|Year : 2022 | Volume
| Issue : 1 | Page : 14-18
Cost-effectiveness of cervical cancer screening in rural Bengaluru with demographic analysis of epithelial cell abnormalities: A cross-sectional descriptive study
Amrit Kaur Kaler1, M Shilpa Rao1, M Roopamouli2, Y Srinivasalu3, SN LV Narasimha Raju4, US Vishal Rao5
1 Department of Pathology, The Oxford Medical College, Hospital and Research Centre, Bengaluru, Karnataka, India
2 Sahaya Hastha Trust, Bengaluru, Karnataka, India
3 Director, The Oxford Medical College, Hospital and Research Centre, Bengaluru, Karnataka, India
4 Chairman, The Oxford Medical College, Hospital and Research Centre, Bengaluru, Karnataka, India
5 Centre for Academic Research, HCG Cancer Center, Bengaluru, Karnataka, India
|Date of Submission||11-Jun-2021|
|Date of Decision||24-Sep-2021|
|Date of Acceptance||11-Mar-2022|
|Date of Web Publication||03-May-2022|
Dr. Amrit Kaur Kaler
Consultant Molecular Pathologist, Department of Laboratory Medicine, Kokilaben Dhirubhai Ambani Hospital, Mumbai, Maharashtra
Source of Support: None, Conflict of Interest: None
Aim: Cervical cancer is the fourth-most common cancer in women worldwide and ranks third among all the malignancies for women. In contrast to developed countries, cervical cancer is a public health problem in developing countries like India and accounts for a quarter of the global disease burden. It is also one of the leading causes of cancer mortality in India, accounting for 17% of all cancer deaths among women aged between 30 and 69 years. The aim of this study is to perform a demographic analysis of cervical cancer by using Papanicolaou (PAP) test as a screening modality in Doddaballapur, rural Bengaluru, Karnataka.
Materials and Methods: A cross-sectional descriptive study was conducted on cervical cancer screening utilizing PAP smear screening. Camps were organized in Doddaballapur, rural Bengaluru, organized by Non-Profit Organization, Sahaya Hastha Trust between December 2017 and 2018. The PAP smears were stained and evaluated for epithelial cell abnormality using Bethesda System criteria free of cost at The Oxford Medical College and Hospital, Bengaluru.
Results: A total of 647 patients were evaluated in this prospective study and abnormal epithelial cell abnormalities (ECA) were observed in 24 (3.7%) cases. Among the 24 cases, 2 cases (8.3%) of squamous cell carcinoma, 11 cases (45.8%) of atypical squamous cell of undetermined significance, 5 cases (20.8%) of Atypical Squamous cells - cannot rule out high-grade squamous intraepithelial lesion (HSIL), 3 cases (12.5%) of low-grade squamous intraepithelial lesion (3), 2 cases (8.3%) of high-grade squamous intraepithelial lesion (HSIL), and a single case (4.2%) of atypical glandular cells of undetermined significance were noted. Of the remaining 623 smears (96.2%) diagnosed with negative for intraepithelial lesion or malignancy, 428 cases (68.7%) were reported as nonspecific inflammation, while 56 smears (8.9%) showed atrophic smears and 20 cases (3.1%) were unsatisfactory for evaluation. 119 cases (19.1%) displayed a specific infectious etiology; coccobacilli (bacterial vaginosis) being the most common 66 cases (55.5%), followed by Trichomonas vaginalis 46 cases (38.6%) and Candida infection has 7 cases (5.8%).
Conclusions: In Dodabullapur, a rural Bengaluru suburb, 3.7% of cervical cancer patients had ECA. It is hypothesized that a low-cost screening program is exceptionally beneficial in lowering the disease burden of cervical cancer, especially among middle-aged women and those living in low-income areas. This humanitarian purpose might motivate women in rural regions to be educated with the sole goal of uplifting the impoverished.
Keywords: Cervical Cancer, demographic analysis, epithelial cell abnormalities, infectious conditions, Papanicolaou smears
|How to cite this article:|
Kaler AK, Rao M S, Roopamouli M, Srinivasalu Y, Narasimha Raju SL, Vishal Rao U S. Cost-effectiveness of cervical cancer screening in rural Bengaluru with demographic analysis of epithelial cell abnormalities: A cross-sectional descriptive study. J Precis Oncol 2022;2:14-8
|How to cite this URL:|
Kaler AK, Rao M S, Roopamouli M, Srinivasalu Y, Narasimha Raju SL, Vishal Rao U S. Cost-effectiveness of cervical cancer screening in rural Bengaluru with demographic analysis of epithelial cell abnormalities: A cross-sectional descriptive study. J Precis Oncol [serial online] 2022 [cited 2022 Oct 4];2:14-8. Available from: https://www.jprecisiononcology.com//text.asp?2022/2/1/14/344539
| Introduction|| |
Carcinoma of the uterine cervix is a major health problem faced by Indian women, and every year, approximately 120,000 women develop this disease., India accounts for 15.2% of the total cervical cancer deaths in the world, particularly middle-aged women., 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 the natural history of progression from epithelial abnormalities (precancerous lesions) to the development of cervical cancer makes it as a relatively early preventable disease and provides the rationale for screening. Papanicolaou (PAP) smears are an underutilized screening modality among the rural population in Indian minorities. Lack of awareness, cultural barriers, and economic factors prevent them from seeking timely care. The screening is equally important to minimize the frequency of the disease, it can be widely used as a mass screening program for women in the reproductive age group for the early detection of precursor lesions. Hence, we need to organize the public health system for cervical cancer screening for the early detection of precursor lesions.
The objective of the screening program was to assess the incidence of cervical cancer in addition to contributing toward decreasing the disease burden by early diagnosis among the rural population of Bengaluru, Doddaballapur.
| Materials and Methods|| |
A prospective cross-sectional descriptive study was carried out in Doddaballapur taluk, rural Bengaluru. The camps were organized every Sunday in collaboration with NGO Sahaya Ahastha, which provided manpower, counselors, motivation camps, and screening kits. Random sampling method was used to select the women for the pap smear screening. The inclusion criteria were women between 18 and 80 years with proper clinical history was taken which included parity, menstrual history, first childbirth and duration of married life, and clinical examination. The exclusion criteria included menstruating and pregnant women. The Pap smear was collected by skilled personnel employed by Sahaya Ahastha and the smears were immediately fixed in alcohol. The slides were transported to the Department of Pathology at The Oxford Medical College and Hospital (TOMCH) for evaluation. The nomenclature and criterion in the Bethesda system for reporting cervical cytology were employed in the reporting of the abnormal epithelial findings. The incidence of epithelial cell abnormality on the PAP smear was calculated in proportions/percentages. The results were analyzed using SPSS (The statastical package for social sciences IBM corporations, IBM SPSS statistics for windows version 26.0 Armonk NY: IBM Corp) latest version. All patients with epithelial cell abnormalities (ECA) were referred for colposcopy according to the standard procedure and recommendations. Cases which were reported to have epithelial abnormalities (malignant changes) were informed promptly and referred to the specialty oncology center, KIDWAI in Bengaluru for appropriate management. Details of the above patients were noted for follow-up posttreatment.
| Results|| |
A total of 647 pap smears were collected and reviewed during the course of the camp. Majority of the smears (623 smears, 96.3%) harbored no ECA and were reported as negative for intraepithelial lesion or malignancy (NILM) [Table 1]. The nonepithelial findings in 623 cases of NILM, were as follows: nonspecific inflammation was seen in 428 smears (68.7%), atrophy in 56 smears (8.9%), and unsatisfactory for evaluation in 20 smears (3.1%). In 119 smears (19.1%), a specific infectious agent could be identified; coccobacilli (bacterial vaginosis) were the most common 66 smears (55.5%) followed by Trichomonas vaginalis 46 smears (38.6%), Candida infection 7 smears (5.8%) [Figure 1]. All atypical epithelial changes due to inflammation were reported as reactive and were not considered premalignant. ECA was observed in a small fraction of screened smears and accounted for 3.7% of the total cases in the study cohort [Figure 2]. Among the 24 cases, the highest prevalence among the ECA was atypical squamous cell of undetermined significance (ASCUS) 45.8% (11), ASC-H 20.8% (5), low-grade squamous intraepithelial lesion (LSIL) 12.5% (3), high-grade squamous intraepithelial lesion (HSIL) 8.3% (2), atypical glandular cells of undetermined significance (AGUS) 4.2% [Figure 2]. The total number of invasive malignant cases was 2 and represented 8.3% of the total cases with ECA. The mean age of cases with LSIL was 45 years, those with HSIL was 49 and invasive carcinoma was 45 years [Table 2]. The unsatisfactory smears were found to be 3.1%. The patients were explained about the same and advised to repeat the smear for re-evaluation but could not be assessed during the period of the study.
|Figure 1: Age-wise distribution of negative for intraepithelial lesion or malignancy (Benign) on Papanicolaou smear|
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|Figure 2: Distribution of epithelial cell abnormalities on PAP smear: AGUS: Atypical Glandular cells of undetermined significance, ASCUS: Atypical squamous cell of undetermined significance, ASC-H: Atypical squamous cell of undetermined significance, cannot rule out HSIL; SIL: Squamous intraepithelial lesion, HSIL: High-grade squamous intraepithelial lesion, LSIL: Low-grade squamous intraepithelial lesion, SCC: Squamous cell carcinoma|
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|Table 2: Age-wise distribution of epithelial cell abnormalities on Papanicolaou test smear|
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| Discussion|| |
Cancer is one of the leading causes of adult mortality globally in women. Annually, 14 million new cases of cancer are detected and 8 million cases die of cancer and cancer-related mortalities., In India, cervical cancer contributes to approximately 6%–29% of all cancers in women. The high burden of cervical cancer in India and Southeast Asian countries is due to poor to moderate living standards, a high prevalence of human papillomavirus (HPV) (more than 10% in women aged more than 30 years) and due to lack of screening. It is one of the leading causes of cancer-associated mortality, accounting for 17% of all cancer deaths among women aged between 30 and 69 years.
Screening for cancer is known to reduce mortality by early detection and treatment. However, there are two prerequisites for screening to reduce the rate of death from cancer. First, screening must reduce the time of diagnosis of cancers and second early treatment of these cancers should be of some advantage over treatment at the clinical presentation that is destined to cause death. The cause of reduction in death rate is related to PAP smear in detecting precancerous lesions of different grades. Therefore, PAP smear has increased the deductibility rate of potentially curable cancer in its early stages which some of it might progress to cancer if left untreated. Screening should be a multidisciplinary approach, including community education, social awareness, vaccination, screening, treatment, and palliative care.
The age distribution of women volunteered in the present study was between 17 and 80 years which was comparable to the studies as described by Jain et al., Robyr et al., Mostafa et al.,, The ECA on PAP smears were found to be more common among the age group of 40–50 years attributing to 41.6%, which was comparable to the study by Jain et al. and Pradhan but higher age group is found when compared to the study of Gupta who reported most of the abnormal cytology cases, (40.37%) in the age group of 30–39 years. In the present study, LSIL was found in the age group of 40–50 years (12.5% of the total ECA) which differed from the study of Gupta et al. where LSIL was found in 1.36% (age group of 30–39 years). HSIL was seen in the 40–60 years age group (8.3% out of the total ECA) in our study which was comparable to the study of Gupta et al. where HSIL was reported in 0.91% (age group of 40–49 years). In the present study, invasive cervical cancer was most commonly seen in the 40–49 years age group which was comparable to the study by Pradhan where carcinoma was most commonly reported in 21–50 years.
In the present study, demographic distribution showed approximately 3.7% of the study population had ECA which was considerably lower than the reported figure in the literature. Among the ECA, AGUS constituted 6.5% and this was the least category of all ECA and ASCUS was the most common category. This was in accordance to a population study in Romania, where ASCUS was the most common epithelial cell abnormality, constituting 2.6% of cases reviewed. Vaghela et al. reported that LSIL was the most common epithelial abnormality, found in 12.4% of their individuals, followed by HSIL in 5% of the cases. The present study did downgrade the atypical changes present on the slide as reactive in the background of severe inflammation. However, squamous metaplastic (mature and immature) changes could not be ignored and were reported as ASCUS in patients above 50 years [Figure 3].
|Figure 3: Conventional Papanicolaou stained smears showing epithelial cell abnormalities. (a) ASC-H featuring scattered, isolated, atypical cells show high N/C ratio with nuclear irregularity; (b) Squamous cell carcinoma shows dysplastic squamous cells (arrow) in a dirty inflammatory background indicative of invasion; (c) low-grade squamous intraepithelial lesion. The nuclei show nuclear enlargement, hyperchromasia, and nuclear membrane irregularities with koilocytosis; (d) atypical squamous cell of undetermined significance with a mild increase in N/C ratio with mild hyperchromasia and nuclear irregularity|
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The unsatisfactory PAP results were found to be 3.1% which could be explained to the operator improper sample collection or blood/mucus obscuring the cells. However, women could not be convinced to repeat the smears due to their lack of willingness to turn up for re-evaluation despite being explained about the necessity of the same. This might had have led to a false negativity rate which could be related to the low socioeconomic status of the patients and illiteracy (58.7%) in rural areas of Bengaluru. Even the lack of cooperation was seen among women to convince them for a biopsy diagnosed with LSIL/HSIL smears. However, 2 women with squamous cell carcinoma immediately opted for surgery and treatment due to their health issues and the cost was taken care of by the NGO, Sahaya Hastha Trust. We conclude that clinical correlation and patient examination should be the first step and these might help to separate patients for follow-up with unsatisfactory diagnosis. Failure to elucidate factors should still prompt close interval repeat PAP to promote improved follow-smear(s).
The infectious diseases reported in the present study were bacterial vaginosis (55.5%) followed by Trichomonas vaginalis (38.6%), Candida infection (5.8%) which were quite common in this particular belt [Figure 4]. This necessitates the need of awareness and orientation on preventive and personal feminine hygiene practices. However, the stigma in terms of openness in discussing women's health, hygiene, and cancer was difficult to address. In a study conducted by Tiwari et al., a higher rate of abnormal Pap smear was observed among women using cloth, especially old washed cloth rather than sanitary napkin. Fifty percent of women who did not wash their genitalia after urination had abnormal Pap smears. The rural areas need more doctors not only to provide health care but also to increase awareness on various health issues.
|Figure 4: Specific infections on Papanicolaou smear. (a) Conventional Papanicolaou stained smear showing clue cell (arrow); (b) showing Candidiasis infection (arrow)|
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Cost-effectiveness is an important characteristic of a screening program as the benefits out ways its effectiveness. Cancer diagnosed at an earlier age increases the quality of life and decreases the cost burden of the treatment. The cost-effectiveness of screening, irrespective of method, was sensitive to the costs associated with the treatment of invasive cancer and the target age. Hence, including screening programs as part of national health policy can be beneficial to the general population and to the Government. The present camp provided us information to understand the demographics in terms of the incidence of cervical cancer in Rural Bengaluru. By increasing awareness and giving a timely diagnosis helped them save on an enormous cost.
| Conclusion|| |
In Dodabullapur, Rural Bengaluru, Karnataka, the incidence of ECA in cervical cancer was reported to be 3.7%. This emphasizes the need of establishing a cervical cancer screening program as a priority program to encourage early detection and educate on cervical cancer management, measures, and prevention. As a result, the cost-effectiveness of cancer screening programs far surpasses the disease burden of cancer treatment. In addition, we advise women aged 21–69 to have a cervical screening every 3 years. The PAP smear may be utilized as a cost-effectiveness analysis tool for public health programs on cervical cancer screening., The HPV vaccination must be incorporated in health policy between the ages of 9 and 15, or before they become sexually active, as primary prevention is far superior. Future camps and research are suggested for Bengaluru's remaining demographic zones.
Financial support and sponsorship
Sahaya Hastha Nonprofit organization, Bangaluru, Karnataka, India for logistics and treatment cost.
Conflicts of interest
There are no conflicts of interest.
The prospective study was approved by the Human Research Ethics Committee of the TOMCH (Registration No: 2018/RR-16).
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2]