JMidlifeHealth.2015AprJun6(2):5358.

PMCID:PMC4481740

doi:10.4103/09767800.158942

Comparativestudybetweenpapsmearandvisualinspectionwithaceticacid(via)inscreeningof
CINandearlycervicalcancer
AshishKumarBhattacharyya,JyanDipNath,andHarajyotiDeka
DepartmentofObstetricsandGynaecology,GauhatiMedicalCollegeandHospital,Guwahati,Assam,India
AddressforCorrespondence:Dr.JyanDipNath,DepartmentofObstetricsandGynaecology,GauhatiMedicalCollegeandHospital,Guwahati781032,Assam,India.Email:
nathknowledge@rediffmail.com
Copyright:JournalofMidlifeHealth
ThisisanopenaccessarticledistributedunderthetermsoftheCreativeCommonsAttributionNonCommercialShareAlike3.0License,whichallowsotherstoremix,tweak,andbuild
upontheworknoncommercially,aslongastheauthoriscreditedandthenewcreationsarelicensedundertheidenticalterms.

Abstract
Background:

Cervicalcanceristhesecondmostcommonamongwomenglobally.InmostcasesofAssam,CaCervixisdetectedlateduetolackof
effectivescreeningprogramme.
Aim:

ToscreenthepatientatGynaecologyOPDattheage1860yrsbydoingpapsmear,VIA(VisualInspectionwithAceticAcid)andto
detectsensitivityandspecificityfordetectingCINandearlyCaCervix.
MaterialandMethod:

Itisacrosssectionalstudyof300women(1860yrs)whofulfillselectioncriteria.ThepapsmearandVIAaredoneinthesecases.In
positivecases,cervicalbiopsyandhistopathologicalstudiesaredone,Thesensitivityandspecificityofeachtestaredeterminedand

compared.
Resultandobservation:

Thepositiveresultdetectedfromcytologyare22,VIAwaspositivein52cases.Thehistologyof19casesaresuggestiveofCINandCa
Cervix.
Discussion:

Thefindingswerecomparedwithotherstudiesandevaluated.
Summary:

Themostcommonfindinginperspeculumexaminationiscervicalerosion.ThesensitivityofVIAis89%(versuspapsmear52%)the
specificityofVIAis87%(versuspapsmear95%).TheaccuracyVIAis87%comparedtopapsmear93%.
Conclusion:

ThelackofeffectiveandimplementablescreeningprogrammeleadtoreportingofadvancedcasesofCaCervix.IfdetectedatCINor
earlyCacervixstage,effectivetreatmentcanbeprovidedwithencouragingresults.Thereforeeffective&implementableCaCervix
screeningneedtobeprovidedinourcountry.
Keywords:CaCervix,PapSmear,VIA
INTRODUCTION
Cervicalcanceristhesecondmostcommoncanceramongwomenglobally.Anestimated550,700newcasesand286,823deathsdueto
cervicalcancerareestimatedtohaveoccurredin2010.Morethan85%casesand88%deathsfromcervicalcanceroccurindeveloping
countries,wherewomenoftenlackaccesstocervicalcancerscreeningandtreatment.Indiaaloneaccountsforonefourthoftheglobal
cervicalcancerburden.Althoughadvancedcervicalcancercaseshavebecomeveryrareindevelopedcountries,mostcasesinAssamare
detectedlate(stage3or4)duetolackofeffectivescreeningprogram.
Theincidenceinthedevelopedworldisonly1.8perlakhwomen(2464years)incontrastto18.9perlakhwomeninKamrupMetro
Districtin2006(ICMR).
Despitetheimportanceofpublichealth,therearenoeffectivepreventionprogramsinthenortheasternpartofIndiaandhencetheriskof
anddeathfromcervicalcancerremainlargelyuncontrolled.

Invasivecervicalcancerisprecededbyalongphaseofprecancerouslesionthatcanbedetectedbyscreeningandtreatedeffectivelyby
simpletreatment,whichcanpreventinvasivecancer.
ThecytologybasedscreeningiseffectivebutbeyondthecapacityofhealthservicesinAssam.Interpretationofcytologyisdifficultas
cytologistsarenoteasilyavailableinperiphery.Moreover,patient'sneedtocometocollectreportmayleadtolossofthepatientfor
followup.Henceothermethodsofearlydetectionofcervicalneoplasm,particularlythosebasedonvisualinspectionarebeing
investigated.
Asimplelowcosttechniquescreeningtest,namelyvisualinspectionwithaceticacid(VIA),whichisbasedontheabilityofthetrained
healthcarepersonneltodetectacetowhiteinthecervicaltransformationzone,iscurrentlybeingevaluatedintheexperimentalsettingasa
potentialalternativetocervicalcytology.
PublishedresultsshowthatVIAhassimilarsensitivitybutsomewhatlowerspecificitywhencomparedtoqualitycytology.
Thescreeningprogramshouldinvolvewomenbetweenagesof18and55yearsatthreeyearintervals.
AimandObjectiveoftheStudy

ToscreenpatientscomingtogynecologyOPDbetweenagesof18and60yearsbyPapsmearandVIAandtodetectthespecificityand
sensitivityofeachtestforidentifyingcervicalintraepithelialneoplasia(CIN)andcervicalcancerbycomparingwiththehistologyfrom
positivelyscreenedwomeninallthree,sothatwecanapplyVIAatgrassrootslevel(wherePapsmearisnotfeasible)andtodetectCIN
andcervicalcancerattheearlieststage.
MATERIALSANDMETHODS
ThepresentstudywasconductedintheDepartmentofObstetricsandGynecology,GauhatiMedicalCollegeandHospital,Guwahati,
fromJune1,2012toMay31,2013attheGynecologyOPD.Thiswasacrosssectionalstudyconductedin300women(1860years)
whofulfilltheselectioncriteriaaftertakingproperconsent.TheaveragenumberofwomenwhoattendedGynecologyOPDwas60per
day.Amongthem,womenwhofulfilledtheselectioncriteriawererandomlyselected.PositivetestsforcytologywereCIN1orabove,
VIAshowingopaqueacetowhitelesiononapplying4%aceticacidorVILI(visualinspectionwithLugol'sIodine)detectionofdefinite
yellowiodinenonuptakeareaswithLugol'siodineinthetransformationzoneorclosetotouchingthesquamocolumnarjunction.The
studywascombinedwithVIA,VILI,Papsmearinfindinglesioninthecervixfordoinglargestudywithdifferenttechniques.Inthis
study,thecomparisonwasdonebetweenPapsmearandVIA.Positivecaseswerescheduledforbiopsiesandhistologicalevaluation.
SELECTIONCRITERIA

Inclusioncriteria

Patientsintheagegroupof1860yearswereincludedinthestudyandprioritywasgiventopatientswiththefollowingriskfactors:
Earlymarriage.
Earlypregnancy(teenagepregnancy).
Sexualactivityatearlyage.
Multiparity.
Multiplesexualpartners.
WomenwithSTI,leukorrhea,abnormalvaginalbleeding.
ExclusionCriteria

Unmarriedpatients.
Patientsbelow18yearsandabove60years.
PatientswithbleedingP/Vandactiveinfectionatthetimeofexamination.
Womenwithfrankinvasivecervicalcancer.
RESULTSANDOBSERVATIONS
ThepresentstudyComparativestudyamongPAPsmearandVIAinscreeningofCINandearlycervicalcancerwascarriedoutinthe
DepartmentofObstetricsandGynecology,GauhatiMedicalCollegeandHospitalfromJune1,2012to31May,2013.Theresultsand
observationsofthestudyarepresentedbelow.Positiveresultsobtainedfromcytologywere22.VIAwaspositivein52womenandVILI
waspositivein26.Cervicalbiopsywasdonein62womenwhohadpositiveresults(10werepositiveforallthreetests,4werepositive
forVIAandPapsmear,14werepositiveforVIAandVILI,24werepositiveforonlyVIA,2werepositiveforonlyVILI,and8were
positiveforonlyPapsmear).Histologyin19caseswassuggestiveofCINandcarcinoma.Althoughnotincludedinthepresentstudy,
VILIwasaddedtomakethestudylargeandtoincludeadifferenttechnique.
Relationwithage[Figure1a]

Inourstudy,14%ofthecaseswereintheagegroupof1829years,34%intheagegroupof3039years,36%intheagegroupof4049
yearsand16%intheagegroupof5059years.InCINgroup,3%wereintheagegroupof1829years,3%in3039years,24%in40
49yearsand18%in5059years.Incervicalcancergroup,1(3%)wasintheagegroupof4049yearswhile2(6%)wereintheage
groupof5059years.

Relationwithparity[Figure1b]

Inourstudy,45caseshadparity2while255caseshadmorethanparity2.TheincidenceofCINwasmoreincaseswithparitymore
than2(54%).Therewerenocasesreportedofcervicalcancerwithparity2orlesstheincidenceofcervicalcancerwas6%inparity
above2.
Relationwithliteracy[Figure1c]

Inthisstudy,156(52%)caseswereilliteratewhile144caseswereliterate.Theliteracyratewasnotseentoaffecttheresult.
Relationwithdurationofmarriage[Figure1d]

Inthisstudy,21casesweremarriedforlessthan10years,129casesweremarriedfor1020years,while150casesweremarriedfor
morethan20years.ThehighestnumberofCIN(30%)andcervicalcancer(6%)areinthegroupmarriedformorethan20years.
Relationwithageofmarriage[Figure1e]

Inourstudy,243casesweremarriedattheageof18yearsorlessand57casesweremarriedatmorethan18yearsofage.Theincidence
ofCINwasmore(46%)incasesmarriedat18yearsorless,whiletheincidenceofcervicalcancerwas6%intheearlymarriagegroup.
Relationwithsocioeconomicstatus[Figure1f]

Inourstudy,180casesbelongedtolowsocioeconomicstatus,108casesbelongedtomiddleclass,while12casesbelongedtohigh
class.IncidenceofCINwasfoundtobehigher(30%)inthelowsocioeconomicgroup.Asthecaseofcervicalcancerislow,itis
difficulttocommentontheeffectofsocioeconomicstatusincervicalcancer[Tables14].
DISCUSSION
Agedistribution

Inthepresentstudy,highincidenceofCINwasfoundintheagegroupof4049years(36%).
Paritystatus

Inthepresentstudy,incidenceofCINwasfoundmoreincaseswithparity>2(54%)alsotheincidenceofcervicalcancerincreased
withparitymorethan2(6%).
Socioeconomicstatus

InthepresentstudyitwasfoundthattheincidenceofCINwashigherinlowersocioeconomicclass(30%)alongwithincreased
incidenceofcarcinomaceiTixinthisgroup(3%).
ThefactorresponsibleforhigherincidenceofCINandcacervixinlowereconomicgroupincludepoorpersonalhygiene,poorliving
condition.Illiteracy,unstablemarriage,earlyageatfirstintercourse.
Durationofmarriage

Durationofmarriageanddurationofexposuretosexualintercoursehasanimportantroleinthegenesisofcervicaldysplasia.
Inourstudy,thehighestnumberofCINcases(30%)andcacervix(6%)areintheagegroupmarriedformorethan20yrs.Itwasalso
foundearliertheageofmarriage(age<l8)moreistheincidenceofCIN.
Papsmearfindings

PositiveresultsobtainedfromPapwere7.3%(22).SensitivityofPapsmearwasfoundtobelow52%comparedtospecificitywhichwas
95%.Thiswasattributedtohighnumberfalsenegativesmear.
VIAfinding

VIAwaspositivein52womenoutof300cases.
SensitivityofVIAwasfoundtobe89%comparedtospecificity,whichwas87%.
SUMMARY
ComparativestudybetweenpapsmearandVIAwithcervicalbiopsy

Inthepresentstudy,acomparisonwasdonebetweenPapsmearandVIAwithhistopathology.ThesensitivityofVIAwasfoundtobe
89%(versusPapsmear,whichhad52%)whilethespecificityofVIAwas87%(versusPapsmear,whichhadaspecificityof95%).
Thus,VIAshowedhighersensitivitycomparedtoPapsmear,whereasVIAhadlowerspecificitycomparedtoPapsmear.Lower
specificityofVIAwhencomparedtoPapsmearwasduetothehighincidenceofsuspectedacetowhiteepithelium,whichmightbe
inflammation,immaturemetaplasiaorlatentHPVinfection.
Theresultsweretabulatedandanalyzed.
Incidenceofpreinvasivecarcinomacervixismoreinthe4049yearsgroup.

IncidenceofCINandcarcinomacervixismoreinwomenmarriedformorethan20years.
IncidenceofCINandcarcinomacervixismoreinlowsocioeconomicclass.
IncidenceofCINandcarcinomacervixismoreinparitymorethan2.
IncidenceofCINandcarcinomacervixismoreinthecasesmarriedat18yearsorless.
Themostcommonfindinginperspeculumexaminationiserosion.Inthepresentstudy,comparisonwasdonebetweenPapsmearand
VIAwithhistopathology.SensitivityofVIAwasfoundtobe89%(versusPapsmear,whichhad52%)andspecificityofVIAwas87%
(versusPapsmear,whichhadspecificityof95%).
Thus,VIAshowedhighersensitivitycomparedtoPapsmear.VIAhaslowspecificityascomparedtoPapsmear.Itwasobservedthat
thereisasignificantassociationbetweenthehistopathologyreportandthePapsmearreportasfarasthenegativepredictivevalueis
concerned.AccuracyofVIAis87%comparedto93%inPapsmear.NegativepredictivevalueofVIAis99%ascomparedto96%in
Papsmear.Positivepredictivevalueis45%inPapsmearascomparedto32%inVIA.
CONCLUSION
Thishighincidenceofcervicalcancermaybeattributedtothelackofawarenessamongthemassesaswellaseveninsomeofthe
doctorsworkingintheperiphery.Thelackofeffectivescreeningprogramleadstoreportingofveryadvancedcasesofcervicalcancer
cervixwheremortalityandmorbidityisveryhigh.Itisafactthatmanycasesreportingforvaginalbleedingordischargearenoteven
examinedvaginally,thus,missingthediagnosisatanearlystage.Advanceddiseasesinvolvehighfinancialburden,limitedtreatment
options,stress,losstothefamilyandhighermortality.Thisgrimscenarioprevalentinoursocietyispreventableprovidedwecancreate
awarenessandimplementeffectivescreeningprogramasapublichealthmeasure.
PAPsmearscreeningneedsgoodinfrastructure,trainedmanpowertomake&interprettheslideswhichisnotfeasibleconsideringthe
facilitiesavailableintheperiphery.
Thepatientalsousuallydoesnotcomebacktocollectthereportandmaybelosttofollowup.
ThereisalsointerpersonalinterpretationvariationincaseofPapsmear.
HoweverVIAcanbedoneevenbysistersintheremotestplacewithminimumfacilities&patientisdiagnosed.Sopatientcomplianceis
alsobetter.TheVIAisaccuratescreeningtestandsuitablealternativetopapsmear.SowewanttoincludeVIAinscreeningprogramme.
FromtheresultsofthisstudyitisevidentthatVIAismoresensitivethanPapsmearandspecificityofVIAisslightlylesstoPap
smear(generallyspeakingPapsmearismorespecific).

ThusbycombiningVIAalongwithPapsmearwecanmaximizethesensitivityandspecificityofcancercervixscreening,whichare
morecosteffectiveandpracticallyimplementable.
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FiguresandTables
Figure1(a)

Relationwithage
Figure1(b)

Parity
Figure1(c)

Relationwitheducationstatus
Figure1(d)

Durationofmarriage
Figure1(e)

Ageatmarriage
Figure1(f)

Socioeconomicstatus
Table1

AssociationbetweencervicalbiopsyreportwiththeresultofPAPSMEARtest(d.f.degreeoffreedom,**highlysignificant
Table2

SensitivityansspecificityofPAPSMEARwithcervicalbiopsyreportInterpretationithasbeenfoundthatthereissignificantassociation
betweenthehistopathologyreportandPAPSMEARreport(asP<0.01)
Table3

ShowingtheassociationbetweencervicalbiopsyreportwithresultofVIA
Table4

Sensitivity&SpecificityOfVIAwithCervicalBiopsyReport

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