Untitled Document

ORIGINAL ARTICLE

Year : 2020  |  Volume : 3 |  Issue : 2 |  Page : 7-11 |  DOI : https://DOI-10.46319/RJMAHS.2020.v03i02.003

 

Pap Smear Screening for Cervical Cancer in a Tertiary Care Hospital - A Retrospective Study

Aakanksha Koul1, Chaithra H2, Shivani Sudhakar3

1, 2 Assistant Professor, Department of Pathology,
3 Postgraduate, Department of Obstetrics and Gynaecology
Sri Siddhartha Medical College & Research Centre, Tumakuru,
Sri Siddhartha Academy of Higher Education, Tumakuru.

DOI-10.46319/RJMAHS.2020.v03i02.003
Abstract
Background: Carcinoma cervix is the 2nd commonest cancer in the world among women. It is the commonest carcinoma causing death of women in developing countries. 14% of all female carcinoma cases in India are cervical carcinomas. This study aims at screening of women for cervical cancer and to evaluate different types of malignant and benign lesions of cervix by Conventional Pap smear. Material and methods: This is a retrospective study of Conventional Pap Smear screening done for 4 months duration. The data was collected from 1,000 patient records during the study period. The results were classified according to The Bethesda System (2014). Results: Out of 1,000 cervical smears, 27 cases (2.8%) were Low grade Squamous Intraepithelial Lesion (L-SIL), 14 cases (1.4%) were High grade Squamous Intraepithelial Lesion (H-SIL), and 05 cases (0.5%) were Squamous Cell Carcinoma (SCC). The premalignant lesions were seen mostly between 30-70 years of age. Conclusions: Conventional Pap Smear is a widely accepted and economical screening procedure for early detection of cervical precancerous lesions in developing countries. Pap Smear screening should be introduced at 30 years of age and subsequent follow up with Human Papilloma Virus (HPV) DNA testing done at higher centre.

Keywords: Pap smear, Carcinoma cervix, H-SIL, L-SIL, Bethesda , Squamous Cell Carcinoma.

Introduction
Carcinoma cervix is a global health issue and one of the leading causes of adult deaths worldwide. According to GLOBOCAN 2018, among females, cervical cancer ranks 4th worldwide for incidence and mortality.[1] In India, Cancer of the cervix is the most common type of cancer in women.[2] In developing countries, cervical cancer accounts for nearly 86% of all deaths, which is responsible for one fourth of the burden of cervical cancer in the world.[1] Women usually present to the clinic only when they have symptoms such as pain, foul smelling white discharge per vagina, and post coital bleeding or abnormal bleeding. [3]
Most commonly affected groups with cervical cancer include: People with Human Papilloma Virus (HPV) infection, multiple sexual partners, early childbearing, sexually transmitted infections, early intercourse smoking, prolonged use of oral contraceptives, immuno suppression, low socioeconomic status, Diethyl Stilbesterol (DES) Exposure, previous dysplasia. Currently, conventional pap smear cytology is the most efficient and widely accepted cancer screening modality.[4]
It is a type of secondary prevention which helps in reducing the mortality by early detection and treatment of the precancerous lesions. The recurrence of cervical cancer after treating dysplasia is less than 1% and deaths due to the disease is less than 0.5%.[5] Conventional Pap smear is an easily available, cost effective method of screening, having a sensitivity and specificity of 62.11% and 93.51% respectively.[6] This study was conducted to screen women for cervical cancer and to evaluate different types of malignant and benign lesions of cervix by Conventional Pap smear in this region.
Material and methods
This was a retrospective study, conducted on 1000 women. All the patient records from January 2020 to April 2020 were included in the study. Sexually active women more than 18 years of age were included in this study. Records of pregnant females and those with a previous history of cervical cancer were excluded.
After getting clearance from the Institutional Ethical Committee, all the records in the pathology department, fulfilling the criteria, were included in the study. All the relevant socio demographic data, clinical details and the pap smear results were collected and noted in a structured proforma.
Pap smear was taken in the OPD of the department of OBG and slides were sent to the Department of pathology. Slides were fixed in 95% ethanol and stained with Pap Stain, followed by mounting them with DPX (Distrene dibutyl phthalate xylene). Slides were then seen under the microscope and categorised according to The Bethesda System of Classification 2014.[7] Data was entered in MS Excel sheet and analysed using Epi Info 3.4.3. Descriptive statistics was used.
Results
The total number of cases included in this study were 1000. The youngest patient was 22 years and the oldest 75 years of age. Most of the patients belonged to the age group of 40-49 years (43%), followed by 30-39 years (26%). (Table 1).
Table-1: Age distribution of patients


Age group

Number (n)

Percentage (%)

20-29

70

07

30-39

260

26

40-49

430

43

50-59

160

16

60-69

60

06

>70

20

02

Total

1000

100

Majority of the pap smears were inflammatory (51%), consisting of neutrophilic infiltrate, mixed inflammatory infiltrate and reactive cellular changes. Next common were normal smears constituting 24.6%. (Table 2). This was followed by infections (19.7%), constituting most commonly of bacterial vaginosis (09%), followed by trichomonas vaginalis (8.2%), candida (1.8%) and leptothrix (0.7%). (Table 3) (Figures 1-4).
Table-2: Distribution pattern of different types of lesions in PAP smears


Pap smear analysis report

Number of patients (n)

Percentage (%)

Normal smear

246

24.6

Infection

197

19.7

LSIL

28

2.8

HSIL

14

1.4

SCC

05

0.5

Inflammatory

510

51

Total

1000

100

Table-3: Distribution of infection


Type of infection

Number of patients

Percentage (%)

Bacterial Vaginosis

90

09

Trichomonas Vaginalis

82

8.2

Candida

18

1.8

Leptothrix

07

0.7

Total

197

19.7

Table-4: Age distribution pattern in different types of lesions


Age (yrs)

Normal

Infection

Inflammation

LSIL

HSIL

SCC

20-29

22 (2.2%)

18 (1.8%)

30 (03%)

0

0

0

30-39

43(4.3%)

58 (5.8%)

159 (15.9%)

0

0

0

40-49

134(13.4%)

60 (06%)

225 (22.5%)

10 (01%)

01(0.1%)

0

50-59

32 (3.2%)

28 (2.8%)

83 (8.3%)

09(0.9%)

07(0.7%)

01(0.1%)

60-69

12 (1.2%)

23 (2.3%)

10 (01%)

08(0.8%)

05(0.5%)

02(0.2%)

>70

03 (0.3%)

10 (01%)

03 (0.3%)

01(0.1%)

01(0.1%)

02(0.2%)

Total

246(24.6%)

197(19.7%)

510(51%)

28(28%)

14(14%)

05(0.5%)

1
Figure 1: Clue cells in Bacterial Vaginosis (Pap;100x)
2
Figure 2: Trichomonas Vaginalis (Pap;100x)
3
Figure 3: Candida (Pap;40x)
4
Figure 4: Leptothrix (Pap;100x)
Epithelial cell abnormalities constituted of Low grade Squamous Intraepithelial Lesion (LSIL) (2.8%), High grade Squamous Intraepithelial Lesion (HSIL) (1.4%) and Squamous Cell carcinoma (SCC) (0.5%).  In the age group of 20-29 years, majority of pap smears were inflammatory (03%), followed by normal (2.2%) and 1.8% had infection. (Table 4).
In the age group of 30-39 years, 15.9% inflammatory smears, followed by infection in 5.8% and 4.3% normal smears. In the age group of 40-49 years, 22.5% smears were inflammatory, followed by normal in 13.4% and infection in 06% smears. 0.1% patients showed LSIL and HSIL, respectively.
In the age group of 50-59 years, 8.3% patients had inflammatory smears, followed by 3.2% normal smears and 2.8% presented with infection. There were 0.9% cases of LSIL, 0.7% HSIL and 0.1% had SCC. Among 60-69 years age group, infection was commonest, in 2.3% patients, followed by 1.2% normal cases, 01% inflammatory smears, 0.8% LSIL, 0.5% HSIL and 0.2% SCC. In  age group more than 70 years, normal and inflammatory smears constituted 0.3% each, followed by infection in 0.1%. LSIL, HSIL and SCC were present in 0.1%, 0.1% and 0.2% patients, respectively.
Discussion
Since 1950's, Conventional Pap smear techniques has been the preferred procedure for screening of cervix.[8] Screening helps in early detection and treatment of precancerous lesion, thereby preventing their progression into cancer and increasing the survival rate of patients.
In this study, 1,000 pap smears were analysed using the Bethesda System of Classification. Among them, there was a predominance of inflammatory smears accounting for 51% (510). Following that there were 24.6% (246) normal cases. Infection constituted 19.7% (197) of all the smears, constituting bacterial vaginosis 9% (90), candida 1.8 % (18), trichomonas vaginalis 8.2% (82) and leptothrix0.7% (07).
This majority of inflammatory smears and increased rate of infections could be attributed to the poor hygiene and low socio-economic conditions in the rural setup. In our study, there were 4.7% (47) of epithelial abnormalities in 1,000 smears. Among them, 2.8% (28) were L-SIL, 1.4% (14) were H-SIL, and 0.5 % (05) were SCC.
This was compared with a study done by L Sarala et al[3] where out of 1000 cases, 6 cases (0.6%) showed ASCUS, 2 cases (0.2%) showed LSIL, HSIL was seen in 3 cases (0.3%) and invasive squamous cell carcinoma was reported in 1 case (0.1%). Another study performed by Sabina Shreshta et al[10], where out of 1000 cases, 2.7% (27) were reported as ASCUS, 4.3% (43) were L-SIL, and 2.9% (29) were H-SIL.The lower percentage of epithelial changes in this study might be due to social and cultural differences, age, and lack of awareness of cervical screening programmes.
 Also, anxiety, fear of the positive results and lack of cure of cervical cancer could add on to a low Pap test uptake.[4] In developing countries, conventional pap smear screening programs have led to a decrease in new cases of cervical cancer.[6]
This study establishes that Conventional pap smear is a good and effective screening procedure for early diagnosis of cervical cancer. In the present era, Liquid based cytology is considered the standard procedure for pap smear. This study has its limitation due to unavailability of the newer techniques. The sensitivity of Pap smear can be improved if it is assisted with other screening techniques like visual inspection along with HPV DNA testing.
Conclusion
Conventional Pap smear test is a convenient and potent procedure for screening of cervical cancer, as it is reasonably affordable, easily performed and widely available for the patients. For developing countries like India, which have a high disease burden, HPV vaccines can prove highly successful in controlling cervical cancer. There is a high need to create awareness about Pap smear test and HPV vaccination by educational activities and media programmes on a broader scale.
Acknowledgements: Nil
Financial support and sponsorship: Nil
Conflict of interest: Nil


References
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Address for Correspondence: Dr Aakanksha Koul, Postgraduate, Dept of Pathology, Sri Siddhartha Medical College, Tumkur, Karnataka, India Email: akoul91@gmail.com


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