Cervical cancer is the fourth most prevalent cancer in women globally with around 660000 new cases and around 350000 deaths in 2022.^[1]In India it ranks second most prevalent cancer in women with 123907 cases diagnosed yearly and 77348 deaths reported due to the disease.^[2]Usually, it is diagnosed in the age of 35 and 44, with the average age being 50, while it rarely develops in women younger than 20.^[3]The known risk factors are low socio-economic status, smoking, young age at the first coitus, multiple sexual partners, multiple sexual partners of spouse, marrying before age 18 yearsand multiple childbirths.^[4]Nearly inallthe casescommon cause is Human papillomavirus (HPV) infection.^[5]It is considered to be preventable disease as it is preceded by a longpre-invasive phase known as cervical intraepithelial neoplasia (CIN)that can be detected by screening and treated effectively by simple treatment.^[6,7]Early detection of disease is important meanwhile late diagnosis reduces the chance of survival.Diagnosis can be done using a variety of screening tests, generally Papanicolaou smear test (Pap)which uses cell cytology is employed.^[8]The Pap test detects precancerous CIN and the early stage of invasive cervical cancer.^[9]It is known for its high specificity;however, it has moderate sensitivity, requires skilled personnel and involves delays in results and frequent follow-ups.^[10]Alternative strategies like visual inspection of cervix after application of 3-5% acetic acid (VIA) and visualinspection after lugol’s iodine (VILI) are alsoused.^[11]They are simpler, cost-effectiveand provide immediate results. Despite these benefits, they have variable accuracy, risk of overtreatment, and are less suitable for older women, they lack consistent training standards.^[10]The well efficient screening by cytology reduces the occurrence of morbidity and mortality in developed countries.^[12]The present study aimed to assess the sensitivity and specificity of tests like Pap smear, VIA and VILI as screening test in cervical cancer. Comparing above methods is crucial as each method differs in diagnostic accuracy, cost, and feasibility. Assessing their sensitivity and specificity helps determine which test offers the best balance between detecting cervical cancer early and minimizing false results, particularly in resource-limited settings. This study evaluatesallthree screening modalitieswhich adds valuable data from a potentially under-represented setting, enhancing global estimates on test performance and help in developmentof cervical cancer prevention strategies in similar healthcare environments.

MATERIALS AND METHODS

Study design

The cross-sectional study was conductedat<the study site has been removed for peer review process> from June 2013 to May 2014. The protocol for study was approved byInstitutional Ethics Committee. Written inform consent was obtained from all the patients about whole treatment process and follow ups.

Inclusion criteria and exclusion criteria

The patients aged above 18years, sexually active, symptomatic women undergoing routine checkup were included in study.Patients with active vaginal bleeding, with frank growth, pregnant women, postpartum patients, who were never been sexually active, patients who have undergone prior treatment for CIN or cancer cervix and post hysterectomy patients were excluded from the study.

Data collection

A detailed history regarding chief complaints, present illness, menstrual cycle, obstetric history, coital historyandcontraception was taken. General physical examination, systemicexamination-chest, cardiovascular and abdomen was done. Patientswere put in dorsal position after passing urine and speculumexamination was done. Findings were noted. The history andexamination findings were recorded on predesigned proforma.

Screening tests and examination

Examinations like Pap smear, VIA test, VILI and colposcopywere performed.For Pap smear, sample collection was done using an Ayre's spatula and an endocervical brush,cytology was evaluated by Bethesda system 2001.^[13]In VIA test naked eye examination of cervix swabbed with 3-5% diluteacetic acid for 1-2 minutes with a good source of light was performed. The VIA test interpretation of results was done as negative and positive based on presence or absence of acetowhite areas.^[14] In VILI test cervix was visualized after application of Lugol’s iodine with a swabstick.Interpretation of VILI test was done as test negative when squamous epithelium turns brown or test positive when iodine non uptake,yellow in colour.^[15]

Sample calculation

From previous studies it is known that ROC of PAP smear is 0.89.^[16]Assuming VIA to be more sensitive, area under the curve was assumed to be0.92.^[17] Correlation between method and outcome was assumed to be 0.8. Keeping alpha at 0.5 and beta at 0.2 total sample size came out to be 508.

Statistical analysis

Data was analyzedusing SPSS 15.0 for Windows (SPSS Inc., Chicago,Illinois, USA). Continuous variables were expressed by mean(SD), ordinal variables as median and minimum–maximum, and frequentvariables represented as rates.Frequencies were calculated as mean (SD) Sensitivity, specificity, positive and negative predictive value was calculated asper standard formulae using VassarStats software.

RESULT

A total of 500 patients were enrolled in the study. The mean (SD) age of patients was 45.15 (9.62)years. Most of the patients were in the age group of 41-50 years (35.6%). The majority of patients (70.2%) were graduate and many of them (63.2%) were Sikh. The commoncomplaint presented (5.6%) was discharge per vaginum. Other complaints presented were menorrhagia (4%), irregular menstrual bleeding (4%), abdominal pain (4%), urinary symptoms (3%) and dyspareunia (1%) (Table 1).

Out of all the patients included in the study, 20 (4%), 11 (2.2%) and 13 (2.6%) were positive for VIA, VILI and Pap smear respectively. The patients who had positive results in any of the screening tests were subjected to colposcopy and/or biopsy (Table 2).

The patients positive for Pap smear were subjected to colposcopy and cervical biopsy but only 8 patients were followed up and 5 lost to follow up. The sensitivity of the Pap smear was evaluated and found to be 85.7% and specificity was 80%. Out of the patients positive for VIA, only 16 underwent cervical biopsy and 4 were lost to follow-up. The sensitivity of VIA was found to be 100% while the specificity was 60%. The patients found to be VILI positive were 11 and out of them 9 patients followed up and underwent cervical biopsy.  The sensitivity of VILI was evaluated and came out to be 85.7% and specificity was 70%. (Table 3). While correlating VIA with Pap smear, the 11 (55%) VIA positive patients out of 20 were negative for intraepithelial lesion or malignancy (Neg). Whereas, 4 Pap smear positive patients were VIA negative (atypical squamous cells of undeterminedsignificanceASCUS (n=1), atypical glandular cells of undeterminedsignificanceAG-NOS (n=1)). The VIA-negative result strongly indicates a normal Pap smear category.Only 3 (15%) VIA positive patients out of 20 were atypical squamous cells (ASC-H) - cannot exclude high-grade squamous intraepithelial lesion.

The correlation of VILI and Pap smear results indicates that 3 (27.2%) out of 11 VILI positive patients were neg. While, 5 VILI negative patients (ASCUS (n=1), ASC-H (n=1) AG-NOS (n=3))had positive findingson Pap smear (Table 4).

Histopathologic examination of colposcopy-directed cervical biopsy was used as the reference standard for diagnosing CIN. The patients positive on cervical biopsy were 7 out of 17 wherein, 3 (18.7%) were CIN 1, 1 (6.2%) was CIN 2, 2 (12.5%) were CIN 3 and only 1 (6.2%) had squamous cellcarcinoma (Table 5).

The colposcopy was positive in 7 (1.4%) patients which revealed CIN 1 in 2 patients and normal in others. The patients who were positive for VIA, VILI and Pap smear and followed up for cervical biopsy, 6 out of them had abnormal cervical biopsy. Only 1 patient out of these 7 was VIA positive wherein biopsy came out to be CIN 1.

Table 1. Demographic characteristics

Table 2. Findings of the three screening tests

Table 3. Sensitivity analysis of VIA, VILI and Pap smear

Table 4. Correlation of Pap smear cytology with VIA and VILIoutcomes.

Table 5. Correlation of histopathology to VIA,VILI and Pap smear

DISCUSSION

Cervical cancer is a major health problem faced by the Indian women.^[18]Usually, it is preceded by premalignant lesions, which laterdevelop to invasive cancer. When identified and treated early, they have high rate of reversal with simple surgicalprocedure. Once reached advanced stage cancers survival rate decreases.^[19] In the present study we attempted to evaluate techniques Pap smear, VIA, VILA in atertiary care hospital in northern India for early detection.

In this study 500 females were enrolled with mean age of 45.15 years and 35.6% of the patients were in the age group of 41-50 years. Another study also reported mean age of patient as 44.09 years and were in range of 35-57 years.^[20] Age of menarche was reported between 13-14years in 74% of patients this was similar to a study where they have seen this age at menarche as higher risk of cervical cancer.^[21] The first intercourse between 21-25 years was seen in 65.2% patient, these results are consistent with other studies which reported early age at first intercourse is at major risk.^[22,23]Most of the patients (86.6%) were multiparous, this was similar to other study where they reported patients with 84.0% multiparity.^[24]Majority of patient (74.8%) tested positive for cervical cancer at routine checkup, while only 5.6% had complaint of discharge per vaginum, other studies also reported vaginal discharge as common complaint.^[15]

The Pap smear was positive in 13 (2.6%) patients including atypical glandular cells not otherwise specified(AG-NOS) in 4 and atypical squamous cells of undetermined significance (ASCUS) in 3 patient and Atypical squamous cells-cannot exclude high grade lesion (ASC-H) in 3 patients.The similar results were seen in other studies.^[15]The sensitivity of the Pap smear was evaluated and found to be 85.7% and specificity was 80% in another studies variation in sensitivity and specificity of test was seen.^[25]

The sensitivity of VIA was found to be 100% while the specificity was 60% while another study reported it 88.8% and 43.8% respectively.^[26]The sensitivity of VILI was evaluated as 85.7% and specificity was 70%. In another study the sensitivity of VILI was 78.6% and specificity was 85.1% respectively.^[27] 

The PPV and NPV of all the three tests werecalculated. VIA had NPV of 100% thereby implying that itcan be used as a test for screening in low resource countries.^[28]Pap smear had highest PPV of 75% in thepresent study amongst all three tests emphasizing highest specificity of thistestConsequently in another study the PPV of Papwas extremely low at 31.11%.^[29]

Out of 7 patients positive on cervical biopsy, 3 (18.7%) patients were CIN 1, 1 (6.2%) was CIN 2, 2 (12.5%) were CIN 3, these results were consistent with study of Ghosh et al.^[15]

Strength and Limitations of the study

VIA and VILI offer affordable, simple, point-of-care cervical screening achievable by non-specialist health workers, with immediate results enabling a ‘screen-and-treat’ approach. Their sensitivity in low-resource contexts is comparable to Pap smear, enhancing real-world effectiveness.

The study was conducted in a single hospital;hence the results may not represent the whole community.Detection of true positive by each screening test was used for the calculation of sensitivity, specificity, positive and negative predictive value. Therefore, these values could be anapproximate estimation.

Future prospective

Tests that allow increased screening coverage with low cost and reducing the number of patients for follow up are likely to improve cervical cancer screening services in developing countries like India. Integration of VIA and VILI based screening programme at primary care level of health services will help to downstage cervical cancer.

CONCLUSION

In this study VIA and VILI are less specific in comparison to Pap smear butthey are more sensitive in detecting preinvasive lesions. Hence VIA and VILIcan be used as screening tools for cervical cancer in low resource setting.

Funding: None

Acknowledgement: None

Conflict of Interest: The authors declare no conflicts of interest

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