Abstract
Background:
Papanicolaou (Pap) test is an important and easy diagnostic tool to detect any abnormalities on vaginal cytology. Pap test is routinely done in women of reproductive age group in many countries.
Aim:
The aim of this study was to detect spectrum of abnormalities in female sex workers (FSWs) on vaginal cytology.
Materials and Methods:
A total of 60 cases were included over a period of 1 year (July, 2011-June, 2012). The age range of the patients was 14-61 years. Pap stained slides were evaluated by two consultant cytopathologists and reported as normal smear, inflammatory smear, specific infection, low grade squamous intraepithelial lesion (LSIL), high grade squamous intraepithelial lesion (HSIL), atypical squamous cell of undetermined significance (ASCUS), squamous cell carcinoma (SCC) and atypical glandular cell of undetermined significance (AGUS).
Results:
Most of the smears were abnormal accounting for 86.7% of total cases (52/60). Incidence of HSIL was very high in FSWs. Out of 60 cases, 8 normal smears (13.3%), 12 inflammatory smears (20%), 3 cases of infections (5%), 9 cases of LSIL (15%), 23 cases of HSIL (38.3%), 2 cases (3.3%) each of ASCUS and SCC and 1 case (1.3%) AGUS were encountered.
Conclusions:
Close follow-up and histologic examinations are necessary to avoid unnecessary spread of the neoplastic disease and untimely death of the patients. Awareness about diseases in FSWs and diagnostic utility of Pap test are also a must.
Keywords: Female sex workers, Papanicolaou test, vaginal cytology
Introduction
Cervical cancer is the most common cancer among women in India.[1] It is estimated that there were 1,12,609 cases of cervical cancer in the year 2004 and the number will rise to 1,39,864 in the year 2015.[1] This country has the largest burden of cervical cancer patients in the world and one of every five cervical cancer patients belongs to this country.[2]
However, diagnosed in the early stages and treated early, cervical cancer is a curable disease. There are several methods for cervical cancer screening and several studies have established the importance of Papanicolaou (Pap) smear as one of the easy and important screening methods for cervical cancer.[3,4] Routine cervical screening by Pap smear resulted in decreasing the incidence of cervical cancer in many countries of the developed world.[5,6,7] However in India, in spite of national recommendation, routine cervical screening program is not done and as a result, the prevalence of different epithelial lesions of the cervix is not known.[2]
Our study was initiated to detect the prevalence and spectrum of cervical epithelial abnormalities among female sex workers (FSWs) by Pap smear. This study group was selected because many other studies done previously showed high rates of epithelial lesions among this population due to different risk factors.[8,9,10]
Materials and Methods
This was a prospective study carried out during a period of 1 year (from August 2011 to July 2012). All the FSWs attending outpatient department during this time period with different clinical symptoms such as abdominal pain, bleeding per vagina, vaginal discharge, irregular menstruation etc., were included in the study after informed consent. Samples were taken by brushes/Ayre spatula, immediately fixed in alcohol and stained using Pap technique by trained technicians. Reporting was done by two consultant cytopathologists according to The Bethesda system (TBS). Slides were reported as normal smear, inflammatory smear, specific infection, atypical squamous cell of undetermined significance (ASCUS), low grade squamous intraepithelial lesion (LSIL), high grade squamous intraepithelial lesion (HSIL), squamous cell carcinoma (SCC) and atypical glandular cell of undetermined significance (AGUS). Inadequate smears according to TBS were excluded from the study.
Results
A total of 60 cases were included in this study during the time period of 1 year. The age range of the patients was 14-61 years. Total 16 (26.67%) out of 60 patients were below the age of 30 years and 44 (73.33%) were above 30 years of age. Out of 60 smears, 52 (86.67%) smears showed pathologic findings [Figures 1 and 2]. Premalignant lesions were found in 37 (61.67%, n = 60) smears of which ASCUS was 2 (3.3%), LSIL-9 (15%), HSIL-23 (38.3%), SCC-2 (3.3%) and AGUS-1 (1.7%) [Table 1]. Among the patients of below 30 years (n = 16), premalignant lesions were found in 8 (50%) patients of which ASCUS was 1 (6.3%), LSIL-5 (31.2%) and HSIL-2 (12.5%) [Table 1]. Total inflammatory smears were 36 (60%, n = 60), of which 12 smears showed nonspecific inflammation, 10 smears were associated with HSIL, 8 smears were associated with LSIL, 2 smears were associated with ASCUS, 1 smear was associated with AGUS and 3 smears were associated with specific infections. One smear showed features of both human papilloma virus (HPV) and herpes simplex virus (HSV) infections, 2 smears were associated with features of both HPV and Trichomonas vaginalis infections.
Figure 1.
(a) Photomicrograph showing inflammatory smear (Pap, ×100). (b) Photomicrograph showing low grade squamous intraepithelial lesion with koilocytic change in some of the cells (Pap, ×400). The cells have mild increase in nucleocytoplasmic ratio and hyperchromatic nuclei
Figure 2.
(a) Photomicrograph showing high grade squamous intraepithelial lesion having moderate increase in the nucleocytoplasmic ratio, anisonucleosis and hyperchromatic nuclei with irregular nuclear membrane (Pap, ×400). (b) Photomicrograph showing squamous cell carcinoma having overlapping of the nuclei, severe increase in the nucleocytoplasmic ratio, hyperchromatic nuclei with conspicuous nucleoli (Pap, ×400)
Table 1.
Spectrum of abnormalities in cervical Pap smears among female sex workers
Discussions
Cervical cancer has a long latent phase with identifiable and treatable premalignant lesions which precede the invasive disease, and the benefit of conducting screening exceeds the cost involved. This makes it an ideal disease for screening.[2,11]
Several observations have been made in this study. Firstly, the incidence of ASCUS and LSIL was almost same for the below 30 and above 30 years age group, but the incidence of HSIL and SCC was greatly increased in the above 30 years age group indicating the gradually increasing incidence of malignancy with age. These results are in accordance with the studies of Bal et al.,[12] and Elhakeem et al.[13]
Secondly, in the age group of below 30 years, 9 out of 16 (56.25%) patients were candidates for follow-up (due to the presence of HSV infection, ASCUS, LSIL/HSIL), emphasizing the need for screening even in the below 30 years age group.
Thirdly, 24 out of 36 (66.67%) inflammatory smears were associated with epithelial lesions, indicating the importance of proper hygiene maintenance in prevention of cervical epithelial lesions.
We compared the results obtained in this study with some studies made on the general population.[12,14,15] In comparison to these studies, a very high incidence of epithelial lesions was found in this study [Table 2]. The probable causes for the discrepancy observed, include the fact that our study population (FSWs) are exposed to all the risk factors for cervical epithelial lesions in contrast to the general population. Secondly, our study has a small denominator population.
Table 2.
Comparison of results with other studies carried out among general population
We also compared the results obtained in this study with few studies done on sex workers.[8,9] In comparison, our study showed a higher incidence of epithelial lesions, particularly HSIL [Table 3]. The main reason for this discrepancy is because this study includes only the symptomatic patients who came to the out patient's department for medical advice. Other possible causes for the discrepancy may be a small denominator population in this study, and a poorer standard of living and lack of awareness in our study population in contrast to that of other developed countries.
Table 3.
Comparison of results with other studies carried out among sex workers
There were a few limitations in our study. First of all, we could not include a control population in our study and secondly, we could not find the true incidence because the asymptomatic cases could not be included in the study population.
Conclusion
Despite the small study population, several important deductions can be made from this study. Firstly, considering the higher incidence of epithelial lesions in the below 30 years age group, it is recommended that the age of routine cervical cancer screening should be much earlier than the National Recommendation. Secondly, as the incidence of epithelial lesions is quite high in our study population (61.67%), close follow-up of this target population (i.e., FSWs) and histological examination, is necessary to avoid unnecessary spread of neoplastic disease and untimely death of the patients. Furthermore, awareness about the disease and diagnostic utility of Pap test, among FSWs is also a must.
Footnotes
Source of Support: Nil
Conflict of Interest: None declared.
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