|Year : 2017 | Volume
| Issue : 1 | Page : 32-34
Visual inspection of cervix with acetic acid: An alternative to cytology and colposcopy in early screening of cervical cancer in low-resource setup
Shalini Manisha, Neelajkumar Bagde, Dipti Shrivastava
Department of Obstetrics and Gynaecology, Jawaharlal Nehru Medical College, DMIMS (DU), Wardha, Maharashtra, India
|Date of Web Publication||25-Jul-2017|
Department of Obstetrics and Gynecology, Jawaharlal Nehru Medical College, DMIMS (DU), Sawangi (Meghe), Wardha, Maharashtra
Source of Support: None, Conflict of Interest: None
Introduction: Cervical cancer is an emotive disease, with multiple connotations. Cervical cancer is major health problem worldwide. Cervical malignancy is the commonest malignancy amongst Indian women. The life time estimated risk of cervical cancer is 2-4%. In Indian women, Cervical malignancy accounts for 26.1- 43.8% of all cancers. Cancer cervix is a preventable and curable disease provided, it is diagnosed early by screening tests and appropriate measures are taken. Aim and Objectives: 1)To compare the efficacy of Visual Inspection with Acetic acid, cytology(Pap smear) and colposcopy in detection of cervical intraepithelial lesions. 2) To assess the role of Visual Inspection with Acetic acid as an alternative to cytology (Pap smear), in screening for cervical cancer in low resource set- up. Material and Method: 200Women in 30-50 years age group who attended the gynecology department OPD, at Acharya Vinobha Bhave Rural Hospital, Sawangi (Meghe), Wardha for routine check up. Results: In the present study, the sensitivity of Pap smear came to be 90.48% and Specificity came out to be 81.40%.The sensitivity of VIA in detecting cervical cancer was 95.24% and the Specificity was 44.19%. The sensitivity of colposcopy in detecting cervical cancer was 90.48% and the Specificity was 67.44%. Conclusion: VIA as compared to Pap smear(cytology) and colposcopy can be a better screening test due to its high sensitivity, simple administration and low cost.
Keywords: Cervical cancer, colposcopy, Pap smear, screening test, visual inspection with acetic acid
|How to cite this article:|
Manisha S, Bagde N, Shrivastava D. Visual inspection of cervix with acetic acid: An alternative to cytology and colposcopy in early screening of cervical cancer in low-resource setup. J Datta Meghe Inst Med Sci Univ 2017;12:32-4
|How to cite this URL:|
Manisha S, Bagde N, Shrivastava D. Visual inspection of cervix with acetic acid: An alternative to cytology and colposcopy in early screening of cervical cancer in low-resource setup. J Datta Meghe Inst Med Sci Univ [serial online] 2017 [cited 2019 Nov 18];12:32-4. Available from: http://www.journaldmims.com/text.asp?2017/12/1/32/211578
| Introduction|| |
Cervical cancer is a major health problem worldwide. Cervical malignancy is the most common malignancy among Indian women. The lifetime estimated risk of cervical cancer is 2%–4%. In Indian women, cervical malignancy accounts for 26.1%–43.8% of all cancers. Cervical cancer is preceded by a long phase of premalignant cytological change. Cervical cancer can be prevented if cellular changes are detected and treated in early stage. In developed countries, the incidence of cervical cancer has decreased, due to screening, early detection, and early treatment of precancerous lesions. The reasons for the higher prevalence of cervical cancer in developing countries are a lack of resources, lack of awareness, lack of effective screening programs, and poorly organized health system aimed for detecting precancerous condition. In developing countries, 80% of cervical cancers are incurable at the time of detection due to the advanced stage. Hence, there is a need for low-cost, mass approach for effective cervical cancer screening programs. Although cytology (Pap smear) is reliable, the laboratory infrastructure, counseling, follow-up, and logistics including technical expertise may not be available in low-resource settings. The use of acetic acid during visual examination of the cervix is termed as visual inspection with acetic acid (VIA).
Aim and objectives
- To compare the efficacy of VIA, cytology (Pap smear), and colposcopy in the detection of cervical intraepithelial lesions
- To assess the role of VIA as an alternative to cytology (Pap smear), in screening for cervical cancer in low-resource setup.
| Materials and Methods|| |
Two hundred women in 30–50 years' age group who attended the Gynecology Outpatient Department at Acharya Vinoba Bhave Rural Hospital, Sawangi (Meghe), Wardha, for routine checkup were enrolled in the study. This is a cross-sectional study. The Study design is Cross Sectional Study for Pap smear, VIA, and colposcopy. First Pap smear was taken, followed by VIA and then colposcopy. All patients who tested positive on any screening test then underwent biopsy for confirmation (gold standard).
| Results|| |
In this study, participants' age ranged from 30 to 50 years and the mean age was 39.87 years. Range of parity was from nullipara to parity 6. Mean age of marriage was 17.9 years. The major presenting complaint was white discharge in 34.5% of patients. Per speculum examination was done for 200 cases. It was found that a maximum of 49.5% women had cervical erosion.
VIA of cervix was done for 200 cases. Forty-four cases (22%) showed acetowhite areas and were positive and 156 cases (78%) were negative, that is, neither showed acetowhite areas nor had transient acetowhite areas suggestive of inflammation.
Pap smear was done for all the 200 cases. A maximum of 156 patients (78%) were negative for intraepithelial lesion and malignancy (NILM). Inflammatory smear was seen in 17 (8.5%) patients. Atypical squamous cell of undetermined significance (ASCUS) was found in five (2.5%) patients. Low-grade squamous intraepithelial lesion (LSIL) was seen in 11 (5.5%) patients. High-grade squamous intraepithelial lesion (HSIL) was seen in nine (4.5%) patients. Squamous carcinoma was seen in two (1%) cases only. In the study, NILM and inflammatory cytology were taken as negative (normal) smear. Normal smear was 173 (86.50%). ASCUS, LSIL, HSIL, and squamous cell carcinoma (SCC) were taken as positive (abnormal) Pap smear. Total abnormal Pap smear was 27 (13.50%).
Colposcopy was done on all the 200 patients. Those with Reid's index score 0–3 were taken as normal and those with a score above 3 were considered abnormal. In the study, 167 (83.5%) patients had normal colposcopy and 33 (16.5%) had abnormal colposcopy.
In this study, all the patients who tested positive on any of the screening tests underwent cervical biopsy from the suspected area. Out of the 200 cases, 136 (68%) did not require biopsy and 64 patients (32%) required biopsy. Out of the 64 biopsies done, 35 (17.5%) had chronic cervicitis, 8 patients (4%) had normal histopathology report, 14 (7%) biopsies came as dysplasia, and only 7 (3.5%) came as squamous carcinoma.
In this study, taking histopathology (biopsy) as gold standard, Pap smear (cytology) results were compared using Chi-square test. The sensitivity of Pap smear was 90.48% and specificity was 81.40%. The positive predictive value was 70.37% and the negative predictive value (NPV) was 94.59%. The accuracy of the test was 84.37%.
Statistical analysis was done for VIA. The sensitivity of VIA in detecting cervical cancer was 95.24% and the specificity was 44.19%. The positive predictive value was 45.45% whereas the NPV was 95%. Overall diagnostic accuracy was 60.93%.
The sensitivity of colposcopy in detecting cervical cancer was 90.48% and the specificity was 67.44%. The positive predictive value was 57.58% whereas the NPV was 93.55%. Overall diagnostic accuracy was 75%.
| Discussion|| |
In the present study, the age range taken was between 30 and 50 years. This consideration was taken because the prevalence of human papillomavirus (HPV) infection is highest, at the younger age when sexual activity starts, i.e., 15–20 years of age. The peak prevalence of precancerous lesions of cervix occurs 10 years later following HPV infection, i.e., 25–30 years of age. In the present study, most patients were in the age group of 36–40 years. Mean age was 39.87 years.
Similar considerations were taken in a study done by Goel et al. where the study participants belonged to the age group of 30–34 years. Khan et al. studied screening method in the age range of 25–65 years. Denny  conducted a screening program in the age group of 35–65 years in South African women.
Cytology/Pap smear finding
In the present study, histopathology (biopsy) was taken as gold standard. Sixty-four patients underwent biopsy; Pap missed two cases of dysplasia and gave the report of NILM. Biopsy confirmed one case of ASCUS, one case of LSIL, and three cases of HSIL as squamous carcinoma. Pap correctly identified two cases of SCC.
The sensitivity of Pap smear was 90.48% and specificity was 81.40%. The positive predictive value was 70.37% and the NPV was 94.59%. The accuracy of the test was 84.37%.
Visual inspection with acetic acid findings
Among the 64 biopsies that were taken, 44 cases were VIA positive and 20 cases were VIA negative. Out of the 44 positive cases, 14 cases were dysplasia, 6 were squamous carcinoma, 22 VIA-positive cases came as chronic cervicitis, and 2 were normal. VIA missed only one case of squamous carcinoma.
The statistical analysis of the present study was done using Chi-square test. The sensitivity of VIA in detecting cervical cancer was 95.24% and the specificity was 44.19%. The positive predictive value was 45.45% whereas the NPV was 95%. Overall diagnostic accuracy was 60.93%.
Total abnormal colposcopy was 33. The biopsy/histopathology report suggested that out of 33 abnormal cases, 12 were dysplasia, 7 were squamous carcinoma, 12 abnormal colposcopy came out as chronic cervicitis, and two as normal on biopsy. Colposcopy missed two cases which came out to be dysplasia. In the present study, the statistical analysis was done, and the sensitivity of colposcopy in detecting cervical cancer was 90.48% and the specificity was 67.44%. The positive predictive value was 57.58% whereas the NPV was 93.55%. Overall diagnostic accuracy was 75%.
| Conclusion|| |
VIA as compared to Pap smear (cytology) and colposcopy can be a better screening test due to its high sensitivity, simple administration, and low cost. VIA had high specificity and NPV, which means that when a test is negative, the women can go home, assured that she is not likely to have a neoplastic cervical lesion. Thus, time has come to integrate VIA-based screening program at the primary level of health-care services and help to downstage cancer cervix in our country. 
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Denny L. The prevention of cervical cancer in developing countries. BJOG 2005;112:1204-12.
Cervical cancer control in developing countries: Memorandum from a WHO meeting. Bull World Health Organ 1996;74:345-51.
Bosch FX, Muñoz N. The viral etiology of cervical cancer. Virus Res 2002;89:183-90.
Aswathy S, Quereshi MA, Kurian B, Leelamoni K. Cervical cancer screening: Current knowledge & practice among women in a rural population of Kerala, India. Indian J Med Res 2012;136:205-10.
] [Full text]
Nelson R. HPV Testing most successful method for cervical cancer screening in developing countries. N Engl J Med 2009;360:1385-94.
Goel A, Gandhi G, Batra S, Bhambhani S, Zutshi V, Sachdeva P. Visual inspection of the cervix with acetic acid for cervical intraepithelial lesions. Int J Gynaecol Obstet 2005;88:25-30.
Khan S, Jha R, Pant PR. Accuracy of cytology, visual inspection with acetic acid or lugol's iodine in cervical cancer screening. N J Obstet Gynecol 2007;2:48-53.
Visual inspection with acetic acid for cervical-cancer screening: Test qualities in a primary-care setting. University of Zimbabwe/JHPIEGO Cervical Cancer Project. Lancet 1999;353:869-73.
Nessa A, Nahar KN, Begum SA, Anwary SA, Hossain F, Nahar K. Comparison between visual inspection of cervix and cytology based screening procedures in Bangladesh. Asian Pac J Cancer Prev 2013;14:7607-11.
Singh KN, More S. Visual inspection of cervix with acetic acid in early diagnosis of cervical intraepithelial neoplasia and early cancer cervix. J Obstet Gynecol India 2010;60:55-60.
Bhatla N, Mukhopadhyay A, Kriplani A, Pandey RM, Gravitt PE, Shah KV, et al
. Evaluation of adjunctive tests for cervical cancer screening in low resource settings. Indian J Cancer 2007;44:51-5.
] [Full text]
Hegde D, Shetty H, Shetty PK, Rai S. Diagnostic value of acetic acid comparing with conventional Pap smear in the detection of colposcopic biopsy-proved CIN. J Cancer Res Ther 2011;7:454-8.
Saleh HS. Can visual inspection with acetic acid be used as an alternative to Pap smear in screening cervical cancer? Middle East Fertil Soc J 2014;19:187-91.