 60% 60% 40% 40% 30% 30%
Persistence Persistence 30% 30% 35% 35% 48% 48%
Progression to CINIII Progression to CINIII 10% 10% 20% 20% - -
Progress to carcinoma Progress to carcinoma <1% <1% 5% 5% 22% 22%
VIA & Colposcopy in MMCH VIA & Colposcopy in MMCH
2010 2010
Total VIA done Total VIA done - 3214 - 3214
VIA –ve VIA –ve - 3139 - 3139
VIA +ve VIA +ve - 75 - 75
Total colposcopy done Total colposcopy done - 433 - 433
Normal Normal - 200 - 200
CINI CINI - 172 - 172
CINII CINII - 22 - 22
CINIII CINIII - 08 - 08
Unsatisfactory Unsatisfactory - 11 - 11
Invasive Invasive - 20- 20
Histopathology results of Histopathology results of
cases with colposcopic cases with colposcopic abnormalities in MMCH abnormalities in MMCH
CIN I CIN I 92 92
CIN II CIN II 4545
CIN III CIN III 15 15
Invasive carcinoma Invasive carcinoma 15 15
Squamous epithelium Columnar epithelium
Colpoccopy – Abnormal Findings