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Selective screening for carcinoma cervix in south Indian women
Inc. J. Gynaecol. Obstet., 1986,24: International
Federation
SELECTIVE
SCREENING
P. SHRIVASTAVa,
P. JAIRAJa,
& Obstetrics
FOR CARCINOMA
N. BALASUBRAMANIAM’and
‘Department of Obstetrics and Gynaecology Ho&tal, Vellore, 632 004 (India). (Received (Accepted
September May 30th.
331
331-342
of Gynaecology
CERVIX IN SOUTH INDIAN WOMEN
H. KRISHNASWAMlb
and Family Welfare and bDepartment
of Pathology. Christian Medical College and
30th, 1985) 1986)
Abstract Shrivastav P, Jairaj P, Balasubramaniam N, Krishnaswami H (Department of Obstetrics and Gynaecology and Family Welfare and Department of Pathology, Christian Medical College and Hospital, Vellore, 632 004, India). Selective screening for carcinoma cervix in south Indian women. Int J Gynaecol Obstet 24: 337-342, 1986 In India, the need exists for a scheme of selective screening for women at high risk of developing cervical carcinoma. In this study, the incidence of abnormal cervical cytology amongst 500 pregnant south Indian women (gravida 3, para 2 or more) who were booked under the Post Parturn Programme of the Government of India was compared to that of 200 primi and second gravidas from the same out patient clinic population. Abnormal cytology was detected in 3.6% of the women in the study group which was significantly higher (P < 0.05) than that in the control (0.5%), indicating that the former are at higher risk of developing cervical cancer. Within the study group, abnormal cytology was not found to correlate with increasing age and gravidity or with any clinical parameter. The study and follow up could be carried out using existing facilities and manpower. Using existing personnel involved in the Post Partum Programme, a follow up rate of 67% could be achieved from among women with abnormal cervical cytology. 0020-1292/86/$03.50 0 1986 International Federation Published and Printed in Ireland
The cost-ejfectiveness of this scheme oj’ selective screening is borne out by the extremely modest additional cost incurred.
Carcinoma cervix: High risk Keywords: group; Selective screening; Papanicolaou Post-partum sterilization program: smear; Cost-effectiveness. Introduction Carcinoma of the cervix is the most common malignant tumor seen in Indian women, the prevalence of this disease being highest in the southern part of the country. Reports [ 1,51 from different south Indian states show that between 55 and 70% of all malignancies in women are carcinoma of the cervix. The average age of Indian women at the time of presentation with this disease is 10 years less than in their western counterparts [ 121. Fifty-nine percent of these women are less than 40 years of age [ 41. Most present at an advanced stage of the disease. The magnitude of this problem calls for a screening program to be made available. This would lead to the detection of preinvasive and early invasive stages of the disease which respond well to treatment. However, with currently available resources annual screening for all sexually active women cannot be justified [ 31. This has led to the advent of selective screening, whereby. by concentrating on the high risk groups, a reduction in exInt J G.\naecol Ohstet -74
of Gynaecology
& Obstetrics
3 38
Shrivastav
ef al.
penditure is achieved without a great reduction in the return. However, Indian women at the highest risk of developing cervical carcinoma are those least likely to voluntarily enroll in a screening programme or to attend a gynecological clinic. The objectives of the present study were to ascertain the feasibility of carrying out a program of selective screening for cervical carcinoma in south Indian women and to evaluate its cost-effectiveness. Materials and methods
The government of India introduced the Post Partum Programme in 1969, whereby pregnant women in urban and rural areas are motivated to undergo sterilization in the immediate post-partum period. The study group consisted of randomly selected women booked under this program who were attending the general obstetric outpatient clinic of the department of Obstetrics, Gynaecology and Family Welfare, Christian Medical College Hospital, Vellore, South India. Randomly selected primi and second gravida women from the same Obstetric clinic constituted the control group. The cervix was visualized by a bivalve speculum. Exocervical scrapes using a wooden spatula were taken, smeared onto two glass slides and dipped into a fixative containing a 1 : 1 mixture of ether and 95% alcohol. Endocervical aspiration and smearing was not done. The slides were screened for abnormal cells in the department of Pathology, Christian Medical College Hospital, Vellore. Smears that showed moderate dysplasia or a higher grade of cytological abnormality were considered abnormal. These women were followed up during pregnancy and in the post partum period. Any infection present was treated and serial smears taken both during pregnancy and at 6 weeks post partum. Cervical biopsies were not taken during pregnancy unless cytology showed evidence of invasive disease. If such a biopsy proved the presence of invasive disease, the woman Int J Gynaecol
Obstet
24
was treated for the malignancy in accordance with the stage of the disease and the period of gestation. In the remaining women with serially abnormal smears, vaginal delivery was permitted. If abnormal cytology persisted at 6 weeks post partum, a cold knife conization of the cervix was performed. Subsequent management depended on the histological report. Women with symptoms of abnormal bleeding or discharge within 6 months post partum had repeat cervical smears taken. Colposcopic examination of the cervix was not possible due to a lack of facilities. Women with normal smears were encouraged to attend the gynecological clinic for repeat smearing at 2 yearly intervals. The importance of long term follow up was impressed upon women with abnormal cytology. If they failed to appear at the outpatient clinic for follow up, two letters at 4 weekly intervals were dispatched urging them to attend the clinic. If, despite this the woman defaulted, the health worker who had motivated her to undergo sterilization was contacted and requested to bring her to the clinic. When the defaulting woman was “self motivated” for the sterilization, the health worker operating in her neighborhood was requested to contact her. Results
The study group was women and the control general characteristics of two groups are shown
Table 1. groups.
General characteristics
Mean age at marriage
comprised of 500 group of 200. The the women in the in Table I. Since
of the women in the two
Study group
Control group
17.94 k3.01
18.88 t 3.90
3.90 f 1.11 26.95 k 3.59
1.33 20.47 22.21 k 3.80
(years) Mean gravidity Mean age at screening (years)
Selective screening for carcinoma cervix
Table 11. Cervical cytology
in the two groups
Normal
Study group Control
3(0.6)a
at initial screening.
Inflammatory
Mild dysplasia
Moderate dysplasia
Severe dysplasia
Smears suggestive of invasive disease
Total abnormal smears
41(8.2)
438(87.6)
12(2.4)
S(1 .O)b
l(O.2)
18c3.6)’
98(49.0)
l(O.5)
87(43.5)
14(7.0)
aFigures in parenthesis are percentages. bone abnormal smear detected post partum when the woman ‘The difference is statistically significant (P < 0.05).
increasing gravidity and age are inter-related age matched controls could not be obtained. The religious distribution of the women in the two groups was similar. The percentage of Hindus, Muslims and Christians in the study group was 8970, S%, 3% respectively while the distribution in the control group was 85.50/o, 5.5% and 9%, respectively. In the study group 2% of the women had the initial smear taken during the first trimester, 37% in the second trimester and 6 1% in the third trimester; the corresponding figures in the control group were 5%, 34.5% and 60.5%. In the control group, there was only one abnormal smear while the study group showed eighteen abnormal smears (Table II). This difference was found to be statistically significant (f’ < 0.05). Moreover, there appeared to be an overall shift towards a higher degree of cytological abnormality Table 111.
Clinical
appearance Study
Healthy Erosion Chronic cervicitis Healed lacerations Endocervical polyp Growth on cervix
3 39
of the cervix. group
1 80(36.0)a 137(27.4) 169(33.8)’ 8S(17.0)d 1 l(2.2) l(O.2)
Control
group
140(70.O)b 49(24.5) ll(5.5) _ _ _
aFigures in parenthesis are percentages. bathe difference is highly significant (P < 0.001). ‘The difference is highly significant (P < 0.001). dThe difference is highly significant (P < 0.001).
complained
of excessive
_
I (o.5)c
vaginal discharge.
in the study group, there being significantly more women showing mild dysplasia as compared to the control group (P < 0.001). The control group showed significantly more normal and inflammatory smears as compared to the study group (P < 0.00 1). Table III shows that on clinical examination, a healthy cervix was found in significantly more women in the control group (P < O.OOl), while evidence of chronic cervicitis and healed lacerations on the cervix were significantly higher in the study group (P < 0.001). In the study group, 38% of the women had had all previous deliveries at home and were being booked for a hospital delivery for the first time. Another 17% had had only one hospital delivery in the past. Motivation for sterilization may have been the major reason for these women to opt for regular antenatal care and a hospital delivery in the present pregnancy. Three percent of the women in the study group gave a history suggestive of threatened abortion or antepartum hemorrhage at some time during the present pregnancy, but only one (0.2%) was bleeding at the time of the initial screening. Within the study group, abnormal cervical cytology was not found to correlate with age and gravidity or clinical parameters such as an unhealthy cervix or contact bleeding from the cervix during the exocervical scrape. ItIt J Gtwaecol Ohstet ,74
340
Shrivastav et al.
In the 18 women with abnormal cervical cytology, the mean age at screening was 28.17 + 3.60 years and the mean gravidity 4.11 + 1.lO, neither of which was significantly different from that of the entire study group. However, the mean age at marriage of the women with abnormal cytology was 16.28 + 2.11 years which was significantly lower than that of the entire study group (P < 0.05). Seventeen of these abnormal smears were detected at the time of initial antenatal screening. One woman had a smear reported as mild dysplasia at the time of the initial screening but a repeat smear taken 5 months post partum, because she complained of abnormal vaginal discharge, showed cytology suggestive of severe dysplasia. The initial smear was reviewed and its benign nature confirmed. Six (33.3%) of these 18 women defaulted and thus a follow up rate of 66.7% was obtained. Of the remaining 12, one had cytology suggestive of invasive carcinoma. On reexamination a small growth was seen protruding through the cervix and on punch biopsy this proved to be a well differentiated papillary adenocarcinoma. The growth was staged as IB and as the woman was at a gestational age of 20 weeks an upper segment hysterotomy and bilateral tubectomy were performed, following which radiotherapy was instituted. All the remaining eleven women were permitted vaginal delivery. Four showed persistently abnormal cytology in the postpartum period. Three had severe dysplasia and a cold knife conization of the cervix was performed at 6 weeks post partum. One biopsy specimen showed evidence of microinvasive carcinoma and a total abdominal hysterectomy and right salpingooophorectomy was subsequently performed. Carcinoma-in-situ and severe dysplasia were found in the other two biopsy specimens and these women have been advised hysterectomy. The fourth woman had repeated smears showing moderate dysplasia and is presently being followed up. Women with abnormal cytology at the time of initial Int J Gynaecol Obstet 24
screening but who subsequently had normal smears are also being followed up. Discussion and conclusions Women who utilize the facilities offered by the Post Partum Programme usually come from the lower socioeconomic class, are gravida 3, para 2 or higher and most are between 25 and 35 years of age. Many of them are availing of organized medical care and visiting a hospital for the first time. After sterilization most are unlikely to reappear in a hospital for many years. The present pregnancy would thus constitute a good opportunity to screen them for cervical carcinoma. The results of this study show that the women booked under this program had a significantly higher incidence of abnormal cervical cytology (3.6%) as compared to the control group (0.5%) (P < 0.05). The mean age at marriage of the women in the study group was 17.94 f 3.01 years, the mean duration of married life was 9 years and they were of high gravidity (mean 3.90 f 1.l 1; range 3-9). They thus constitute a group at high risk to develop cervical carcinoma. This may explain the higher incidence of abnormal cervical cytology in this study as compared to figures reported from the west (0.7- 1.6%) from unselected obstetrical populations [6,8,9,11,131. From South Africa, Khatree et al. [ 71 have reported a 1.l% abnormal cervical cytology rate in unselected pregnant black women. Within the study group, women seem to be at uniformly high risk to develop cervical carcinoma irrespective of their age or gravidity. Thus it seems reasonable to screen all women booked under the Post Partum Programme with no selection bias towards greater age and gravidity. The present study confirms reports [ 2,101 that have shown that during pregnancy, the clinical appearance of the cervix is not a reliable indicator of cervical cytology. Similarly, contact bleeding during the exocervical scrape did not show any
Selective
significant correlation with the presence of abnormal cytology. Thus clinical parameters are unhelpful in the selection of pregnant women for a screening programme. Thirty eight percent of the women booked under the Post Partum Programme had delivered all their previous babies at home. Another 17% had only a single hospital delivery in the past. The motivation for sterilization and possibly the incentive of free antenatal, intra partum and post partum care could have resulted in their opting for a hospital delivery this time. For many of them, this could be the first and last opportunity to avail of organised gynecological care and is thus an ideal time to screen them for cervical carcinoma. Furthermore, as the women are under medical supervision over a period of months, follow up is relatively easy. The Post Partum Programme thus provides an excellent “catchment area” for the screening of non-accessible women at high risk of developing cervical carcinoma. During the antenatal period, follow up of women with abnormal cytology was easy since most attended the antenatal clinic regularly. Once the necessity of long term follow up had been impressed upon them, most came voluntarily for the post partum follow up. Women who failed to attend the clinic on the date advized usually responded to postal recall. For the few who did not, it was necessary to ask the health worker who had motivated the women to undergo sterilization or the health worker operating in the area in which the woman resided, to contact the woman and bring her to the clinic. This resulted in a follow up rate of 66.7% from amongst the women with abnormal cytology. The default rate of 33.3% could be attributed to the mobile nature of this population. Women in South India come to their parental homes for confinement, returning to their own homes shortly after the delivery. Lack of colposcopic facilities was a major limitation of this study. However, if this scheme of selective screening is to be im-
screening
for
carcinoma
cervix
34 1
plemented on a mass scale, it is unrealistic to expect such facilities to be available at each centre conducting the Post Partum Programme. In this study the two cases of invasive disease present could be detected by cervical smear screening. It has been suggested 191 that in the presence of abnormal cytology but not cytology suggestive of invasive disease, colposcopy may be omitted if a reliable cytologist is available. In such women, if repeated smears exclude the presence of invasive disease, it would be permissible to allow continuation of the pregnancy and a vaginal delivery at term as in the present study; cervical conization being postponed to the post partum period. However, if cytology suggestive of invasive disease is detected in a pregnant woman with a clinically normal cervix, a shallow cone biopsy, or multiple Schiller stain-directed punch biopsies will have to suffice in the absence of colposcopic facilities. In a developing country with limited resources and trained manpower, the costeffectiveness is an extremely relevant factor. The cost of conducting the study was extremely modest. Existing medical and paramedical personnel were utilized for the screening and subsequent follow up. This scheme can be successfully incorporated into the work schedule of these personnel thus obviating the need for an additional cadre of workers. The cost of screening 500 women in the study group was US$ 1000. This puts the cost of detecting one woman with an abnormal cervical smear at US$ 56 and the cost of detecting one case of preinvasive or early invasive disease at US$ 250, which is extremely modest as compared to the cost of treating a late stage of the invasive disease (US$ 5001000). In conclusion it can be stated that: (1) south Indian women booked under the Post Partum Programme constitute a group at high risk to develop cervical carcinoma; (2) the feasibility of instituting a program of selective screening for cervical carcinoma Int J GFnaecol
Ohstet
24
342
Shrivastav et al.
on these women using the existing facilities has been shown; and (3) the cost-effectiveness of this program is borne out by the modest expenditure incurred in detecting women with abnormal cervical cytology. A similar scheme of selective cervical screening can be incorporated into the national programs of other developing countries to cater to their female population at high risk of developing cervical carcinoma.
Acknowledgments
The authors wish to thank Dr. Matthews and of Obstetrics Department Mathai, Christian Medical College Gynaecology , Hospital, Vellore for his assistance and critical review of this manuscript. We are also grateful to Mrs. Ravi Rani Samuel and ‘Mrs. Usha Rani Joseph from the Department of Pathology, Christian Medical College Hospital, Vellore for their help in the screening of the cervical smears. References
4 Gault EW, Asirwadham M, Balasubrahmanian
5
6
7
8
9
10
11
12
13
M, D’Sena GWL, Thomas E, Isaiah P: Cancer of the cervix. Indian J Med SciS: 297, 1951. Gault EW: Cancer, Volume III. p 281. London, Butterworths Medical Publishers, 1958. Kay S: Results of routine cervical cytologic smears in the obstetric patient. Surg Gynaecol Obstet 114: 83, 1962. Khatree MHD, Houlton MCC, Moodley J: Cervical cytology in pregnant black patients and potential selective screening programmes. S Afr Med J 58: 358, 1980. Lurain JR, Gallup DG: Management of abnormal Papanicolaou smears in pregnancy. Obstet Gynaecol 53: 484, 1979. McDonnel JM, Mylotte MJ, Gustatson RC, Jordan JA: Colposcopy in pregnancy. A 12 year review. Br J Obstet Gynaecol88: 414, 1981. Moore JG, Wells RG, Morten DC: Management of superficial cervical cancer in pregnancy. Obstet Gynaecol 27: 307, 1966. Ortiz R, Newton M: Colposcopy in the management of abnormal cervical smears in pregnancy. Am J Obstet Gynecol109: 46, 1971. Rewell RE: Ethnological factors in the etiology of cancer of the uterine cervix. J Obstet Gynaecol Br Commonw 64: 821,1957. Rutledge CE, Cristopherson WM. Parker JE: Cervical dysplasia and carcinoma in pregnancy. Obstet Gynaecol 19: 351, 1962.
Address for reprints: Ahuja P, Reddy DB: Carcinoma of the cervix. J Obstet Gynaecol India 13: 5 11, 1963. Boutselis JG: Intra-epithelial carcinoma of the cervix associated with pregnancy. Obstet Gynaecol 40: 657, 1972. Draper GJ, Cook GA: Changing pattern of cervical cancer rates. Br Med J 287: 510, 1983.
Int J Gynaecol Obstet 24
P. Shrivastav, M.D. Department of Obstetrics and Gynaecology and Family Welfare Christian Medical College Hospital Vellore, 632 004 India
Federation
SELECTIVE
SCREENING
P. SHRIVASTAVa,
P. JAIRAJa,
& Obstetrics
FOR CARCINOMA
N. BALASUBRAMANIAM’and
‘Department of Obstetrics and Gynaecology Ho&tal, Vellore, 632 004 (India). (Received (Accepted
September May 30th.
331
331-342
of Gynaecology
CERVIX IN SOUTH INDIAN WOMEN
H. KRISHNASWAMlb
and Family Welfare and bDepartment
of Pathology. Christian Medical College and
30th, 1985) 1986)
Abstract Shrivastav P, Jairaj P, Balasubramaniam N, Krishnaswami H (Department of Obstetrics and Gynaecology and Family Welfare and Department of Pathology, Christian Medical College and Hospital, Vellore, 632 004, India). Selective screening for carcinoma cervix in south Indian women. Int J Gynaecol Obstet 24: 337-342, 1986 In India, the need exists for a scheme of selective screening for women at high risk of developing cervical carcinoma. In this study, the incidence of abnormal cervical cytology amongst 500 pregnant south Indian women (gravida 3, para 2 or more) who were booked under the Post Parturn Programme of the Government of India was compared to that of 200 primi and second gravidas from the same out patient clinic population. Abnormal cytology was detected in 3.6% of the women in the study group which was significantly higher (P < 0.05) than that in the control (0.5%), indicating that the former are at higher risk of developing cervical cancer. Within the study group, abnormal cytology was not found to correlate with increasing age and gravidity or with any clinical parameter. The study and follow up could be carried out using existing facilities and manpower. Using existing personnel involved in the Post Partum Programme, a follow up rate of 67% could be achieved from among women with abnormal cervical cytology. 0020-1292/86/$03.50 0 1986 International Federation Published and Printed in Ireland
The cost-ejfectiveness of this scheme oj’ selective screening is borne out by the extremely modest additional cost incurred.
Carcinoma cervix: High risk Keywords: group; Selective screening; Papanicolaou Post-partum sterilization program: smear; Cost-effectiveness. Introduction Carcinoma of the cervix is the most common malignant tumor seen in Indian women, the prevalence of this disease being highest in the southern part of the country. Reports [ 1,51 from different south Indian states show that between 55 and 70% of all malignancies in women are carcinoma of the cervix. The average age of Indian women at the time of presentation with this disease is 10 years less than in their western counterparts [ 121. Fifty-nine percent of these women are less than 40 years of age [ 41. Most present at an advanced stage of the disease. The magnitude of this problem calls for a screening program to be made available. This would lead to the detection of preinvasive and early invasive stages of the disease which respond well to treatment. However, with currently available resources annual screening for all sexually active women cannot be justified [ 31. This has led to the advent of selective screening, whereby. by concentrating on the high risk groups, a reduction in exInt J G.\naecol Ohstet -74
of Gynaecology
& Obstetrics
3 38
Shrivastav
ef al.
penditure is achieved without a great reduction in the return. However, Indian women at the highest risk of developing cervical carcinoma are those least likely to voluntarily enroll in a screening programme or to attend a gynecological clinic. The objectives of the present study were to ascertain the feasibility of carrying out a program of selective screening for cervical carcinoma in south Indian women and to evaluate its cost-effectiveness. Materials and methods
The government of India introduced the Post Partum Programme in 1969, whereby pregnant women in urban and rural areas are motivated to undergo sterilization in the immediate post-partum period. The study group consisted of randomly selected women booked under this program who were attending the general obstetric outpatient clinic of the department of Obstetrics, Gynaecology and Family Welfare, Christian Medical College Hospital, Vellore, South India. Randomly selected primi and second gravida women from the same Obstetric clinic constituted the control group. The cervix was visualized by a bivalve speculum. Exocervical scrapes using a wooden spatula were taken, smeared onto two glass slides and dipped into a fixative containing a 1 : 1 mixture of ether and 95% alcohol. Endocervical aspiration and smearing was not done. The slides were screened for abnormal cells in the department of Pathology, Christian Medical College Hospital, Vellore. Smears that showed moderate dysplasia or a higher grade of cytological abnormality were considered abnormal. These women were followed up during pregnancy and in the post partum period. Any infection present was treated and serial smears taken both during pregnancy and at 6 weeks post partum. Cervical biopsies were not taken during pregnancy unless cytology showed evidence of invasive disease. If such a biopsy proved the presence of invasive disease, the woman Int J Gynaecol
Obstet
24
was treated for the malignancy in accordance with the stage of the disease and the period of gestation. In the remaining women with serially abnormal smears, vaginal delivery was permitted. If abnormal cytology persisted at 6 weeks post partum, a cold knife conization of the cervix was performed. Subsequent management depended on the histological report. Women with symptoms of abnormal bleeding or discharge within 6 months post partum had repeat cervical smears taken. Colposcopic examination of the cervix was not possible due to a lack of facilities. Women with normal smears were encouraged to attend the gynecological clinic for repeat smearing at 2 yearly intervals. The importance of long term follow up was impressed upon women with abnormal cytology. If they failed to appear at the outpatient clinic for follow up, two letters at 4 weekly intervals were dispatched urging them to attend the clinic. If, despite this the woman defaulted, the health worker who had motivated her to undergo sterilization was contacted and requested to bring her to the clinic. When the defaulting woman was “self motivated” for the sterilization, the health worker operating in her neighborhood was requested to contact her. Results
The study group was women and the control general characteristics of two groups are shown
Table 1. groups.
General characteristics
Mean age at marriage
comprised of 500 group of 200. The the women in the in Table I. Since
of the women in the two
Study group
Control group
17.94 k3.01
18.88 t 3.90
3.90 f 1.11 26.95 k 3.59
1.33 20.47 22.21 k 3.80
(years) Mean gravidity Mean age at screening (years)
Selective screening for carcinoma cervix
Table 11. Cervical cytology
in the two groups
Normal
Study group Control
3(0.6)a
at initial screening.
Inflammatory
Mild dysplasia
Moderate dysplasia
Severe dysplasia
Smears suggestive of invasive disease
Total abnormal smears
41(8.2)
438(87.6)
12(2.4)
S(1 .O)b
l(O.2)
18c3.6)’
98(49.0)
l(O.5)
87(43.5)
14(7.0)
aFigures in parenthesis are percentages. bone abnormal smear detected post partum when the woman ‘The difference is statistically significant (P < 0.05).
increasing gravidity and age are inter-related age matched controls could not be obtained. The religious distribution of the women in the two groups was similar. The percentage of Hindus, Muslims and Christians in the study group was 8970, S%, 3% respectively while the distribution in the control group was 85.50/o, 5.5% and 9%, respectively. In the study group 2% of the women had the initial smear taken during the first trimester, 37% in the second trimester and 6 1% in the third trimester; the corresponding figures in the control group were 5%, 34.5% and 60.5%. In the control group, there was only one abnormal smear while the study group showed eighteen abnormal smears (Table II). This difference was found to be statistically significant (f’ < 0.05). Moreover, there appeared to be an overall shift towards a higher degree of cytological abnormality Table 111.
Clinical
appearance Study
Healthy Erosion Chronic cervicitis Healed lacerations Endocervical polyp Growth on cervix
3 39
of the cervix. group
1 80(36.0)a 137(27.4) 169(33.8)’ 8S(17.0)d 1 l(2.2) l(O.2)
Control
group
140(70.O)b 49(24.5) ll(5.5) _ _ _
aFigures in parenthesis are percentages. bathe difference is highly significant (P < 0.001). ‘The difference is highly significant (P < 0.001). dThe difference is highly significant (P < 0.001).
complained
of excessive
_
I (o.5)c
vaginal discharge.
in the study group, there being significantly more women showing mild dysplasia as compared to the control group (P < 0.001). The control group showed significantly more normal and inflammatory smears as compared to the study group (P < 0.00 1). Table III shows that on clinical examination, a healthy cervix was found in significantly more women in the control group (P < O.OOl), while evidence of chronic cervicitis and healed lacerations on the cervix were significantly higher in the study group (P < 0.001). In the study group, 38% of the women had had all previous deliveries at home and were being booked for a hospital delivery for the first time. Another 17% had had only one hospital delivery in the past. Motivation for sterilization may have been the major reason for these women to opt for regular antenatal care and a hospital delivery in the present pregnancy. Three percent of the women in the study group gave a history suggestive of threatened abortion or antepartum hemorrhage at some time during the present pregnancy, but only one (0.2%) was bleeding at the time of the initial screening. Within the study group, abnormal cervical cytology was not found to correlate with age and gravidity or clinical parameters such as an unhealthy cervix or contact bleeding from the cervix during the exocervical scrape. ItIt J Gtwaecol Ohstet ,74
340
Shrivastav et al.
In the 18 women with abnormal cervical cytology, the mean age at screening was 28.17 + 3.60 years and the mean gravidity 4.11 + 1.lO, neither of which was significantly different from that of the entire study group. However, the mean age at marriage of the women with abnormal cytology was 16.28 + 2.11 years which was significantly lower than that of the entire study group (P < 0.05). Seventeen of these abnormal smears were detected at the time of initial antenatal screening. One woman had a smear reported as mild dysplasia at the time of the initial screening but a repeat smear taken 5 months post partum, because she complained of abnormal vaginal discharge, showed cytology suggestive of severe dysplasia. The initial smear was reviewed and its benign nature confirmed. Six (33.3%) of these 18 women defaulted and thus a follow up rate of 66.7% was obtained. Of the remaining 12, one had cytology suggestive of invasive carcinoma. On reexamination a small growth was seen protruding through the cervix and on punch biopsy this proved to be a well differentiated papillary adenocarcinoma. The growth was staged as IB and as the woman was at a gestational age of 20 weeks an upper segment hysterotomy and bilateral tubectomy were performed, following which radiotherapy was instituted. All the remaining eleven women were permitted vaginal delivery. Four showed persistently abnormal cytology in the postpartum period. Three had severe dysplasia and a cold knife conization of the cervix was performed at 6 weeks post partum. One biopsy specimen showed evidence of microinvasive carcinoma and a total abdominal hysterectomy and right salpingooophorectomy was subsequently performed. Carcinoma-in-situ and severe dysplasia were found in the other two biopsy specimens and these women have been advised hysterectomy. The fourth woman had repeated smears showing moderate dysplasia and is presently being followed up. Women with abnormal cytology at the time of initial Int J Gynaecol Obstet 24
screening but who subsequently had normal smears are also being followed up. Discussion and conclusions Women who utilize the facilities offered by the Post Partum Programme usually come from the lower socioeconomic class, are gravida 3, para 2 or higher and most are between 25 and 35 years of age. Many of them are availing of organized medical care and visiting a hospital for the first time. After sterilization most are unlikely to reappear in a hospital for many years. The present pregnancy would thus constitute a good opportunity to screen them for cervical carcinoma. The results of this study show that the women booked under this program had a significantly higher incidence of abnormal cervical cytology (3.6%) as compared to the control group (0.5%) (P < 0.05). The mean age at marriage of the women in the study group was 17.94 f 3.01 years, the mean duration of married life was 9 years and they were of high gravidity (mean 3.90 f 1.l 1; range 3-9). They thus constitute a group at high risk to develop cervical carcinoma. This may explain the higher incidence of abnormal cervical cytology in this study as compared to figures reported from the west (0.7- 1.6%) from unselected obstetrical populations [6,8,9,11,131. From South Africa, Khatree et al. [ 71 have reported a 1.l% abnormal cervical cytology rate in unselected pregnant black women. Within the study group, women seem to be at uniformly high risk to develop cervical carcinoma irrespective of their age or gravidity. Thus it seems reasonable to screen all women booked under the Post Partum Programme with no selection bias towards greater age and gravidity. The present study confirms reports [ 2,101 that have shown that during pregnancy, the clinical appearance of the cervix is not a reliable indicator of cervical cytology. Similarly, contact bleeding during the exocervical scrape did not show any
Selective
significant correlation with the presence of abnormal cytology. Thus clinical parameters are unhelpful in the selection of pregnant women for a screening programme. Thirty eight percent of the women booked under the Post Partum Programme had delivered all their previous babies at home. Another 17% had only a single hospital delivery in the past. The motivation for sterilization and possibly the incentive of free antenatal, intra partum and post partum care could have resulted in their opting for a hospital delivery this time. For many of them, this could be the first and last opportunity to avail of organised gynecological care and is thus an ideal time to screen them for cervical carcinoma. Furthermore, as the women are under medical supervision over a period of months, follow up is relatively easy. The Post Partum Programme thus provides an excellent “catchment area” for the screening of non-accessible women at high risk of developing cervical carcinoma. During the antenatal period, follow up of women with abnormal cytology was easy since most attended the antenatal clinic regularly. Once the necessity of long term follow up had been impressed upon them, most came voluntarily for the post partum follow up. Women who failed to attend the clinic on the date advized usually responded to postal recall. For the few who did not, it was necessary to ask the health worker who had motivated the women to undergo sterilization or the health worker operating in the area in which the woman resided, to contact the woman and bring her to the clinic. This resulted in a follow up rate of 66.7% from amongst the women with abnormal cytology. The default rate of 33.3% could be attributed to the mobile nature of this population. Women in South India come to their parental homes for confinement, returning to their own homes shortly after the delivery. Lack of colposcopic facilities was a major limitation of this study. However, if this scheme of selective screening is to be im-
screening
for
carcinoma
cervix
34 1
plemented on a mass scale, it is unrealistic to expect such facilities to be available at each centre conducting the Post Partum Programme. In this study the two cases of invasive disease present could be detected by cervical smear screening. It has been suggested 191 that in the presence of abnormal cytology but not cytology suggestive of invasive disease, colposcopy may be omitted if a reliable cytologist is available. In such women, if repeated smears exclude the presence of invasive disease, it would be permissible to allow continuation of the pregnancy and a vaginal delivery at term as in the present study; cervical conization being postponed to the post partum period. However, if cytology suggestive of invasive disease is detected in a pregnant woman with a clinically normal cervix, a shallow cone biopsy, or multiple Schiller stain-directed punch biopsies will have to suffice in the absence of colposcopic facilities. In a developing country with limited resources and trained manpower, the costeffectiveness is an extremely relevant factor. The cost of conducting the study was extremely modest. Existing medical and paramedical personnel were utilized for the screening and subsequent follow up. This scheme can be successfully incorporated into the work schedule of these personnel thus obviating the need for an additional cadre of workers. The cost of screening 500 women in the study group was US$ 1000. This puts the cost of detecting one woman with an abnormal cervical smear at US$ 56 and the cost of detecting one case of preinvasive or early invasive disease at US$ 250, which is extremely modest as compared to the cost of treating a late stage of the invasive disease (US$ 5001000). In conclusion it can be stated that: (1) south Indian women booked under the Post Partum Programme constitute a group at high risk to develop cervical carcinoma; (2) the feasibility of instituting a program of selective screening for cervical carcinoma Int J GFnaecol
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on these women using the existing facilities has been shown; and (3) the cost-effectiveness of this program is borne out by the modest expenditure incurred in detecting women with abnormal cervical cytology. A similar scheme of selective cervical screening can be incorporated into the national programs of other developing countries to cater to their female population at high risk of developing cervical carcinoma.
Acknowledgments
The authors wish to thank Dr. Matthews and of Obstetrics Department Mathai, Christian Medical College Gynaecology , Hospital, Vellore for his assistance and critical review of this manuscript. We are also grateful to Mrs. Ravi Rani Samuel and ‘Mrs. Usha Rani Joseph from the Department of Pathology, Christian Medical College Hospital, Vellore for their help in the screening of the cervical smears. References
4 Gault EW, Asirwadham M, Balasubrahmanian
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M, D’Sena GWL, Thomas E, Isaiah P: Cancer of the cervix. Indian J Med SciS: 297, 1951. Gault EW: Cancer, Volume III. p 281. London, Butterworths Medical Publishers, 1958. Kay S: Results of routine cervical cytologic smears in the obstetric patient. Surg Gynaecol Obstet 114: 83, 1962. Khatree MHD, Houlton MCC, Moodley J: Cervical cytology in pregnant black patients and potential selective screening programmes. S Afr Med J 58: 358, 1980. Lurain JR, Gallup DG: Management of abnormal Papanicolaou smears in pregnancy. Obstet Gynaecol 53: 484, 1979. McDonnel JM, Mylotte MJ, Gustatson RC, Jordan JA: Colposcopy in pregnancy. A 12 year review. Br J Obstet Gynaecol88: 414, 1981. Moore JG, Wells RG, Morten DC: Management of superficial cervical cancer in pregnancy. Obstet Gynaecol 27: 307, 1966. Ortiz R, Newton M: Colposcopy in the management of abnormal cervical smears in pregnancy. Am J Obstet Gynecol109: 46, 1971. Rewell RE: Ethnological factors in the etiology of cancer of the uterine cervix. J Obstet Gynaecol Br Commonw 64: 821,1957. Rutledge CE, Cristopherson WM. Parker JE: Cervical dysplasia and carcinoma in pregnancy. Obstet Gynaecol 19: 351, 1962.
Address for reprints: Ahuja P, Reddy DB: Carcinoma of the cervix. J Obstet Gynaecol India 13: 5 11, 1963. Boutselis JG: Intra-epithelial carcinoma of the cervix associated with pregnancy. Obstet Gynaecol 40: 657, 1972. Draper GJ, Cook GA: Changing pattern of cervical cancer rates. Br Med J 287: 510, 1983.
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P. Shrivastav, M.D. Department of Obstetrics and Gynaecology and Family Welfare Christian Medical College Hospital Vellore, 632 004 India