Introduction
Cervical cancer occurs when the cells of the cervix grow abnormally and invade other tissues and organs of the body. When it is invasive, this cancer affects the deeper tissues of the cervix and may have spread to other parts of the body (metastasis), most notably the lungs, liver, bladder, vagina, and rectum.1,2
Cervical cancer is the most common cancer related cause of death among women in developing countries. Current data from the National Cancer Registry Program indicate that the most common cancer in women in India is the breast and the cervix. 3,4 Cancer cervix is the Fourth most common cancer, after breast and colorectal cancer and the fourth leading cause of cancer death in women worldwide.5
Most women diagnosed with precancerous changes in the cervix are in their 20s and 30s, but the average age of women when they are diagnosed with cervical cancer is the mid 50s.6 This difference in the age at which precancerous changes are most frequently diagnosed and the age at which cancer is diagnosed highlights the slow progression of this disease and the reason why it can be prevented if adequate steps are taken.
This has been possible due to its early detection by screening for cervical cancer is one of the few cancers that can be easily detected at premalignancy phase.7,8 Exfoliative cervicovaginal cytology, (Pap smear) has been regarded as the gold standard for cervical cancer screening programs.
Materials and Methods
This retrospective study was conducted by the Department of Pathology, Government Medical College, Bhavnagar and attached hospital, Gujarat, India from 2011 to 2014.
After taking a history (regarding parity, menstrual history, and duration of married life) and recording the findings (healthy or unhealthy) of per vaginal examination of the patients, the Pap smear was collected with the help of a Ayer spatula and cytobrush under aseptic method.
The smear was immediately fixed in alcohol for 30 minutes.
Then Pap staining was done followed by light microscopy and slide interpretation.
A total of 1100 slides were examined.
Specimen adequacy as well as reporting was assessed according to the revised 2001 Bethesda system. Unsatisfactory smears were repeated.
All patients with epithelial cell abnormalities were referred for colposcopy according to the standard procedure and recommendations.
Results
A total of 1100 cases of cervical Pap smears were retrieved from the archives of the laboratory during the study period.
All collected pap smears were classified in different age group (Table 1). Majority of pap smear of age group 31-40 year (n=396, 36%) followed by 41-50 year(n=319,29%).
Table 1
| Age Group(year) | Number(n) | Percentage(%) |
| 21-30 | 220 | 20 |
| 31-40 | 396 | 36 |
| 41-50 | 319 | 29 |
| >50 | 165 | 15 |
| Total | 1100 | 100 |
Age wise distribution of participants
Table 2
| Parity | Number of patients with abnormal smear(n=603) | Percentage (%) |
| 0-2 | 111 | 18.50 |
| 3-4 | 396 | 36.40 |
| ≥5 | 319 | 45.27 |
Number of parity among the patients with abnormal Pap smear
The mean parity was 4.34 and the parity of a majority (45.32%) of patients was ≥ 5(Table 2)
Table 3
| Different cytological findings | Number | percentage |
| Unsatisfactory smears | 46 | 4.18 |
| NILM | 515 | 46.81 |
| Abnormal smear | 603 | 54.81 |
| Total | 1100 | 100 |
Common findings in all the Pap smears
The findings of pap smears were broadly classified into two groups such as unsatisfactory smears and satisfactory/adequate smears. There were 46 (4.18%) unsatisfactory smears and 1054 (95.82%) adequate smears.
The unsatisfactory or inadequate smears were due to either paucity of squamous cells, excess blood, or heavy inflammatory obscuring squamous cells.
Table 4
| No of pap smear(n) | Percentage(%) | |
| NILM | 515 | 46.81 |
| ASCUS | 69 | 6.54 |
| LSIL | 111 | 10.53 |
| HSIL | 55 | 5.21 |
| SCC | 5 | 0.47 |
| Inflammation | 289 | 27.41 |
| AGC | 10 | 0.94 |
| Total | 1054 | 100 |
Number and percentage of the specific findings in the abnormal Pap smears
NILM: Negative for intraepithelial malignancy, AGC: Atypical glandular cell carcinoma, LSIL: Low squamous intraepithelial lesion, HSIL: High squamous intraepithelial lesion, SCC: Squamous cell Carcinoma, ASCUS: Atypical squamous cells of undetermined significance.
Inflammatory Pap smear results increased across all age groups (27.41%).
Atypical squamous cell of undetermined significance(ASCUS), low grade squamous intraepithelial lesion (LSIL), and high grade squamous intraepithelial lesion (HSIL) were reported in 69 (6.5 4%), 111(10.53 %), and 55 (5.21%) women respectively. Atypical glandular cell and squamous cell carcinoma were reported in 10 (0.94 %) and 5 (0.47%) respectively.
Discussion
Carcinoma of the uterine cervix is a major health problem faced by the Indian women, and every year, approximately 120,000 women develop this disease.9 India accounts for 15.2 per cent of the total cervical cancer deaths in the world[ Although the incidence of carcinoma cervix has declined in the urban population, in the rural areas it continues to be highly prevalent The usual 10-20 years of natural history of progression from mild dysplasia to carcinoma cervix makes this cancer as relatively early preventable disease and provides the rationale for screening.10
In our study, the mean age of patients with abnormal smears was 37.5 years. Similar finding was detected by other studies.11,12 Vaginal discharge was the most common presenting complaint in our study. Other studies also reported similar findings. In a study conducted by Herbert and Smith (1999) cervical premalignant lesions peak in the late 20s. Human papillomavirus (HPV) the causative organism of cervical cancer is mainly sexually transmitted, it follows that peak incidence of HPV infection like any other sexually transmitted infection will be shortly after commencement of sexual intercourse and CIN the precursor lesions of cervical cancer also peaks about a decade after the peak incidence of HPV infection and a decade earlier than invasive cervical cancer. That is one of the reasons why screening for cervical cancer is recommended to start in the early 20s. This is the age that screening is most likely to be successful in preventing cervical cancer. Screening beyond this age will detect more advanced lesions or invasive cancer.13
We have studied a total of 1100 smears during the duration between June 2011 to 2014; out of these, 46 smears were inadequate or unsatisfactory due to blood/mucus. Proportion of inadequate samples were 4.18 % in our set up while two separate studies done by Rawat K et al (16.1%) and Gupta S et al reports similar findings.14,15 The unsatisfactory rate is an important quality assurance indicator in cervical cytology as it identifies women who are being inadequately screened.
Sampling technique skills, storage or transportation could be the reason for higher inadequate smear proportion. Regular training of healthcare personnel about proper preparation of pap smears and feedback is necessary, in our setup.
In our study we found that Inflammatory Pap smear results increased across all age groups (27.41%). Atypical squamous cell of undetermined significance(ASCUS) low grade squamous intraepithelial lesion (LSIL), and high grade squamous intraepithelial lesion (HSIL) were reported in 69 (6.54%), 111(10.53%), and 55 (5.21%) women respectively. Atypical glandular cell and squamous cell carcinoma were reported in 10 (0.94%) and 5 (0.47%) respectively. Similar finding was obtained in study done by Bamanikar et al 1995.16
Conclusion
This study emphasized the importance of Pap smears screening for early detection of premalignant and malignant lesions of cervix. Pap smear testing is a very useful, simple, economical and safe tool to detect preinvasive cervical epithelial lesions. Hence on a routine basis, every woman above the age of 30 must be subjected to Pap smear and this must be continued even in post-menopausal period as most of patients with epithelial abnormalities in our study falls in this group.
