A comparative study of cervical cancer screening methods in a rural community setting of North India.

CONTEXT: Pap smear testing as a conventional cervical screening approach has limitations for implementation and aided visual cervical testing has varying results in different regions. AIMS: The aim of this study is to demonstrate the performance of aided visual cervical screening tests as against conventional Pap smear testing in a rural community setting of North India. SETTINGS AND DESIGN: This was a rural community based cross‑sectional study. MATERIALS AND METHODS: All 7603 ever married women of age 30‑59 years surveyed in a pocket of Dadri Tehsil, Uttar Pradesh, India were targeted for screening by Pap, visual inspection of cervix using acetic acid (VIA) and visual inspection of cervix using Lugol’s iodine (VILI) methods. Screen positives were referred to colposcopy and confirmation by histology. STATISTICAL ANALYSIS USED: Detection of histological cervical intraepithelial neoplasia (CIN) II + and CIN III + assessed separately by sensitivity, specificity and likelihood ratio’s and predictive values. Analysis of data was performed by using IBM SPSS statstics software version 16.0. RESULTS: A total of 65.6%(4988/7604) eligible women of 30‑59 years age group in the target population were screened. Out of 4988, further analysis was performed on 4148 after excluding those who did not complete all screenings, who lost to follow‑up and had missing histology results. Screen positivity rates by Pap (ASCUS and above), VIA and VILI were 2.6%, 9.7% and 13.5% respectively. Sensitivity and specificity of detecting the CIN III+ lesions were 87.5 and 98.8% for Pap, 50.0% and 96.7% for VIA and 50.0% and 95.7% for VILI respectively. CONCLUSIONS: VIA screening demonstrated as a feasible primary screening test for detecting high grade CIN and as to perform better when the Pap test is not feasible.

Visual inspection of cervix with Lugol's iodine for early detection of premalignant & malignant lesions of cervix.

Background & objectives: Majority of cases of cervical cancer are diagnosed at an advanced stage as cytology based screening programmes are ineffective in developing countries. The present study was done to look for carcinoma cervix and its precursors by visual inspection with Lugol's iodine (VILI), visual inspection with acetic acid (VIA) and Papanicolaou smear, and to analyse their sensitivity, specificity and predictive values using colposcopic directed biopsy as reference. Methods: In this cross-sectional study, 350 women were subjected to Pap smear, VIA, VILI and colposcopy. Cervical biopsy and endocervical curettage was taken from patients positive on any of these tests and in 10 per cent of negative cases. Results: The Pap smear was abnormal in 3.71 per cent, including (2.85%), low grade (LSIL) and (0.85%) high grade squamous intraepithelial lesions (HSIL). Thirteen per cent of the patients were found to be positive by VIA and 11.71 per cent were positive on VILI. Sensitivity for VIA, VILI and Pap smear was 89.5, 100 and 52.6 per cent, respectively, while the specificity for VIA, VILI and Pap smear was 91.2, 93.3 and 99.1 per cent, respectively. Interpretation & conclusions: In low resource settings, cervical cancer screening by Pap smear can be replaced by visual methods like VILI, which has the highest sensitivity (100%) to detect any grade of dysplasia, and a good specificity (93.3%).

Diagnostic efficiency of toluidine blue with Lugol's iodine in oral premalignant and malignant lesions.

Background and Objectives: In vivo stains are prompt resources, which have emerged, in the recent years, to aid as clinical diagnostic tools in detecting early premalignant and malignant lesions. The aim of the study was to determine the diagnostic efficiency of toluidine blue with Lugol's iodine in oral premalignancies and malignancies and to evaluate the reliability of in vivo staining with toluidine blue and Lugol's iodine in the lesions at risk of malignancy. Materials and Methods: The study group comprised 30 subjects with clinically suspicious premalignant lesions and 30 subjects with clinically suspicious malignant lesions. All the lesions were stained consecutively with toluidine blue and Lugol's iodine and the dye retention were recorded with photographs. Depending on the retention of the dyes, the biopsy site was determined. The biopsy specimens were sent for histological confirmation and results were statistically analyzed. Results: The overall diagnostic accuracy of Lugol's iodine when used consecutively with toluidine blue stain in distinguishing premalignant lesions and malignant lesions was 90%. As the degree of differentiation of malignant lesions progressed toward more severity, they failed to show the retention of Lugol's iodine and the result was highly significant statistically, with a P value < 0.001. Interpretation and Conclusion: Lugol's iodine when used with toluidine blue helped in delineating the inflammatory lesions and was the mean source in determining clinically the degrees of differentiation of malignant lesions as the poorly differentiated malignant lesions without glycogen content failed to show Lugol's iodine retention. Toluidine blue with Lugol's iodine can be used as a pretherapeutic assessment of the biologic aggressiveness of the disease.

A study of cervical cancer screening for prevention of carcinoma cervix.

To identify precursor lesions of cancer cervix and early cancer cervix in married women with primary complaint of leucorrhoea in a tertiary referral centre with reference to effectiveness of screening methods, 100 successive women attending colposcopy clinic with primary complaints of leucorrhoea were selected . All women had speculum examination, Pap smear, vaginal pH, Whiff test, visual inspection of cervix after application of acetic acid (VIA), visual inspection of cervix after application of Lugol's iodine (VIL), colposcopy done. Biopsy was taken when indicated. A total of 63 women were referred. There were 93 menstruating women. The mean age was 34.5 years. Whiff test was positive in 6 women. Downstaging showed 74 women with abnormal cervix. VIA was postive in 44 women and VIL in 53 women. The sensitivity and specificity of VIA was 77.7% and 75%, and that of VIL was 69% and 57% respectively. Diagnostic accuracy of VIA was 76%,VIL was 63%. Pap smear showed 87% accuracy. The correlation between colposcopy and histopathological examination was 93-98%. Precursor cancer cervical lesions, were found in 27% of women. Referral women with cancer precursor lesions formed the largest group of 24% (n=24) of total women. Early carcinoma cervix was detected in 3% (n=3) of which one woman was referred. The burden of carcinoma cervix in India can be brought down by screening camps and early referral.

Visual inspection for cervical cancer screening: evaluation by doctor versus paramedical worker.

BACKGROUND: In the absence of an effective cervical cancer screening programme, efforts are being made to explore the feasibility of using the existing infrastructure to develop effective low-cost screening methods. AIMS: To evaluate and compare test performance of visual inspection of the cervix by a doctor and a paramedical worker. SETTING AND DESIGN: Gynaecology outpatient department (OPD), All India Institute of Medical Sciences, New Delhi; cross-sectional study. MATERIAL AND METHODS: One hundred women with complaints of vaginal discharge, irregular bleeding, post coital bleeding or unhealthy cervix underwent visual inspection with acetic acid (VIA) and Lugol's iodine (VILI) by a doctor and nurse, followed by colposcopy and biopsy. STATISTICAL ANALYSIS USED: Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated for each test and compared. Concordance was determined by kappa statistics. RESULTS: VIA by nurse had a higher sensitivity (100% versus 87.5%), but lower specificity (53% versus 63%) when compared with the doctor, but it was not statistically significant. There was moderate agreement between their VIA findings (kappa=0.56). VILI findings were comparable to that of the VIA, both by the doctor and nurse. There was almost perfect agreement (kappa=0.89) between VILI by the doctor and nurse. CONCLUSION: Visual inspection can be performed reliably by trained paramedical workers and doctors and is an effective screening option in low resource settings.