Cervix biopsy under intramuscular sedation and para cervical block with 1% Lignocaine injection was done in whom either PAP smear or Colposcopy or both were abnormal. Biopsy was not taken in whom both PAP smear and Colposcopy were normal and women were asked to follow up at 4-6 months interval, till 3 subsequent negative PAP smears were obtained. Histopathology was done by Senior pathologist. Sensitivity, specificity, positive predictive value, negative predictive value of Colposcopy in diagnosing lesions which were likely to be CIN I or CIN II or CIN III was calculated. Modified Reid’s index on Colposcopy was validated with histopathology and this validation was compared with previous studies.
It is useful in women with smears reported as ASCUS to identify the patients at high risk for HSIL or invasive cancer. The specimen is combined with a base solution that disrupts the virus and releases DNA which combines with RNA probes forming the RNA-DNA hybrid which is captured on a solid phase coated with the universal capture antibodies. These antibodies are coated with alkaline phosphatase (AKP) which is detected following cleavage of the chemical dioxetene substrate that produces light and is then measured with the luminometer in retative light units (RLU).
The present study revealed a good correlation between LBC and Biopsy reports. It had a high sensitivity rate of 96.1% and specificity of 98%. The PPV was 98%, NPV was 96%, and the accuracy rate was 97% (Table 3). In this study, LBC is having higher sensitivity and specificity and accuracy rate than colposcopy and Pap smear. The sensitivity and specificity of combined Colposcopy and pap smear are almost equal to LBC results. Since LBC is more expensive, in our settings, we can use the combined Colposcopy and Pap smear for the cervicalcancerscreening (Table 4).
Cervicalcancer is the second most frequent cancer worldwide, in women after breast carcinoma. However invasive cancer of the cervix was considered to be a preventable condition as it associated with a long pre invasive stage (CIN) making it amenable to screening and treatment. In the present study screening was done in 100 women with abnormal symptoms like excessive white discharge post coital bleeding, post-menopausal bleeding and women with dysplastic smears, with colposcopy and its result were correlated with pap smear and biopsy to determine the sensitivity and specificity of these methods in detecting CIN. Regarding age distribution, high incidence of CIN was found among the age group of 30- 49 years with mean age 41 years which was seen 19% of cases. Kushtagi P et al and Fernands P et al, in their study showed the prevalence of CIN was higher in women over 30 year, while Vaidya showed in his study that CIN was more prevalent in the age group of >35 years. 4,5 Shalini et
Cervicalcancer is one of the preventable and highly curable conditions when diagnosed in the precancerous stage. One of the major problems faced is the lack of awareness of the disease in the vast majority of the population and absence of an organized screening system in our country. The progression of preinvasive cancercervix to invasive carcinoma cervix takes at least 10 years. Therefore, with adequate cervicalcancerscreening the incidence of deaths resulting from cervicalcancer can be brought down. Various screening methods are available including Pap smear, colposcopy, visual inspection with acetic acid, and HPV DNA testing. In this study sensitivity and specificity of Pap smear was 53.1% and 98.7% respectively. The sensitivity and specificity of colposcopy was 87.87% and 72.72% respectively. The results from the present study supports that combination of screening tests as a part of routine screening for cervicalcancer rather than a single test can help maximize the early diagnosis in women. As it is rightly said, “prevention is better than cure”. It is important to strictly implement the screening programme and spread awareness of the disease symptoms and its management
Carcinoma of the uterine cervix is the most common cancer in South Indian women and occupies the top rank among cancers in women in most developing countries, constituting 34% of all women’s cancers. To an estimated annual global incidence of 500,000 cervical cancers, India contributes 100,000, ie. 1/5 of the world burden. 23 The magnitude of the problem is thus more than evident. The world pattern of cervicalcancer, together with the age adjusted rate and ranking, clearly indicate that cervicalcancer is predominantly a problem of poorer socio-economic societies. 1
The recognition of high-risk human papillomaviruses (HPVs) as etiological agents of cervicalcancer has in- creased the demands to use testing for HPV for the detection of abnormal cervical smears and for cervicalcancerscreening. The present study compared the performance of the Hybrid Capture 2 (HC2) assay with that of PCR for the detection of significant cervical lesions in 1,511 women with different risks for HPV infections in three New Independent States of the former Soviet Union. The results showed that the level of agreement between the HC2 assay and PCR was substantial, with a kappa (Cohen) value of 0.669 (95% confidence interval [CI], 0.629 to 0.709). Of the 228 samples with discrepant results, 92 were positive by the HC2 assay but negative by PCR, whereas 136 samples were PCR positive but HC2 assay negative. The positive predictive values (PPVs) of the HC2 assay and PCR in detecting high-grade intraepithelial lesions (HSILs) were 4.5% (95% CI, 3.5 to 5.5%) and 3.6% (95% CI, 2.7 to 4.5%), respectively, and the negative predictive values (NPVs) were 99.6% (95% CI, 99.3 to 99.9%) and 99.3% (95% CI, 98.9 to 99.7%), respectively. The sensitivities of the HC2 assay and PCR for the detection of HSILs were 85.2 and 74.0%, respectively, and the specificities were 67.2 and 64.1%, respectively. In receiver operating characteristic (ROC) analysis, the performance of the HC2 assay for the detection of HSILs was excellent (P ⴝ 0.0001); the area under the ROC analysis curve was 0.858 (95% CI, 0.811 to 0.905), and the optimal balance between sensitivity (86.5%) and specificity (80%) was obtained with an HC2 assay cutoff level of 15.6 relative light units/positive control. Use of this cutoff would increase the specificity of the HC2 as- say to 80.0% without compromising sensitivity. In conclusion, the results of PCR and the HC2 assay were con- cordant for 85% of samples, resulting in substantial reproducibility. Both tests had low PPVs, equal specificities, and equal (almost 100%) NPVs for the detection of HSILs; but the sensitivity of the HC2 assay was slightly better.
Background: The awareness of cervicalcancer, Papanicolaou’s smear and its utilization is of great importance especially in our environment where cervicalcancer is the number one cancer affecting women. This study was aimed at investigating the risk factors and awareness of cervicalcancerscreening with Papanicolaou’s (Pap) smear and its utilization among female undergraduates. Materials and Method: This is a descriptive cross-sectional study that was conducted among 397 female undergraduates of the Benue State University, Makurdi between May and June 2016. Results: One hundred and eighty-six (49.6%) of the respondents were sexually active and ninety-six (51.6%) of the sexually active respondents had been exposed before the age of 20 years. Their ages for sexual debut ranged from 13 to 25 years. Their mean age at sexual debut was 18.3 (±2.3) while the modal age was 19 years. Fifty-one (27.4%) of the sexually active students had multiple sexual partners, sixty-three (33.9%) had been pregnant at one time or the other, and only 32 (17.2%) of these sex- ually active students were using condom during intercourse. Two hundred and eighty-six (72.0%) were aware of cervicalcancer. There was a fair level (55.7%) of awareness of cervicalcancer as a preventable cancer but there was poor knowledge of individual preventive methods. Only 26.2% were aware of Pap smear and worse still, only 3.3% of them had ever done the test. The main source of awareness was through the mass media. Conclusion: This study showed that there was good knowledge of cervicalcancer among respondent but there was poor knowledge of Pap smear and its utilization. It is therefore important that concerted efforts be made to educate students at the university about cervicalcancer and its prevention methods.
In conclusion, age older than 40 years, poverty and low educational levels are the key factors resulting in poor cervicalcancer knowledge among Uyghur women, particularly those who live in the remote countryside. This study showed that several demographic, awareness and attitudinal factors are associated with a decreased likelihood of women utilizing cervicalcancerscreening. Although these factors are important to consider and policies can address all of them, resources that specific- ally target the factor most closely associated with uptake, namely, women’s lack of knowledge regarding cervicalcancer and its prevention, should be the primary focus. Eliminating this barrier is paramount to achieving the goal of reducing cervicalcancer incidence and mortality.
Various screening methods are available for detecting the pre-invasive lesions of the cervix; however the Pap smear is the gold standard and has become the main stay of population based prevention programmes. It is the most effective prevention technique available today and is used worldwide . Regular screening with Pap smear reduces the mortality from cervicalcancer. Systematic screening programmes being implemented by developed countries have resulted in the reduction of morbidity and mortality from cervicalcancer [11,12,13]. It has been reported that both organized and opportunistic cytological screening tests have lowered the incidence rates of cervicalcancer . Various factors like non availability, poor quality of care provided, poor accessibility, fear and hopelessness concerning diagnosis of cancer, perception of tests as being unnecessary, lack of adequate information to the women, as well as cultural and behavioral barriers are responsible for the very low level of cervicalcancerscreening uptake in developing countries [15,16,17]. The Pap smear test is readily available in our Centre on physician
The VIA test was performed by application of 3%–5% acetic acid into the cervix uteri by using sterile forceps and a small piece of cotton. After 5 minutes a naked-eye assessment was performed under direct illumination of a 100-watt halogen lamp. A positive VIA test was defined as well-marginated, raised, opaque, acetowhite lesion(s) observed on the cervix uteri within the squamo-columnar junction zone (the region in the uterine cervix in which the squamous lining of the vagina is replaced by the columnar epithelium typical of the body of the uterus and which is a common site of neoplastic change). 10
Based on the data gathered we found out that 66.7% of the respondents did not know about cervicalcancerscreening. In comparison to multiple studies worldwide we find that in Riyadh – Kingdom of Saudi Arabia 46.2% of women did not know about the screening, while a study in Bahrain 64% of women have known about Pap smear, also a study in Russia showed that 80.0% of women had a good level of knowledge about HPV and cervicalcancer prevention and screening (Roik, 2017). The women with university education were more likely to have higher knowledge about HPV and CervicalCancer prevention compared to those with lower education, which was not the case in our study. Though most of the participants are educated, they didn't have enough knowledge about Pap smear. This indicates that educational level has no major impact on knowledge of cervicalcancer and its screening. The major cause could be due to lack of health education about it throughout their school and university years, unlike education in Russia in which cervicalcancerscreening was a subject talked about throughout the educational years (Roik, 2017). So, we should start teaching girls from a younger age about cervicalcancer and HPV and its vaccination since it is recommended to be given at such a young age (11-12 years old). We found that women who had highest knowledge were those who found them self in a position where cervicalscreening was recommended to them by a doctor either as a diagnostic investigation or a pre-caution measure (38.9%), we also found that 40.1% of the participants use the internet and TV as a source of knowledge, this may be explained by the lack of official screening programs and of course lack of health education’s programs for cervicalcancer.
Cytology is the most widely recommended test to triage HPV- positive women, where quality-assured cytology is available. HPV-positive women with a cytology diagnosis of ASCUS or worse are referred for colposcopy, and the rest are advised to have repeat HPV testing after 1 year. Cytology performs better in a triaging scenario, since the prevalence of disease is high in the sample and cytologists have a limited number of specimens to evaluate. The current recommendations by the American Society for Colposcopy and Cervical Pathology (ASCCP) are direct referral to colposcopy for HPV 16/18 positive women and repeat testing after 1 year for women positive for other HPV types . 4.3. Triaging with Biomarkers
Majority (33.89%) of the women attending Gynecology and Oncosurgery presented with complaints of white discharge per vaginum followed by 34 % of the population who had come for routine screening. Women who had their routine screen, CIN I was detected in 4 women, 3 women had CIN III and 2 of them had CIN II. Hence total incidence of neoplasia was 9 (14.75 %). 11 (14.28 %) women presenting with white vaginal discharge were detected with neoplasia. Among 8 women having complaints of postmenopausal bleeding 2 (25 %) were detected of neoplasia. One had SCC and 1 had CIN III. Hence, postmenopausal bleeding is one of the risk factors for cervical neoplasia/ squamous cell carcinoma.
Cervicalcancer is responsible for the highest number of cancer-related deaths among women in Ghana, with 3052 new cases and 1556 deaths annually . HPV vaccines are licenced for use, but have not been introduced beyond a pilot program in selected regions commenced in 2013 . Ghana has had a national policy on cervicalcancer pre- vention since 2005, which recommends screening with visual inspection with acetic acid (VIA) and treatment of lesions with cryotherapy for women between the ages of 25–45 years, and papanicolau (PAP) smears for women over the age of 45 . The National Screening Program so far has limited coverage of estimated 2.7% of the eligible population. Both Papanicolaou smears and VIA are avail- able in public and private health clinics at a cost to the pa- tient since the national health insurance does not cover it.
in our study were reluctant to undergo testing due to their fear of pain and their regarding testing as a complicated procedure. An individual’s knowledge and attitudes about the causes and risk factors of a particular illness are interconnected with their practice. In our study, only 81 (38.6%) of 210 women had undergone Pap smear testing within the past five years, although about half (55.2%) claimed to have undergone testing at least once before. Many (68.6%) were not sure of the suitable age and interval between tests. Although many agreed that Pap smear testing was necessary, 44.3% regarded these tests as less important than other issues, perhaps because they did not deem preventive health check-ups as important, especially without any disease symptoms. 32 The
VIA was reported as an alternative method for screening of cervicalcancer in 1982 (14). Applica- tion of 3 to 5% acetic acid causes dehydration of cells and surface coagulation of proteins in active cells, giving its white appearance called acetowhite regions (14). VIA is low cost and relatively ease to administer (it can be administered by paramedical workers), its high sensitivity and its immediate re- sults (it is possible to “see and treat” at the first visit) (13, 15, 16) are important factors that make VIA an alternative screening modality for cervicalcancer in developing countries (17,18). Because VIA allows diagnosis of abnormal cells almost immediately, women can be treated in the same visit with cryother- apy (applying compressed refrigerant gases (N 2 or
The Health Belief Model (HBM) is a conceptual framework used to understand health behaviour and possible reasons for non-compliance with recommended health action [13, 14]. This model is used normally to investigate health related behaviour (Burak and Meyer, 1997) and was originally designed to address issues for people who do not participate in prevention programmes (Bloom and Gundlach, 2000). Designed by a group of social psychologist in early 1950s, HBM was used to establish reasons for the widespread failure in screening and to determine effective preventive measures (Janz and Becker, 1984). HBM can provide guidelines for program development allowing planners to understand and address reasons for non-compliance. The HBM addresses four major constructs for compliance with recommended health actions: (1) perceived barriers of recommended health action, (2) perceived benefits of recommended health action, (3) perceived susceptibility of the disease, and (4) perceived seriousness of the disease. The following appear relevant in terms of HBM operation, modifying variables (culture, education level, past experiences, skill, and motivation, to name a few), cues to action (illness of a family member, media reports, mass media campaigns, advice from others, reminder postcards from a health care provider, or health warning labels on product), and self-efficacy (belief in one’s own ability to do something); affect our perception of susceptibility, seriousness, benefits, and barriers (Paek et al., 2011). Cues to action are normally used to stimulate the delay behaviour towards health. Patients who have had gone through the screening process believed to significantly have more cues to action compared to those who did not (Burak and Meyer, 1997). Summary of key perceived barriers influencing Pap smearscreening uptake is presented in Table 1.
These findings emphasize the need for the establishment of a national organized screening program which at present is the most effective preventive intervention that will lead to a reduction in the incidence of the disease. Cytology screening with the Pap smear has been the mainstay of cervicalcancerscreening for many years, but as knowledge of cervicalcancer and cervicalcancerscreening is poor in Nigerian women, any organized screening program that is established requires to incorporate elements of population-based education and personnel training as integral components of the screening services, while other alternative approaches to screening are being evaluated. In addition to effective coverage of the population at risk, there should be emphasis on follow-up for appropriate treatment.
This is to certify that the dissertation entitled “THE ROLE OF PAP SMEAR IN DETECTION OF CYTOLOGICAL ABNORMALITIES OF UTERINE CERVIX IN HIV INFECTED WOMEN” is a record of bonafide work done by Dr. M.Kavitha , Post graduate student in the Department of Pathology, Coimbatore under the supervision of Dr. M.MURTHY, Professor and Head, Department of Pathology, Coimbatore Medical college and submitted in partial fulfillment of the regulations of the Tamilnadu Dr. M.G.R Medical University, towards the award of M.D.Degree (Branch III) in Pathology.