European Journal of Cardiovascular Medicine

Cervical cancer is ranked as the fourth most common female cancer worldwide ^[1]. It     is also estimated that most deaths (90%) occurred in low- and middle-income nations. In the Caribbean, it is the second cause of death among females ^[2]. Its mortality rate is thrice that of North America and is estimated to increase by 45% by the year 2030 ^[3]. According to the World Cancer statistics, >80% of all the cervical cancer cases are found in developing and low-resource countries, because of lack of awareness and difficulty in running cytology-based screening programs.^[4] More than one-fifth of all cervical cancer deaths occur in India. ^[5] Every year, 122,844 women in India are diagnosed with cervical cancer, and 67,477 women die from the disease. ^[6] Early cervical epithelial changes can be identified by a Pap smear test, which is the primary screening test for detection of precancerous cervical intraepithelial neoplasia and the early stage of invasive cervical cancer. Due to widespread screening programs, there has been a significant reduction in mortality from cervical cancer in developed countries. Therefore there is need of predetection of premalignant changes in cervix.

Cervical cell abnormalities include squamous cell and glandular cell abnormalities. Squamous cell abnormalities include low-grade squamous intraepithelial lesions (LSIL), high-grade squamous intraepithelial lesions (HSIL), atypical squamous cells of undetermined significance (ASCUS), atypical squamous cells cannot exclude HSIL (ASC-H), and invasive squamous cell carcinoma. Glandular cell abnormalities include atypical glandular cells and adenocarcinoma ^[7]. These cellular abnormalities are identified in satisfactory specimens obtained from cervical samples during screening programmes or following symptomatic clinical evaluation of cervical pathology diagnosis ^[8].

The overall sensitivity of the Pap test in detecting a high-grade squamous intraepithelial lesion (HSIL) is 70.80%. ^[9] A Pap screening done in association with an HPV DNA test increases the sensitivity for early detection of precancerous lesions.

There is a need to spread cervical cancer screening awareness programs, educate women regarding the symptoms of cancer, and motivate them to visit the hospital for a cancer screening. Women and all family members should be counseled about the need for cancer screening. Pap smear-positive women need adequate treatment and regular follow-up. Thus, we have to strengthen our health services and health-care system to include screening at primary health centers. The aim of the present study was to evaluate women for precancerous lesions using the Pap smear test and investigate clinical correlation. ^[10]

AIM: To study role of primary screening in various infectious cervical diseases in a Tertiary care centre.

Objective: To study infectious cervical diseases in primary cervical screening and clinical symptoms of various cervical diseases.

This study comprised of the screening of 1107 pap smears using standard cervical cytology protocol over one year. The selection criteria consisted of patients who underwent pap smear examinations at a Tertiary care centre. They were evaluated for patient clinical and histopathology information from the medical records department, which included patient demographics, risk factors, clinical findings, and histopathology diagnosis. The data obtained were analyzed with the descriptive data analysis Statistical Package for the Social Sciences (SPSS) version 23 software. Descriptive data analysis included calculations of central tendencies- mean, percentages and other estimates of the demographic of the sample generated. Further analysis using frequencies and percentages was utilised to determine the frequency of abnormal cervical cytology, clinical signs and symptoms and histopathology.

The samples were smeared on two glass slides and were examined by Pathologist. The smears were stained using the conventional Papanicolaou technique, in which different dyes and acids are selectively retained by cells. The Bethesda lsystem broadly divides lesions into those negative for intraepithelial neoplasia and epithelial cell abnormalities (NILM) that include squamous and glandular cells. Women who had abnormal Pap test results, including atypical squamous cells of undetermined significance (ASCUS), low-grade squamous intraepithelial lesion (LSIL), and HSIL were sent for a Colposcopic examination. Women who had an abnormal Colposcopic finding, i.e., a Reid score 6 or above, underwent a colposcopy-guided biopsy.

Table1: Distribution of age Group

Table2: Frequency of cytology findings from pap smears in the sample population.

Table4: Distribution of various diseases according to Bethesda classification

Cervical cancer is the most common female cancer in developing countries. The widespread use of various screening methods has resulted in a dramatic decline in cervical cancer mortality over the last decades. Over 95% of the cervical cancer burden is potentially avoidable by good-quality screening programmes and vaccination against HPV16 and 18. In high resource settings, cytology (Pap smear) is the most widely used screening test. [8] Cervical cancer screening aims to detect precancerous changes, which, if not treated, may lead to cancer. In resource-poor settings, 30 to 49-year-old women comprise the target audience because cervical cancer is rare in women under 30 and most common in women over 40 years. [10]

In our study we included 1107 females with mean age of 36 and majority of women (50%) were aged between 36-42 years. In our study, Patients presenting complaints were - white discharge (21.4%), abdominal pain (7.4%) and cervix hypertrophy (31%). In a study by Papa Dasariet. al. in 2010 Pap smear was done for persistent symptoms with white discharge per vagina in 44.7% cases, abnormal bleeding per vagina for 12% cases and post coital bleeding in 06% cases. The corresponding figures in the present study were 21.4%, 28.4% and 3.1%, respectively. Those who underwent further evaluation, 3.8% and 7.7% participants were found to have positive findings in colposcopy and HPV testing who inturn were confirmed on histopathological examination. [11]

Our study findings are concordant with findings of Ahmed et al [12], he concluded white discharge as common complaints and Vaginosis as common diagnosis among pap smears observed. Also SCC as highest among the various histologically types of carcinoma cervix, majority (64.4%) were of SCC type, while adenocarcinoma was found among 24.1% of study participants. This was contrary to the observation made by Sherris J et.al. [13] One study performed in Bangladesh by Urmila Banik et. al. showed that among the total of 1699 patients who had their Pap smear done, 139(8.18%) revealed epithelial cell abnormality with breakup of 6.36 % LSIL, 1.18% HSIL and 0.18% cases of ASCUS. [14] In another study carried out by Edelman et.al. Pap smear was performed in 29295 females over a period of one year and the Pap smear abnormalities were as follows: 9.9% ASC- US, 2.5% LSIL, 0.6% HSIL and 0.2% invasive cancer. [15] This difference might be due to different study population belonging to different races and geographical areas with different socioeconomic status and small sample size as well Abnormal cervix is a common nonspecific finding on speculum as well as cytological examination and many cases may be wrongly interpreted as cancerous or precancerous lesions leading to unnecessary 'panic' hysterectomies out of cancer phobia in minds of patients and treating doctors. Colposcopy has proved to be an excellent method, for distinguishing a normal cervix from a cervix with high grade lesions and invasive cancer. [14] Modern colposcopy is an intermediate link between cytology and histology. Its drawback lies impossible over interpretation and thus potential over treatment of low grade lesions which otherwise regress in majority (80%) with a risk of progression to invasive cancer in only 1% of cases. [16] Therefore Colposcopy should be done with pap smear examination to get best, rapid and accurate result. Among total 1107 females 980 females came for normal health checkup, 127 females were diagnosed with various diseases.

Early detection and treatment of precancerous lesions can result in massive improvements of survival, and are especially important in developing countries with low cost set up and where access to expensive cancer treatment is limited. Detecting cervical cancer early with a Pap smear and confirmed by colposcopic examination gives you a greater chance to treat. A Pap smear can also detect changes in your cervical epithelial cells that suggest cancer may develop in the future. Clinical picture with pap smear examination

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