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Cervical Pap smear study and its utility in cancer screening in patients attending out-patient department in a tertiary care hospital

Background: Cervical cancer is one of the major causes of mortality among women worldwide. By simple pap screening test cervical cancer and its precursor lesions can be detected and treated early. The aim of the study was to determine and analyze Pap smear reports from women presenting with various gynaecological indications in a tertiary care hospital. Methods: This retrospective study was conducted in the department of obstetrics and gynaecology at Rama Medical College Hospital and Research Centre, Hapur over a period of 6 months. Patients with various complaints between ages 21 to 70 years were screened during August 2020 to January 2021 by taking Pap smear using Ayres spatula. Total 330 patients were studied. Slides were reported according to the 2014 Bethesda system. Results: Maximum number of cases were in the age group 31-40 years constituting 32.72% of the total cases followed by age group 41-50 years. Vaginal discharge was the commonest chief complaint seen in 32.12% cases followed by menorrhagia. Maximum number of cases reported as non-specific inflammatory smears (64.54%). Among epithelial cell abnormalities incidence of LSIL was 2.42% followed by ASCUS (1.82%). Conclusions: Pap smear testing is an economical, non-invasive and simple OPD procedure to detect potentially precancerous and cancerous lesions of cervix. It should be established as a routine screening procedure to reduce the treatment burden, morbidity and mortality.


INTRODUCTION
Cancer of uterine cervix is a leading cause of mortality and morbidity among women world-wide. Cervical cancer is the fourth most common cancer in women. In developing countries, it is the most common gynaecological cancer and one of the leading causes of cancer death among women.
Nearly 4 lacs new cases of cervical cancers are diagnosed annually worldwide and 80% of them are diagnosed in the developing countries. There are 1.7 million cases in the developing world and as many as 5-13 million women have precancerous lesions. 1,3 According to National Cancer Registry Program of India, cancers of uterine cervix and breast are leading malignancies seen in Indian women. 2 Cervical cancers and its precursor lesions can be detected and treated early by using simple Pap screening test. Usually, Pap smear screening test is recommended starting around 21 years of age until the age of 65 years. Can be repeated at three years interval. In case of abnormal Pap smear report, depending on the type of abnormality the test may need to be repeated in six to twelve months. More sensitive and specific investigations like colposcopy guided cervical biopsy etc are needed to diagnose and prevent further progression to cervical cancer. 4 Pap smear test is performed by opening the vaginal canal with cuscos speculum and collecting cells at the outer opening of the cervix i.e.; at the transformation zone, from posterior vaginal wall and endocervical canal. Then the collected cells are examined under a microscope. 5 The test mainly meant to detect precancerous conditions like cervical intraepithelial neoplasia (CIN) or cervical dysplasia, squamous intraepithelial lesion system (SIL) etc. 6 In 1988, the Bethesda system of reporting has been introduced to classify the lesions into low-and high-grade intraepithelial lesions. It provides uniform system of terminology which makes management and treatment simple. 7 The present study was conducted to study the different patterns of cervical lesions in a tertiary care hospital.

METHODS
This study was a retrospective study conducted in the department of obstetrics and gynaecology of Rama Medical College Hospital and Research Centre, Hapur from August 2020 to January 2021. A total of 330 pap smears were taken from women between ages of 21 to 70 years presenting with different gynaecological complaints and as a routine beyond the age of 45 years by using Ayres spatula. Smears were reported as per the Bethesda system.

Inclusion criteria
Women between 21 to 70 years of age with sexual history were included.

Exclusion criteria
Women below 21 years, without sexual exposure, and women above 70 years.

Procedure
Pap smears were taken by using Ayres spatula. The broad end of spatula was placed on the Cervix and rotated through 360˚ and the collected material was spread over a glass slide. The endo-cervical sample was collected using a cyto-brush and was spread over labelled glass slide. All the slides were labelled and immediately transferred to 95% Ethyl alcohol (transport medium) and sent to pathology department for cytological study. Evaluation was done by cytology using Bethesda Classification. 8

Specimen adequacy
It included-(a) satisfactory for evaluation (note presence or absence of endocervical transformation zone component); and (b) unsatisfactory for evaluation

Other (list not comprehensive)
It included endometrial cells in women 40 years of age or over.

RESULTS
In our study age of patient, presenting symptoms, reports of cytology were observed and analysed. Table 1 shows that maximum number of cases were in the age group 31-40 years constituting 32.72% of the total cases followed by age group 42-50 years constituting 26.06%. Minimum percentage (3.94%) of cases were >60 years of age group.   Table 3 shows maximum number of cases reported as nonspecific inflammatory smears (64.54%). Among epithelial cell abnormalities incidence of LSIL and ASCUS was 2.42% and 1.82% followed by SCC (0.91%).

DISCUSSION
With the changes in the life styles and demographic profiles in developing countries, non-communicable diseases are emerging as an important health problem which demand appropriate control program before they assume epidemic propagation. Cancer has been a major cause of morbidity and mortality. Cancer of the cervix is a preventable disorder as the different screening, diagnostic and therapeutic procedures are effective. One of the essential responsibilities of the gynaecologist is to detect neoplasm of the genital tract at the earliest. Since the introduction of cytology into clinical practice by Papanicolaou and Traut in 1944, it has become possible to detect cervical cancer in its pre-invasive stages, thus reducing the morbidity and mortality from this disease.
According to National Cancer Registry Program of India, cancers of uterine cervix and breast are the leading malignancies seen in females of India. There should be an effective mass screening program aimed at specific age group for detecting precancerous condition before they progress to invasive cancers. 1,3,9 In this study comprising of 330 Pap smear, 324 were satisfactory (98.18%) and 6 were unsatisfactory (1.82%). Unsatisfactory reports can be due to inadequacy of sample, blood stained sample and poor staining. Table 1 shows distribution of patients according to age. In this study age of patients ranged from 21-69 yrs. Out of 330 patients, maximum number of patients were in the age group 31-40 years comprising 32.72% followed by 41-50 years comprising 26.06%. 24.54% were in 21-30 years, 12.73% in 51-60 years and 3.94% were more than 60 yrs. In study conducted by Sunita et al maximum number of women were between 31 to 40 years age group (32.68%). 10 In study conducted by Mandakini et al between 15 to 30 years maximum number of women were studied. 11

CONCLUSION
Pap smear testing is an economical, non-invasive and simple OPD procedure to detect potentially precancerous and cancerous lesions of cervix. It should be established as a routine screening procedure to reduce the treatment burden, morbidity and mortality. Pap smear tests are inexpensive and affordable by the patients. This procedure doesn't need experts and specialists for collection of smear. Reports in our study like many other studies has shown the importance of Pap smear test in screening cervical cancer. By conducting health camps, increasing health awareness and performing Pap smear screening programmes the incidence of cervical carcinoma can be decreased. 15