Screening for cervical neoplasia in Bangladesh using visual inspection with acetic acid Chairperson: Dr. Gopal Chandra Das Assistant Professor Department of Obs & Gynae, MMC Speaker: Dr. Khurshida Jahan MS Obs & Gynae (Thesis part), MMC
Auther: Nessa A, Hussain MA, Rahman JN, Rashid MH, Muwonge R, Sankaranarayanan R. Department of Obstetrics & Gynecology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh. Source: International Journal of Gynaecology & Obstetrics. 111(2010) 115-118.
Introduction • Cervical cancer constitutes 25% of all cancer cases in women and accounts for 13000 new cases and 8000 deaths annually in Bangladesh. More than 80% of patients diagnosed with this eminently preventable cancer present in clinically advanced, inoperable stages.
The aim of the present paper was to briefly describe the organization and functioning of the VIA screening program and discuss the early results, strengths and limitations of the pioneering effort in cervical cancer prevention in Bangladesh.
Objective: • To report the organization and early results of a visual inspection with acetic acid (VIA) screening program for cervical cancer prevention in Bangladesh.
Patients and methods • The VIA screening program is provided through the existing healthcare infrastructure in Bangladesh. • The target population for VIA screening is apparently healthy, ambulant, married women aged 30 years and above attending the healthcare facilities at MCWCs, DHs, MCHs, BSMMU, UHFWCs, and UHCs.
It was an opportunistic screening program. The screening algorithm involved a single visit for screen-negative women and 2-3 visits for screen-positive women, • After counseling and informed consent, a speculum examination was performed for direct visualization of the cervix and vagina to identify the squamocolumnar junction (SCJ), inflammation, polyps, leukoplakia, and growth. Freshly prepared 5% dilute acetic acid was applied to the cervix.
Care was taken to avoid any bleeding and results were reported 1 minute after application under 100-watt illumination. VIA test was considered positive when a definite, well-defined acetowhitening was observed in the transformation zone in close proximity with the SCJ or when a growth turned acetowhite; when in doubt the test was repeated.
All VIA-positive women were referred with a pink referral card to the colposcopy clinics at BSMMU or nearby medical college hospitals. Women with negative VIA were given a blue card and advised to come back after 3 years. A manual register is kept at each VIA screening center that provides the number of women screened, tested positive, and tested negative.
Colposcopy was performed by the trained colposcopist when the screen-positive women reported at the colposcopy clinics at medical college hospitals or BSMMU. All women with suspected CIN and cancer had colposcopy-directed cervical biopsy and the specimens were given to the women or their attendants to submit to the histopathology department. The colposcopic findings were documented in a form.
Women with normal histology and CIN 1 reports were advised to return for follow-up after 6-12 months. Women with CIN 1 who wanted immediate treatment or who were unlikely to report for follow-up and those above 35 years were treated with cryotherapy or LEEP. Women with histologically confirmed CIN 2 or 3 lesions were treated with LEEP or cryotherapy and were advised to return for follow-up after 6 months. Women with cervical cancer were referred to cancer treatment facilities for further investigations and treatment. • The final diagnosis was based on the histopathology or colposcopy if no or an inadequate biopsy sample was taken.
Results • From January 1, 2005, to June 30, 2008, VIA screening was provided for 104 098 women in 44 districts in Bangladesh. The average number of women screened in most districts ranged from 800-4000 women.
Of the women screened, 5013 (4.8%) were positive on VIA and were referred to colposcopy clinics at BSMMU or nearby medical college hospitals. • Overall, 4371 (87.2%) of screen positive women underwent colposcopy.
Table 2: Distribution of women attending different colposcopy clinics.
Total women underwent colposcopy – 4371 • Women attended at BSMMU (VIA +ve cases) – 2188 • Normal colposcopic findings – 1044 (47.7%) • Colposcopic abnormalities • Suggestive of CIN or cancer =1144 • CIN I = 682 • CIN II = 149 • CIN III = 29 • Invasive = 134 • Unsatisfactory = 150
Histopathology results of cases with colposcopic abnormalities • CINI = 369 • CIN II = 127 • CIN III = 30 • Invasive cancer = 123
Of the 4371 women who underwent colposcopy, 2188 attended the colposcopy clinic at BSMMU. The results of colposcopy and histology are given in Table 3. No colposcopic abnormalities were detected in 1044 (47.7%) women, whereas directed biopsies in 1144; women showed colposcopic abnormalities suggestive of CIN or cancer. On histology, 369 women were diagnosed with CIN 1, 127 with CIN 2, 30 with CIN 3, and 123 with invasive cancer.
VIA repeated by gynecologists in 2188 women before they underwent colposcopy was positive in 1060 and negative in 1128 women; the final diagnosis among these 1128 VIA-negative women was as. follows: no lesion (n = 1091); CIN 1 (n = 22); CIN 2-3 (n = 10); and invasive cancer (n = 5).
The sensitivity, specificity, and positive predictive value of VIA to detect CIN 2 and 3 lesions after excluding the 123 invasive cancer cases in this selected sample of women were 93.6%, 58.3%, and 15.6%, respectively (Table 4). • Forty-one women (11%) with CIN 1 and 80 women (50%) with CIN 2-3 lesions received treatment with LEEP (n = 105), cryotherapy (n = 6), or hysterectomy (n= 10) at BSMMU.
Table 3 Accuracy of visual screening with acetic acid to detect CIN 2-3 lesions among 2065 women attending colposcopy services at BSMMU. Sensitivity: 93.6% (95% CI, 88.6-96.9); Specificity: 58.3% (95% CI, 56.1-60.6); Positive predictive value: 15.6% (95% CI, 13.3-18.1); Negative predictive value: 99.1% (95% CI, 98.4-99.6).
Discussion • Among the cancers, cervical cancer accounts for almost one fifth of cases in women. The cervical cancer burden is closer to that of maternal deaths (13 000 deaths) in Bangladesh. Currently, 32 million women are aged between 30 and 60 years and less than 0.4% are screened annually with a Pap smear. It is not feasible to introduce cytology screening for cervical cancer control in Bangladesh given the resource constraints.
The VIA test positivity of around 5% in this program was at the lower range of test positivity reported in other VIA studies in Asia and Africa. • On repeat VIA performed before colposcopy, a little more than half of the women were scored as negative, which indicates the wide variability between the test providers due to the subjective interpretation of the test. • If we extrapolate this finding to the entire study, the test-positive rates are likely to be even lower than 5%.
Treatment coverage of women with high-grade cervical cancer precursors is inadequate: half of such women received treatment at the BSMMU colposcopy clinic. • The treatment rates can be improved if cryotherapy or LEEP are offered immediately following colposcopy at the first visit instead of receiving treatment after histopathology confirmation of punch biopsy specimens at the second visit.
Moreover, the current VIA-based program would facilitate the development of screening, diagnosis, and treatment infrastructure in health services, improve awareness of cervical cancer prevention among the population, and enable incorporation of new developments such as the more accurate, objective & affordable HPV testing technologies when these technologies are commercially available & affordable for wider use in public health services.
CONCLUSION: • A VIA-based program would facilitate the development of screening, diagnosis, and treatment of cervical neoplasia and improve awareness of cervical cancer prevention in Bangladesh.
Approximate rates of spontaneous regression, persistence & progression of CIN CINI CINII CINIII • Regression to normal 60% 40% 30% • Persistence 30% 35% 48% • Progression to CINIII 10% 20% - • Progress to carcinoma <1% 5% 22%
VIA & Colposcopy in MMCH 2010 • Total VIA done - 3214 • VIA –ve - 3139 • VIA +ve - 75 • Total colposcopy done - 433 • Normal - 200 • CINI - 172 • CINII - 22 • CINIII - 08 • Unsatisfactory - 11 • Invasive - 20
Histopathology results of cases with colposcopic abnormalities in MMCH • CIN I 92 • CIN II 45 • CIN III 15 • Invasive carcinoma 15