European Journal of Cardiovascular Medicine

Cervical cancer remains one of the most significant yet preventable malignancies affecting women worldwide, disproportionately burdening low- and middle-income countries (LMICs) where organized screening infrastructure remains limited. Earlier global estimates identified cervical cancer as the fourth most common cancer among women, contributing to nearly 7.5% of female cancer deaths worldwide [1]. More recent data from the Global Cancer Observatory (GLOBOCAN 2022) place the global burden at 662,301 new cases and 348,874 deaths, confirming cervical cancer's continued standing among the leading causes of cancer incidence and mortality in women [2, 3]. The burden is particularly acute in India, where cervical cancer ranks as the second most common malignancy among women, accounting for an estimated 127,526 new cases and 79,906 deaths in 2022 [2, 3], with an age-standardized incidence rate of 10.3 per 100,000 — higher than the rates reported among Chinese (9.5/100,000) and Malay (5.3/100,000) populations [4]. By contrast, high-income countries such as England have achieved substantial declines in incidence and mortality following the introduction of organized cytology-based screening, with incidence falling from 14–16/100,000 in the 1970s–1980s to 9/100,000 by 1995, and mortality declining from 11.2/100,000 in 1950 to 3.7/100,000 by 1997, a decline that coincided with the scale-up of population-based screening programs over the same period [5].

The pathogenesis of cervical cancer is well characterized, arising predominantly from persistent infection with high-risk human papillomavirus (HPV) genotypes, which drives progression through a recognizable continuum of cervical intraepithelial neoplasia (CIN I–III) before culminating in invasive carcinoma. [6] This slow, stepwise natural history — typically spanning years to decades — creates a critical window during which precancerous lesions can be identified and treated, preventing progression to invasive disease [6]. Cervical cancer screening may accordingly be implemented as mass screening of the general population, selective screening of high-risk groups, or multiphasic screening combining several modalities [6].

The Papanicolaou (Pap) smear remains the most widely available, feasible, and cost-effective cervical cytology-based screening tool for detecting premalignant and malignant cervical lesions, and is particularly well suited to resource-limited settings [7]. Its contribution to population-level disease control is well documented: organized cytology-based screening programs, such as those implemented in England, have been associated with sustained reductions in both cervical cancer incidence and mortality over several decades [5], while trial-based evidence from screened populations has confirmed the capacity of Pap cytology to detect high-grade precursor lesions before progression to invasive disease [8]. Nonetheless, diagnostic accuracy varies considerably across studies, ranging between 53% and 78% depending on interpretation methods (Najib FS, 2020), with reported sensitivity and specificity for high-grade lesions (CIN II–III) of 55.4% and 96.8%, respectively [8]. Limitations such as sampling error, observer variability, and false-negative results necessitate repeated screening cycles and, where indicated, referral for colposcopy — an adjunct that remains less widely available and more costly [9]. Histopathological examination via biopsy remains the diagnostic gold standard, though it is invasive and carries risks of pain, bleeding, and fibrosis [10, 11]. Despite these limitations, cytology-based screening continues to be regarded as a practical cornerstone of population-based cervical cancer control, particularly in settings where HPV-DNA testing and other advanced modalities remain inaccessible [6].

Despite this established role, comparative evidence evaluating Pap smear performance specifically under mass screening conditions remains limited to a small number of regional studies [4, 9], leaving a gap in context-specific data needed to guide screening policy in comparable healthcare settings. Therefore, the present study was undertaken to determine the effectiveness of Pap smear in mass screening for cervical lesions

Study Design

This was a hospital-based, observational, prospective study conducted to evaluate the diagnostic effectiveness of Papanicolaou (Pap) smear cytology in the mass screening of cervical lesions, using colposcopically directed cervical biopsy and histopathological examination as the reference standard.

Study Setting

The study was conducted in the Departments of Pathology and Obstetrics & Gynaecology, F.H. Medical College, Tundla, Firozabad, Uttar Pradesh, India, over a period of 18 months.

Study Population

The study population comprised women attending the outpatient gynaecology services for cervical cancer screening during the study period. Eligible participants underwent Pap smear examination as part of routine cervical screening, with demographic and clinical data recorded at the time of enrolment.

Sample Size

The sample size was calculated using the standard formula for estimation of sample size for a single proportion:

n = (Zα/2)² × p × (1 − p) / d²

where Zα/2 = 1.96, the critical value of the standard normal distribution corresponding to a 95% confidence level; p = the expected proportion of patients with a positive Pap smear and a concordant positive biopsy report for intraepithelial lesion or malignancy, taken as 79.5% based on prior published literature; and d = the desired margin of error, taken as 5%. Based on these assumptions, the minimum required sample size was calculated as 250 participants, achieved with 80% statistical power at a 95% confidence level. This a priori prevalence estimate is compared against the prevalence of biopsy-confirmed lesions observed in the present study, as presented in the Results.

Sampling Technique

Consecutive sampling was employed, whereby all eligible women presenting to the outpatient gynaecology department for cervical screening during the study period were enrolled sequentially until the calculated sample size of 250 was achieved. This technique was considered appropriate for a hospital-based screening study, as it minimizes selection bias and yields a study population broadly representative of women accessing routine cervical cancer screening at the study site.

Eligibility Criteria

Inclusion criteria: Women undergoing Pap smear screening for cervical lesions who provided written informed consent for participation.

Exclusion criteria

Women who declined to provide consent, and women who had previously undergone total hysterectomy.

Ethical Considerations

The study was conducted in accordance with the ethical principles of the Declaration of Helsinki. Approval was obtained from the Institutional Ethics Committee (Research Cell) of F.H. Medical College, Tundla, Firozabad, Uttar Pradesh, India (Approval No. FHMC/IEC/R.Cell/2024/32/PAI), prior to the commencement of the study. Written informed consent was obtained from all participants before enrolment. Confidentiality and anonymity of participant data were maintained throughout the study, and all diagnostic tests performed were part of routine clinical care rather than additional investigations undertaken solely for research purposes.

Data Collection Procedure

Following enrolment, a detailed clinical history was recorded for each participant, including demographic details (age, occupation, and residential address), presenting complaints, obstetric history (parity and pregnancy-related complications), menstrual history (cycle regularity, menorrhagia, and postmenopausal bleeding), and relevant personal, behavioural, and drug history, including tobacco use, sexual history, and use of oral contraceptives or hormonal therapy.

A detailed gynaecological examination was subsequently performed, assessing the external genitalia for warts, ulcers, or lesions, and the vagina and cervix for abnormal discharge, erosions, polyps, or visible lesions.

Cervical cytological samples were collected using Ayre's spatula for the ectocervix and a cytobrush for the endocervix. Samples were smeared onto glass slides, immediately fixed, and stained using the conventional Papanicolaou (Pap) staining technique. Slides were subsequently transported to the Department of Pathology for microscopic evaluation. Cytological findings were reported according to the Bethesda System for Reporting Cervical Cytology (2014), [12] with lesions categorized as Negative for Intraepithelial Lesion or Malignancy (NILM), Atypical Squamous Cells of Undetermined Significance (ASC-US), Low-grade Squamous Intraepithelial Lesion (LSIL), High-grade Squamous Intraepithelial Lesion (HSIL), or Squamous Cell Carcinoma (SCC).

In participants with abnormal Pap smear findings, colposcopically directed cervical biopsy was performed. Biopsy specimens were fixed, processed by standard histopathological technique, and examined microscopically. Cytological findings on Pap smear were subsequently compared against histopathological findings on cervical biopsy to determine the diagnostic performance of Pap smear screening.

Outcome Measures

The primary outcome was the diagnostic accuracy of Pap smear cytology in detecting cervical intraepithelial lesions and malignancy, expressed in terms of sensitivity, specificity, positive predictive value, and negative predictive value, using cervical biopsy as the reference standard. Secondary outcomes included the distribution of cytological abnormalities across age groups and the comparative diagnostic yield of Pap smear versus clinical suspicion in identifying biopsy-confirmed lesions.

Statistical Analysis

Data were entered and managed using Microsoft Excel and analyzed using SPSS software, version 25 (IBM Corp., Chicago, IL, USA). Descriptive statistics were expressed as frequencies and percentages for categorical variables, and as means with standard deviations for continuous variables. The Chi-square test was used to assess associations between categorical variables, and the independent samples t-test was used for comparison of continuous variables. Regression analysis was performed to evaluate associations between independent and dependent variables. The diagnostic performance of Pap smear cytology — including sensitivity, specificity, positive predictive value, negative predictive value, and overall diagnostic accuracy — was calculated using cervical biopsy as the reference standard, with corresponding 95% confidence intervals computed for each parameter. A two-tailed p-value of <0.05 was considered statistically significant.

Table 1: Distribution of Study Participants by Age Group

Table 1 shows the age distribution of the 250 study participants. The highest proportion of women belonged to the 41–50 years age group (32.0%), followed by the 31–40 years group (28.0%). Participants aged 21–30 years and 51–60 years each accounted for 16.0%, while women aged more than 60 years constituted 8.0% of the study population.

Table 2: Pap Smear Results Among Participants

Table 2 presents the cytological findings of Pap smear examination. Normal cytology was observed in 64.0% of participants, whereas 16.0% showed inflammatory smears. Atypical squamous cells were detected in 6.0%, LSIL in 8.0%, HSIL in 4.0%, and squamous cell carcinoma in 2.0% of the participants.

Table-3: Results of Pap smear tests and colposcopically directed cervical biopsies.

Table 3 demonstrates the correlation between Pap smear results and colposcopically directed cervical biopsy findings. Of the 155 Pap smear-positive cases, 90 had positive biopsy findings, while 65 had negative biopsy findings. Among the 95 Pap smear-negative cases, 15 had positive biopsy findings and 80 had negative biopsy findings. The association between Pap smear and biopsy findings was highly statistically significant (p < 0.001).Table-4: Results of cervical biopsy against indication for cervical biopsy.

Table 4 shows the distribution of cervical biopsy findings based on the indication for biopsy.

Table 4 shows the distribution of cervical biopsy findings based on the indication for biopsy. Among women with an abnormal Pap smear, 78 had positive ILM and 77 had negative ILM. In comparison, among women biopsied due to clinical suspicion, 27 had positive ILM and 68 had negative ILM. The difference was statistically significant (p = 0.02).

Table-5: Sensitivity and Specificity of Pap Smear.

 Table 5 summarizes the diagnostic performance of the Pap smear. The test demonstrated a sensitivity of 93.3%, specificity of 96.0%, positive predictive value of 89.7%, negative predictive value of 97.5%, and an overall diagnostic accuracy of 95.0%.

Table 6: Summary Correlation of Clinical Suspicion, Pap Smear, and Cervical Biopsy Findings (n = 250).

Table 6 summarizes the findings of clinical suspicion, Pap smear, and cervical biopsy. Clinical suspicion identified 27 (10.8%) positive cases, whereas Pap smear detected 90 (36.0%) positive cases. Cervical biopsy confirmed 105 (42.0%) cases of intraepithelial lesions or malignancy. These findings indicate that Pap smear detected a higher proportion of cervical lesions than clinical suspicion and showed good correlation with biopsy findings.

The present study demonstrates that Pap smear cytology performed with high diagnostic accuracy in the mass screening of cervical lesions, showing strong concordance with colposcopically directed cervical biopsy and outperforming clinical suspicion alone as an indication for biopsy. These findings support the study's objective, confirming Pap smear as an effective, reproducible tool for population-level cervical cancer detection, particularly where histopathological confirmation of every case is not feasible.

The highest proportion of participants belonged to the 41–50-year age group (32.0%). Justa et al. (2024) [13] similarly reported that women aged 41–50 years constituted the largest screened cohort in a prospective hospital-based study conducted in Himachal Pradesh, India, where this age group accounted for nearly half of all participants recruited through routine and opportunistic gynaecological screening. The present findings are consistent with this observation, likely reflecting the cumulative biological effect of long-standing high-risk HPV exposure combined with the increased clinical vigilance directed toward women approaching the perimenopausal transition.

Regarding cytological findings, the present study reported normal cytology in 64.0%, inflammatory smear in 16.0%, atypical squamous cells in 6.0%, LSIL in 8.0%, HSIL in 4.0%, and squamous cell carcinoma in 2.0% of participants. Makwana et al. (2023) [14] reported a broadly comparable distribution, with NILM in 60%, ASC-US in 15.2%, LSIL in 12%, HSIL in 8%, and squamous cell carcinoma in 4.8% of cases. Our findings are comparable to those reported by Makwana et al., (2023) [14] particularly for high-grade lesions. In contrast, Justa et al. (2024) [13] reported a markedly higher proportion of normal cytology (86.11%) and correspondingly lower high-grade lesion rates. This difference may be explained by variation in the screened population and regional HPV prevalence, as well as differing institutional thresholds for biopsy referral.

The present study demonstrated a statistically significant association between Pap smear and biopsy-confirmed diagnosis. Comparable observations have been documented in the literature: Dhakal et al. (2016), [15] in a cytohistological correlation study from Nepal, similarly reported significant concordance between cervical cytology and biopsy findings, reinforcing cytology's role as a reliable triage tool while affirming that histopathology remains the diagnostic gold standard. Additionally, biopsy positivity was significantly higher among women referred on the basis of an abnormal Pap smear than among those referred on clinical suspicion alone, indicating that cytology-guided referral identifies substantially more true lesions than symptom-based assessment — supporting the broader rationale for systematic over purely symptomatic screening.

The present study reported a sensitivity of 93.3%, specificity of 96.0%, positive predictive value of 89.7%, negative predictive value of 97.5%, and overall accuracy of 95.0%. Several recent studies have reported comparable, though not identical, diagnostic performance. Dhakal et al. (2016) [15] reported a sensitivity of 77.8% and specificity of 100%, while Makwana et al. (2023) [14] reported a sensitivity of 95.8% and specificity of 83%. At a broader level, Smith et al. (2023), [16] in a systematic review and meta-analysis of cervical screening tools across low- and middle-income countries, reported a pooled sensitivity of 60.2% and specificity of 97.4% for conventional Pap smear against CIN2+ reference standards. The comparatively higher sensitivity observed in the present study may reflect differences in reference standard definition, population risk profile, and cytopathologist expertise. The observed variation across studies could be attributed to differences in study population, screening protocols, sample size, and disease prevalence, though specificity remained consistently high across settings, reinforcing Pap smear's principal strength as a specific rather than maximally sensitive screening tool.

These findings support the continued applicability of Pap smear in mass screening, aligning with the WHO's (2021) [17] emphasis on scalable, feasible screening strategies to accelerate cervical cancer elimination in resource-limited settings.

This study's strengths include an adequately powered sample size, histopathological confirmation, and standardized Bethesda System reporting. Limitations include its single-centre, cross-sectional design, absence of HPV DNA testing, and lack of longitudinal follow-up. Overall, the present findings support Pap smear as an effective and reliable method for mass screening of cervical lesions, given its favourable diagnostic performance and strong correlation with cervical biopsy.

This study was undertaken to determine the effectiveness of Pap smear as a tool for mass screening of cervical lesions. Among 250 women screened, Pap smear detected a substantially higher proportion of abnormal cervical findings than clinical suspicion alone, highlighting its superior screening yield. Pap smear findings correlated significantly with colposcopically directed cervical biopsy results, confirming its diagnostic reliability. The test demonstrated a sensitivity of 93.3%, specificity of 96.0%, and an overall diagnostic accuracy of 95.0%, reflecting consistent and dependable performance in distinguishing diseased from disease-free individuals. These findings suggest that Pap smear facilitates early identification of precancerous cervical lesions, allowing timely clinical intervention before progression to invasive disease. Its favorable diagnostic performance supports the incorporation of Pap smear into organized, population-based cervical cancer screening programmes, particularly in resource-limited settings where access to advanced diagnostic infrastructure remains constrained. Taken together, these findings reaffirm Pap smear as a dependable and clinically valuable screening test, warranting its continued and wider application in routine cervical cancer screening programmes,

1. Ferlay J, Soerjomataram I, Dikshit R, Eser S, Mathers C, Rebelo M, et al. Cancer incidence and mortality worldwide: sources, methods and major patterns in GLOBOCAN 2012. Int J Cancer. 2015;136(5):E359-86. doi: 10.1002/ijc.29210.
2. International Agency for Research on Cancer. GLOBOCAN 2022: Cancer Today [Internet]. Lyon: IARC; 2022. Available from: https://gco.iarc.who.int/today.
3. Singh K, Grover A, Dhanasekaran K. Unveiling the cancer epidemic in India: a glimpse into GLOBOCAN 2022 and past patterns. Lancet Reg Health Southeast Asia. 2025;34:100546. doi: 10.1016/j.lansea.2025.100546.
4. Kharkwal KC, Lo K, Tahmina A, Daniel TL, Teelashinee N, Hing TC, et al. A study on effectiveness of Pap smear in mass screening of premalignant lesions of cervix. J Basic Clin Appl Health Sci. 2019;2(2):65-8.
5. Quinn M, Babb P, Jones J, Allen E. Effect of screening on incidence of and mortality from cancer of cervix in England: evaluation based on routinely collected statistics. BMJ. 1999;318(7188):904-8. doi: 10.1136/bmj.318.7188.904.
6. Park K. Park's textbook of preventive and social medicine. 22nd ed. Jabalpur: M/s Banarsidas Bhanot; 2013. p. 127-9.
7. Schneider V. Criticism of the Pap smear as a diagnostic tool in cervical cancer screening. Acta Cytol. 2017;61(4-5):338-44. doi: 10.1159/000477653.
8. Mayrand MH, Duarte-Franco E, Rodrigues I, Walter SD, Hanley J, Ferenczy A, et al. Human papillomavirus DNA versus Papanicolaou screening tests for cervical cancer. N Engl J Med. 2007;357(16):1579-88. doi: 10.1056/NEJMoa071430.
9. Karimi Zarchi M, Binesh F, Kazemi Z, Teimoori S, Soltani HR, Chiti Z. Value of colposcopy in the early diagnosis of cervical cancer in patients with abnormal pap smears at Shahid Sadoughi hospital, Yazd. Asian Pac J Cancer Prev. 2011;12(12):3439-41.
10. Aijaz M, Alam K, Maheshwari V, Hakim S, Kamal M. Clinicopathological study of role of CD34 expressions in the stroma of premalignant and malignant lesions of uterine cervix. Ann Diagn Pathol. 2019;38:87-92. doi: 10.1016/j.anndiagpath.2018.11.007.
11. Najib FS, Hashemi M, Shiravani Z, Poordast T, Sharifi S, Askary E. Diagnostic accuracy of cervical Pap smear and colposcopy in detecting premalignant and malignant lesions of cervix. Indian J Surg Oncol. 2020;11(3):453-8. doi: 10.1007/s13193-020-01118-2.
12. Pangarkar MA. The Bethesda system for reporting cervical cytology. Cytojournal. 2022;19:28. doi: 10.25259/CMAS_03_07_2021.
13. Justa U, Mittal R, Negi K, Rathore S, Sharma S, Choudhary A, et al. Prospective observational study of cervical cancer screening by Pap smear in tertiary care hospital in hilly areas of Himachal Pradesh. Int J Reprod Contracept Obstet Gynecol. 2024;13(11):3229-33.
14. Makwana A, Sorathya M, Desai NJ. A correlation study of cervical cytology on pap smear with cervical biopsy in a tertiary care hospital (1 year study). Int J Clin Diagn Pathol. 2023;6(2):5-7.
15. Dhakal R, Makaju R, Sharma S, Bhandari S, Shrestha S, Bastakoti R. Correlation of cervical Pap smear with biopsy in the lesion of cervix. Kathmandu Univ Med J. 2016;14(55):254-7.
16. Smith SK, Nwosu O, Edwards A, Zerihun M, Chung MH, Suvada K, et al. Performance of screening tools for cervical neoplasia among women in low- and middle-income countries: a systematic review and meta-analysis. PLOS Glob Public Health. 2023;3(2):e0001598. doi: 10.1371/journal.pgph.0001598.

World Health Organization. WHO guideline for screening and treatment of cervical pre-cancer lesions for cervical cancer prevention. 2nd ed. Geneva: World Health Organization; 2021.