Prevalence of epithelial abnormalities in cervicovaginal PAP test among Anganwadi workers in Bengaluru

Introduction

Cervical cancer is one of the most preventable and curable forms of cancer, as long as it is detected early and managed effectively. Cervical Cancer is caused by Human PAPilloma virus (HPV). In addition, early sexual contact, multiple sexual partners, and taking oral contraceptives (birth control pills) increase the risk of cervical cancer because they lead to greater exposure to HPV. HPV16 and HPV18, are responsible for most HPV-related cancers.¹ Each year, more than 300 000 women die of cervical cancer. More than half a million women are diagnosed with Cervical Cancer worldwide andevery minute, one woman is diagnosed. Cervical cancer is one of the greatest threats to women's health.² In 2018, estimated agestandardized incidence rates for both sexes and all ages worldwide is 13.1 per 1,00,000 population.³

Cervical cancer is the second most common cancer in India in women accounting for 22.86% of all cancer cases in women and 14.7% of all cancer cases in both men and women.^3,4 According to National Cancer Registry Programme 96922 new cases were registered in 2018. Among which 60,078 deaths were reported which accounts for 61.9% of mortality. The relative five year survival averages to 48.7%. Length of survival depends on the cancer stage at the time of detection. The survival chance of a person becomes better if the cervical cancer is detected and treated at earlier stages.⁴ World Health Organisation (WHO) is working to eliminate cervical cancer as a global public health problem. Also, it says to act early or else deaths from cervical cancer will rise by 50% by 2040. According to “Best Buy” Interventions for the Prevention and Control of Non Communicable Diseases;prevention of cervical cancer by screening women aged 30-49, either through: visual inspection with acetic acid linked with timely treatment of pre-cancerous lesions; PAP smear (cervical cytology) every 3-5 years linked with timely treatment of precancerous lesions or; Human PAPillomavirus test every 5 years linked with timely treatment of pre-cancerous lesions.⁵ National cancer control programme (NCCP) is a public health programme designed to reduce the number of cancer cases and deaths and improve quality of life of cancer patients. National Cancer Institute defines Cervico vaginal PAP smear as a procedure in which a small brush or spatula is used to gently remove cells from the cervix so they can be checked under a microscope for cervical cancer or cell changes that may lead to cervical cancer. A PAP smear may also help find other conditions, such as infections or inflammation of Human PAPilloma Virus. Also called as PAPanicolaou test. PAP test results show if cervical cells are normal or negative for intraepithelial lesion (NIEL), inadequate smear/unsatisfactory, abnormal. Abnormal PAP test results include Atypical Squamous Cells of Undetermined Significance (ASC-US), Atypical Glandular Cells (AGC), Low-Grade Squamous Intraepithelial Lesions (LSIL), Atypical Squamous Cells, Cannot Exclude HSIL (ASC-H), High-Grade Squamous Intraepithelial Lesions (HSIL), or Adenocarcinoma In Situ (AIS). These changes may be referred to as dysplasia, neoplasia, or precancer – cells and cancer cells. An abnormal test result may also be called a positive test result. A positive PAP smear results require further follow-up with repeat PAP test, HPV test, Colposcopy and Biopsy accordingly.⁶

Therefore cervical cancer screening plays a pivotal role in reduction of mortality and morbidity related to it. Thus, this study was conducted among Anganwadi workers to evaluate the epithelial abnormalities and screen for Cervical Cancer using Cervico – vaginal PAP test (CVPT).

Materials and Methods

A cross sectional study was conducted in Bengaluru Urban during the months of October 2018. Approval was obtained from the Institutional Ethics Committee of Bangalore Medical College and Research Institute (BMCRI). Also co-ordinated with Department of Obstetrics and Gynaecology (OBG) and Department of Pathology, BMCRI. The teachers of Anganwadi under ICDS were selected for screening. There were about 250 Anganwadi teachers in Bangalore Urban Anganwadi. A screening camp was organised in a government PHC in co-ordination with OBG department. Those who were present on the day of camp were screened. Universal sampling technique was used to screen the Anganwadi teachers.

A pre-tested semi structured questionnaire was used to collect the data regarding the participants. Socio demographic details, Marital history, Family size, Menstrual history and Obstetric history was taken into accord. PAP test was done using Ayre’s spatula and Cyto brush as per recommendation.

Collection of a cervical cytology specimen was performed with the patient in the dorsolithotomy position. A sterile, or single-use bivalve speculum of appropriate size was inserted into the vagina without lubrication. After complete visualization of the os and ectocervix, per vaginal examination was done under sterile conditions adhering to standard protocol. Findings of the same were noted.

The vaginal fornix and ectocervix were sampled using the notched end of the Ayre’sspatula that corresponds to the contour of the cervix. Spatula was rotated 3600 around the circumference of the cervical os, retaining the sample on the upper surface. Sampling of the endocervix was done by insertion of the endocervical brush into the endocervical canal. The brush was rotated 45-90º and removed and the sample on the spatula was spread evenly and thinly lengthwise down one half of the labelled slide surface, using a single uniform motion. The endocervical brush was then rolled along the remaining half of the labelled slide surface by turning the brush handle and slightly bending the bristles with gentle pressure. The entire slide is then rapidly fixed by immersion or spray and the collection devices were discarded.

The fixed slides were submitted in the Pathology department of BMCRI for reporting. After 3-7 days the reports of the PAP test were collected and the Anganwadi teachers were followed up accordingly.

RESULTS

A total of 196 Anganwadi teachers were screened with PAP smear. Mean age of the screened women was 39. 1years (SD 9.609). All the women were married and majority, 191 (97.4%) of them belonged to Hindu religion. According to Modified Kuppuswamy classification about half of them 103 (52.6%) were Lower Middle (Class III) Socioeconomic status. The diet was predominantly mixed, 152 (77.6%).

Screened women reported no vices. Co-morbidities like Diabetes Mellitus (6.1%), Hypertension (10.7%) and Thyroidism (1.0%) were reported. None of the women had family history of cancer. About 37 (18.8%) of them reported to have white discharge per vagina.

Majority of them had regular cycles 185 (94.3%) with the mean age of menarche being 14.1 years (SD 1.96). Among women who had irregularity of menstrual cycle menorrhagia, 7 (3.6%) was most commonly reported.

The women had mean of married life of 17.89 years (SD 8.48). About 11 (5.6%) of them were nullipara. The mean age of first pregnancy 21.21 years (SD 6.24).More than half of them, 63.2% had 2 pregnancies. 27 (13.8%) women out of 196 had attained menopause and majority by the age of 45- 49 years.

Out of 196, about 34 (17.3%) of the women either refused for PAP smear or were menstruating and 15 (7.6%) were hysterectomised. Thus, PAP smear was taken for 147 (75.0%) of the women who came for screening.

DISCUSSION

The accuracy of CVPT to identify epithelial abnormalities, cancerous and pre-cancerous lesions among women is found to be lesser than Liquid based cytology. However, considering the economic implications of LBC, conventional PAP is more feasible in our setting.⁷ The specificity required for a screening test is found to be 75% for CVPT though the sensitivity is less. CVPT used for screening and along with Cervical biopsy results can be employed for better identification of cancerous and pre-cancerous lesions.⁸

In this study the women were screened for epithelial abnormalities, cancerous and precancerous lesions using CVPT. All the women who attended the camp were taken into consideration. Mass awareness regarding Cervical cancer and importance of screening was given. However, it required individual counselling during data collection for further acceptance of the procedure by the women.

In our study among 147 screened women 41.5% had normal smear or NIEL and about 51.1% had inflammatory smears. In our study 5 smears were found to be of bacterial vaginosis, Candidiasis and Trichomonas Vaginalis. A study conducted by Shaki O et al in 2018,⁹ screened 1100 women in the age group of 21-65 years using CVPT. Of 1100 cases, majority of the cases were benign, 52.8% cases and 18.4% were inflammatory.

On a total about 6 (4.1%) smears showed abnormality. Out of which 4 (2.7%) smears had ASCUS and 1 (0.6%) each of ASGUS and HSIL. In study conducted by Shaki O et al,⁹ ASCUS was about 4%,LSIL in 6.8% and HSIL in 6% of the women.

Conclusion and Recommendation

Cervico-vaginal PAP test is easy, non-invasive, useful, simple, safe, and very economical tool to screen women for pre-invasive cervical epithelial lesions and other epithelial abnormalities. However, it is to be used only as a screening tool and not a diagnostic tool. Cervical biopsy for further evaluation of abnormal smears can be used for confirmation of the lesions.

All women should begin cervical cancer testing (screening) at age 21. Women aged 21 to 29, should have a PAP test every 3 years. Beginning at age of 30, the preferred way to screen is with a PAP test combined with an HPV test every 5 years. It is evident and proven that every woman above the age of 30-35 years must be subjected to cervical screening and this must be continued even in the postmenopausal period. Also, screening among high risk individuals and early detection plays an important role in reducing the morbidity and mortality of cervical cancer.