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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 6  |  Issue : 1  |  Page : 39-43

Predictive accuracy of cervical cytology and colposcopy in diagnosing premalignant and malignant cervical lesions: A hospital-based study from the sub-Himalayan region of Indian subcontinent


1 Department of OBG, Dr. RPGMC, Kangra, Himachal Pradesh, India
2 Department of Pathology, Dr. RPGMC, Kangra, Himachal Pradesh, India

Date of Submission19-Apr-2018
Date of Decision23-Apr-2018
Date of Acceptance15-Aug-2018
Date of Web Publication14-Feb-2019

Correspondence Address:
Rashmi Kaul Raina
C-15, Type-V Quarters, Dr. RPGMC Campus, Tanda, Kangra - 176 001, Himachal Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/cjhr.cjhr_51_18

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  Abstract 


Background: Cancer of the cervix is one of the most common cancers among women in India. The study aimed to detect the predictive accuracy of cytology and colposcopy in cervical cancer screening among Himachali married women who had a high risk for cervical cancer. Materials and Methods: This was a hospital-based cross-sectional study. Two hundred nonpregnant married women with a high risk for cervical cancer and attending the gynecology clinic of a tertiary care center of Himachal Pradesh were included in the study over a period of 1 year. A detail clinical history was taken, and examination was performed in all the cases. Papanicolaou (Pap) smears for cytological examination were taken in all the cases. Colposcopy was performed in all the cases, and cervical punch biopsy was taken in all the women with suspicious lesions on colposcopy. Bethesda classification system (2001) and the WHO classification of tumors of the uterine cervix (2003) were used for reporting cytology and histopathology, respectively. Results: The mean age of the women in the study is 38.6 ± 6.2 years. Pap was reported as negative for intraepithelial lesion or malignancy in 88.5%, inflammatory in 32.5%, low-grade squamous intraepithelial lesion (LSIL) in 5.5%, high-grade SIL (HSIL) in 2.5%, and atypical squamous cells of undetermined significance in 1%. In the current study, the diagnostic accuracy of Pap smear and colposcopy for LSIL was 79.4% and 73.5%, respectively. The diagnostic accuracy of Pap smear and colposcopy for HSIL was 100% and 91.3%, respectively. Conclusion: This study has established the utility of Pap smear cytology and colposcopy as a screening tool for the detection of normal as well as abnormal lesions while analyzing cervical pathology in patients with high risk of cervical cancer.

Keywords: Cervical cancer, Himachal Pradesh, sensitivity, specificity


How to cite this article:
Singhal A, Raina RK, Verma S, Verma A. Predictive accuracy of cervical cytology and colposcopy in diagnosing premalignant and malignant cervical lesions: A hospital-based study from the sub-Himalayan region of Indian subcontinent. CHRISMED J Health Res 2019;6:39-43

How to cite this URL:
Singhal A, Raina RK, Verma S, Verma A. Predictive accuracy of cervical cytology and colposcopy in diagnosing premalignant and malignant cervical lesions: A hospital-based study from the sub-Himalayan region of Indian subcontinent. CHRISMED J Health Res [serial online] 2019 [cited 2019 Mar 23];6:39-43. Available from: http://www.cjhr.org/text.asp?2019/6/1/39/252291




  Introduction Top


Cervical cancer ranks as the second most frequent cancer among women in India. Current estimates indicate that every year 122,844 women are diagnosed with cervical cancer and 67,477 women die from the disease.[1] Cancer screening is a public health priority in India. The health authorities predicted a rise in cancer burden hence rolled out the National program for prevention and control of Cancers, Diabetes, Cardiovascular diseases and Stroke from 2008. The cancers included cervical, breast, and oral. In the hilly state of Himachal Pradesh, cancer cervix is a major public health problem since it ranked as the number one cancer among females as per the annual reports of Regional Cancer Center, Himachal Pradesh from 1998 to 2008.[2] Cervical cancer develops from well-defined precursor lesions and has a long-time lag of premalignant period. The detection of these precancerous lesions in the lead time, by screening, provides us with an excellent opportunity in prevention as well as achieving cure if detected in early or preinvasive stages. In the scenario of the high prevalence of cancer cervix, the diagnostic utility of screening tests such as cytology and colposcopy is very well recognized. The conventional cytology-based Papanicolaou (Pap) smear is the main screening as well as a diagnostic tool to detect cervical cancer. Meta-analysis studies have shown that the sensitivity and specificity of cervical cytology were from 30% to 87% and 86% to 100%, respectively.[3] Colposcopy is based on the principle of visualization of cervical epithelium under magnification. Colposcopy is observer dependent. In a meta-analysis, the diagnostic accuracy of colposcopy had a sensitivity from 29% to 100% and specificity from 12% to 88%.[4] It is debatable which screening tests have better accuracy.[4] Cytology and colposcopy are widely prescribed as screening methods in India. Human papillomavirus testing as a screening method in a country like India is not economically feasible at present. The aim of the current study was to report our observations on the predictive accuracy of cytology and colposcopy in cervical cancer screening among Himachali married women who had a high risk for cervical cancer at a tertiary care center.


  Materials and Methods Top


Study setting

The study was conducted in a tertiary care referral hospital of Kangra district in Himachal Pradesh, India. The hospital is the largest in the region and caters to the medical needs of the population residing in the physiogeographic region of Shivalik and lesser Himalayas and includes lower hills of Kangra, Hamirpur, Una, and Bilaspur and lower parts of Mandi and Chamba districts.

Patient selection

A total of 200 married women of >21 years of age were recruited over a period of 1 year after taking a detailed history and clinical examination. Informed consent was obtained from each participant before recruitment in this study. The inclusion criteria were a history of vaginal discharge, coital bleeding, intermenstrual bleeding, postmenopausal bleeding, multiple sexual partners, smokers, and on examination with features of the unhealthy looking cervix and/or lesions that bled on touch. Patients with pregnancy, treated or already diagnosed cases of carcinoma cervix, were excluded from the study.

Procedure

All the women attending hospital were sensitized about the screening of precancerous and cancerous lesions of the cervix. The women who volunteered to participate were reinformed about the Pap smear, colposcopy, and biopsy and the required follow-up in case of an abnormal Pap test result with the help of an information sheet that was provided to them. Informed consent was taken from each participant on a structured pro forma. A detailed history was taken, and examination was done in all cases.

Methodology

Pap smear was taken using Ayre spatula from ectocervix and cytobrush for endocervix. The cytology reporting was done according to the Bethesda classification System (2001) guidelines.[5] Colposcopy was performed in all the 200 patients. Colposcopic-directed cervical punch biopsy was taken in all the women with suspicious lesions on colposcopy. Histopathology reporting was performed according to the “WHO classification of tumors of the uterine cervix (2003).”[6] All the cytology and histopathology slides were examined and reported by the same pathologist to maintain consistency in reporting.

Statistical analysis

The data obtained was entered in the excel sheet of the Microsoft and analyzed with statistical software SPSS 21.0 (IBM Corp., Armonk, NY, USA). Sensitivity, specificity, and positive predictive value of the Pap smear test were calculated using histopathology diagnosis of cervical biopsy as the gold standard.


  Results Top


This cross-sectional observational hospital-based study was conducted in a tertiary care center of Himachal Pradesh. Two hundred women were recruited over a period of 1 year. The mean age was 38.6 ± 6.2 years, and majority (95%) of the patients were in the reproductive age group. Majority of the patients had a normal age for menarche, and only 2.5% patients had at the age of 11. All the patients had a poor socioeconomic status, and none of the patients had an annual income of more than Rs 120,000. The distribution of parity, education status, and contraceptive use is shown in [Table 1]. Six (3%) had more than one sexual partner. None of the patients was a smoker. The details of the various risk factors observed along with their frequency distribution are depicted in [Table 1].
Table 1: Risk factors observed and their frequency distribution (n=200)

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All 200 women enrolled in the study had Pap smear test. The pattern of cytological abnormalities on Pap smear and their frequency distribution is shown in [Table 2]. The premalignant conditions such as atypical squamous cells of undetermined significance and squamous intraepithelial lesions (SILs) were observed in 9% (18/200) patients [Figure 1]. All the 200 patients had a colposcopic examination. The results are shown in [Table 3]. The premalignant conditions such as SILs were observed in 9.5% (19/200) patients. Among the 200 patients, 41 had colposcopic directed cervical punch biopsy performed. The pattern of histopathological abnormalities and their frequency distribution is shown in [Table 4] and [Figure 1]. The validity of cytology and colposcopy was evaluated and compared with the available histopathology. The results are shown in [Table 5].
Table 2: Pattern of cytological abnormalities and their frequency distribution (n=200)

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Figure 1: (a) Low-grade squamous intraepithelial lesion (Pap, ×400); (b) low-grade squamous intraepithelial lesion with koilocytic atypia and perinuclear halo (Pap, ×400); (c) high-grade squamous intraepithelial lesion (Pap, ×400); (d) low-grade squamous intraepithelial lesion (H and E, ×200); and (e) high-grade squamous intraepithelial lesion (H and E, ×200)

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Table 3: Pattern of colposcopic abnormalities and their frequency distribution (n=200)

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Table 4: Pattern of histopathological abnormalities and their frequency distribution (n=41)

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Table 5: Sensitivity, specificity, positive, and negative predictive values of Pap smear and colposcopy versus histopathology for low-grade squamous intraepithelial lesion and high-grade squamous intraepithelial lesion

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  Discussion Top


In our study, among the various risk factors analyzed were age, the age of menarche, parity, socioeconomic status, education, smoking habits, hormonal contraception, and number of sexual partners, it was observed that the mean age of patients was 38.6 ± 6.2 years, 89.5% of patients were multiparous, all belonged to poor socioeconomic strata, 54% had not received formal education, observed low practice of hormonal contraception (2%), all being nonsmokers, and precocious menarche was in 2.5% of patients only. All the participants were symptomatic having vaginal discharge (54.5%), intermenstrual bleeding (19.5%), postcoital bleeding (10.5%), and postmenopausal bleeding (9%), and participants were referred from peripheral institutions for Pap due to the unhealthy looking cervix (3.5%).

The prevalence of SILs on Pap cytology among the patients in our study is 9%. Various studies have found the different prevalence of SIL from with the range from 2.28 to 40.6%.[7],[8] Our results on SIL prevalence are comparable with findings in other studies.[9],[10] However, lower prevalence of premalignant epithelial cell changes has been reported in a few studies.[11],[12],[13] The higher prevalence of SIL in our patients in comparison to these studies could be because of the screening in high-risk symptomatic patient in a hospital setting.

The prevalence of premalignant conditions on colposcopy, i.e., low-grade SIL (LSIL) and high-grade SIL (HSIL) among the patients was 9.5%. These results are comparable with other studies.[14],[15]

The sensitivity for LSIL on Pap cytology is 81.8%, and specificity is 78.2% with a diagnostic accuracy of 79.4% in our study. However, for HSIL, the sensitivity, specificity, and diagnostic accuracy are 100%. We observed a higher predictive accuracy for HSIL in comparison to LSIL on Pap cytology.

The sensitivity for LSIL on colposcopy is 72.7%, and specificity is 73.9% with a diagnostic accuracy of 73.5% in our study. However, for HSIL, the sensitivity, specificity, and diagnostic accuracy are 100%, 89.4%, and 91.3%, respectively. Our study has lower diagnostic accuracy for LSIL on colposcopy but higher diagnostic accuracy for HSIL when compared to other studies.[16],[17]

The possible reasons for achieving a 100% sensitivity, specificity, and predictive accuracy for HSIL in Pap smear cytology in our study could be due to the following reasons. It is a hospital-based study and not a community-based study, and the screening tests were applied to a population with a high risk for cervical cancer.

Analysis of these results reveals that Pap is more sensitive and specific and has better diagnostic accuracy when compared with colposcopy in the diagnosis of LSIL; however, sensitivity and diagnostic accuracy are similar for HSIL in our study.

There were no malignant lesions observed on histopathology. Similar results were observed in Pap cytology and colposcopy which also ruled out malignant lesions in our study, thus showing concordance with histopathology in the diagnosis of these lesions.

Both Pap cytology and colposcopy revealed very high sensitivity, specificity, and diagnostic accuracy in detecting different cervical lesions when compared with the gold standard histopathology in this study. This study has established the utility of Pap as a screening tool for the detection of normal as well as abnormal lesions while analyzing cervical cytology in patients with high risk of cervical cancer.


  Conclusion Top


This study established the utility of Pap smear cytology and colposcopy as a screening tool for analyzing cervical pathology in patients with high risk of cervical cancer. Pap was more sensitive and specific and had better diagnostic accuracy when compared with colposcopy in the diagnosis of LSIL; however, sensitivity and diagnostic accuracy were similar for HSIL in this study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
India: Human Papillomavirus and Related Cancers, Fact Sheet; 2017. Available from: http://www.hpvcentre.net/statistics/reports/IND_FS.pdf. [Last accessed on 2017 Nov 11].  Back to cited text no. 1
    
2.
Thakur A, Gupta B, Gupta A, Chauhan R. Risk factors for cancer cervix among rural women of a hilly state: A case-control study. Indian J Public Health 2015;59:45-8.  Back to cited text no. 2
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3.
Nanda K, McCrory DC, Myers ER, Bastian LA, Hasselblad V, Hickey JD, et al. Accuracy of the Papanicolaou test in screening for and follow-up of cervical cytologic abnormalities: A systematic review. Ann Intern Med 2000;132:810-9.  Back to cited text no. 3
    
4.
Mustafa RA, Santesso N, Khatib R, Mustafa AA, Wiercioch W, Kehar R, et al. Systematic reviews and meta-analyses of the accuracy of HPV tests, visual inspection with acetic acid, cytology, and colposcopy. Int J Gynaecol Obstet 2016;132:259-65.  Back to cited text no. 4
    
5.
Solomon D, Davey D, Kurman R, Moriarty A, O'Connor D, Prey M, et al. The 2001 bethesda system: Terminology for reporting results of cervical cytology. JAMA 2002;287:2114-9.  Back to cited text no. 5
    
6.
WHO Histological Classification of Tumours of the Uterine Cervix. Available from: http://www.screening.iarc.fr/atlasclassifwho.php. [Last accessed on 2017 Nov 11].  Back to cited text no. 6
    
7.
Mital K, Agarwal U, Sharma VK, Jaiswal TBL. Evaluation of cytological and histological examinations in precancerous and cancerous lesions amongst gynaecological diseases. Indian J Obstet Gynecol 1989;42:713-5.  Back to cited text no. 7
    
8.
Chauhan SH, Tayal OK, Kalia IJ. Detection of uterine cervical dysplasia and carcinoma cervix. Indian J Obstet Gynecol 1990;17:419-21.  Back to cited text no. 8
    
9.
Bukhari MH, Saba K, Qamar S, Majeed MM, Niazi S, Naeem S, et al. Clinicopathological importance of Papanicolaou smears for the diagnosis of premalignant and malignant lesions of the cervix. J Cytol 2012;29:20-5.  Back to cited text no. 9
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10.
Gupta R, Gupta SG, Mishra KB, Singh RI. Pattern of Pap smear cytology and its histopathological correlation at a tertiary care centre. Rec Adv Path Lab Med 2016;2:13-9.  Back to cited text no. 10
    
11.
Bal MS, Goyal R, Suri AK, Mohi MK. Detection of abnormal cervical cytology in Papanicolaou smears. J Cytol 2012;29:45-7.  Back to cited text no. 11
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12.
Sengul D, Altinay S, Oksuz H, Demirturk H, Korkmazer E. Population-based cervical screening outcomes in Turkey over a period of approximately nine and a half years with emphasis on results for women aged 30-34. Asian Pac J Cancer Prev 2014;15:2069-74.  Back to cited text no. 12
    
13.
Nayir T, Okyay RA, Nazlican E, Yesilyurt H, Akbaba M, Ilhan B, et al. Cervical cancer screening in an early diagnosis and screening center in Mersin, Turkey. Asian Pac J Cancer Prev 2015;16:6909-12.  Back to cited text no. 13
    
14.
Ramesh G, Sudha R, Jayashree AK, Padmini J. Colposcopic evaluation of unhealthy cervix. J Clin Diagn Res 2012;6:1026-8.  Back to cited text no. 14
    
15.
Gupta V, Tandon A, Nanda A, Sharma A, Bansal N. Colposcopic evaluation of cervical lesions: A prospective study. Int J Clin Trials 2014;1:110-3.  Back to cited text no. 15
    
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Ashmiata D, Shakuntla PN, Rao SR, Sharma SK, Geethanjali S. Comparision and correlation of Pap smear, colposcopy and histopathology in symptomatic women and suspicious looking cervix in a tertiary hospital care centre. Int J Health Sci Res 2013;3:50-9.  Back to cited text no. 16
    
17.
Chaudhary RD, Inamdar SA, Hariharan C. Correlation of diagnostic efficacy of unhealthy cervix by cytology, colposcopy and histopathology in women of rural areas. Int J Reprod Contracept Obstet Gynecol 2014;3:213-8.  Back to cited text no. 17
    


    Figures

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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