Role Of Pap Smear In Early Diagnosis Of Cervical Cancer

Worldwide, cervical cancer is twelfth most common and the fifth most deadly cancer in women. It affects about 16 per 100,000 women per year and kills about 9 per 100,000 per year. Worldwide, in 2008, it was estimated that there were 473,000 cases of cervical cancer, and 253,500 deaths per year. Cervical cancer mostly affects younger women and during the last two decades the incidence in younger age groups has further increased. The International Federation of Gynecology and Obstetrics (FIGO) staged Cervical cancer (table in main report) however the stage distribution differs in different parts of the world and this is most likely a reflection of the presence or lack thereof of screening programmes that spot the disease at an early stage. The EU established principles for organised population-based cervical screening to control and decrease the incidence of cervical cancer.In 1941, Papanicolaou described cervical mass screening for early detection of cervical cancer. The Pap smear has proved valuable for mass screening and enabling lesions detection at an early enough stage for effective treatment and has an incidence of reducing squamous ICC by at least 80%. For the Pap smear (conventional cytology), cells are collected from the surface of the uterine cervix and the cervical canal, smeared on a glass slide, and analysed in a microscope. The Liquid-based cytology (LBC) the cellular material is immersed in a container with a special liquid but it needs to be performed in a special equipment lab. In 1988 the Bethesda System (TBS) was introduced to standardize cytology reporting and important changes and updates in gynecologic cytology like LBC and (HPV) DNA testing led to minor amendments in 1991 and a new redefined version of TBS in 2001 which has been used to classify our research findings. As per TBS 2001 the minimum requirement for adequacy for a conventional cytology is 8000-12000 visible squamous cells but for LBS only 5000 cells are sufficient.For early stage cervical cancer (I-IIA) the usual treatment is radical hysterectomy and pelvic lymphadenectomy occasionally followed by radiotherapy and chemotherapy but this deprives females of their fertility. Mostly stages IB2 and IIA, are best treated by a combination of radiotherapy and chemotherapy. Hysterectomy is used to treat the Microinvasive cancer stage IA1 but in order to preserve fertility it is done by one excision of the lower part of the cervix.For females at stage IA2 or IB1 the following methods may be used; in case of no lymph node metastasis, fertility sparing surgery is opted. The lymph nodes can be taken away laparoscopically and if negative nodes, the cervix is radically removed by a vaginal approach.The last technique, abdominal approach, requires extensive experience and speciality. Abdominal approach is pelvic lympadenectomy and radical trachelectomy-leaving the uterus. Continual infection with a carcinogenic papillomavirus (HPV), which is a double-stranded circular DNA viruss that infects many species, is a basic cause of squamous cell carcinoma and adenocarcinoma. Amongst women already infected by HPV; long term use of oral contraceptives, high parity, multiple parity and smoking are some of the many high risk factors.The World Health Organisation defines screening as "the presumptive identification of unrecognised disease by means of tests or examinations that can be applied rapidly". Since the precancer time period for cervical cancer is longer as compared to other female cancers hence the mortality rate is comparatively high as well. Also treatment of precancer or early stage ICC usually leads to healthier outcome than late treatment.Saudi Arabia has a population of 6.51 million women ages 15 years and older who are at risk of developing cervical cancer. Current estimates indicate that every year 152 women are diagnosed with cervical cancer and 55 die from the disease. Organized screening has not been introduced in Saudi Arabia. For the purpose of this study data was collected from January 2009-January 2011 at King Abdul Aziz Hospital & Oncology Centre Jeddah. All Pap smears were performed by the same doctor. This was to ensure that there was no compromise on quality and method of sample collection for Pap smear.The age range was 30-65 years and the median age was 47 years. The Pap smears (11=1475) performed were due to one or a combination of the following reasons; vaginal discharge, vaginal itching, lower genital tract burning, suspected urinary tract infection by the patient and/or age of the patient where the doctor performed the pap smear because the patient was in the age range for cervical cancer. For 83% females in the study this was their first Pap smear. The total number of abnormal cervical smears was 43. i.e.2.91% of all screened cytology cases. All the abnormal smears were re-examined and then classified according to the Bethesda System (TBS). Our research indicated a high prevalence of CIN 1 and CIN 3. It has been recognized worldwide, through studies and clinical practices that for early detection of precancerous lesions of cervical cancer the best technique is cytological examination of cervical by Pap smear. This is because an abnormal cervical cytology report shows the existence of a precancer lesion which if left untreated mostly progresses to cancer. It can be said with great certainty that cytological screening programs play a major role in reducing both the incidence and mortality of ICC. In the US, Canada and Europe widespread introduction of cytological screening decreased the incidence of cancer of the cervix that was paralleled by a reduction in mortality. Europe has approximately 55000 new cases each year and 25000 deaths.The greater part of these cases are in Eastern Europe where there are no cervical screening programmes. All abnormal cytology patients were amongst the 83% giving their first Pap smear sample. This indicates that for CIN2 and CIN3, patients earlier Pap smears would have meant earlier detection at the earlier stage leading to an increased rate of recession and hence of mortality. For patients with CIN1 and early stages of cervical cancer a regular yearly Pap smear would have shown the cellular change and for those with abnormal cytology but non cancerous legions the correlated treatment has begun and their follow-up Pap smear is to be performed after 6 months of the first Pap smear. The increasing rate of cervical cancer incidence in Saudi Arabia can be greatly reduced, thus increasing the mortality rate, as Pap smears play a substantial role in not only detection but also prevention of cervical cancer. Especially if performed yearly for women after the age of 34 as it is after this age when majority of the incidence cases have been reported in Saudi Arabia.It is therefore recommended that as part of an organized screening, after 34 years of age a yearly Pap smear should be made mandatory as part of the primary health care system in Saudi Arabia and its results recorded in patients' permanent files. The yearly Pap smear should be performed irrespective of whether any of the before mentioned symptoms exist or not. In case of abnormal but non cancerous cytology a follow-up Pap smear after six months should be performed.Success of organized screening programme is possible when Family physicians at family clinics will be properly trained in performing Pap smears. It is also essential to educate women over 34 about Pap smear, this can be done by the family physician one 34 years age has been reached and also through pamphlets.