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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 35  |  Issue : 1  |  Page : 245-249

Comparison of visual inspection with acetic acid and Pap smear for cervical cancer screening


1 Department of Obstetrics and Gynecology, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Department of Obstetrics and Gynecology, Dar Ismail Hospital, Alexandria, Egypt
3 Department of Pathology, Faculty of Medicine, Menoufia University, Menoufia, Egypt

Date of Submission05-Mar-2021
Date of Decision10-May-2021
Date of Acceptance15-May-2021
Date of Web Publication18-Apr-2022

Correspondence Address:
Asmaa A Mohamed
Sidi Bishr, Alexandria
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_57_21

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  Abstract 


Objectives
This study aimed to compare the sensitivity and specificity of visual inspection with the acetic acid (VIA) test and Pap smear for detecting cervical intraepithelial neoplasia and cervical cancer.
Background
Cervical cancer is the fourth most common cancer in women and the seventh overall. VIA is a simple low-cost technique screening, based on the ability of the trained health care personnel to detect Opaque acetowhite lesions in the cervix.
Patients and methods
This study was carried out on 420 patients attending the family planning clinic, Alexandria, Egypt, and referred for colposcopy-guided biopsy to the women's health clinic from January 2019 to August 2020. VIA and Pap smear were performed for all patients; then, the participants who showed positive result with either Pap smear or VIA or both (98 participants) were referred for colposcopy-guided biopsy.
Results
Of the women screened, VIA was positive in 72 (17.14%) and 41 (9.8%) were positive on pap smear. The sensitivity, specificity, positive predictive value, and negative predictive value of VIA were 86.11, 89.32, 43.05, and 98.56%, respectively, while the Pap smears had a sensitivity of 52.78%, a specificity of 94.27%, a positive predictive value of 46.34% and a negative predictive value of 95.51%.
Conclusion
VIA has the advantage of being easy to learn, low cost, having high sensitivity in comparison with Pap smear and with immediate availability to assess results, and can be used as an alternative primary test to screen premalignant cervical intraepithelial lesions and subclinical early cancer of the cervix.

Keywords: acetic acid, cancer, cervical, intraepithelial neoplasia, Pap smear, screening


How to cite this article:
El-Khouly NI, El-Kelani OA, Mohamed AA, Hemida AS. Comparison of visual inspection with acetic acid and Pap smear for cervical cancer screening. Menoufia Med J 2022;35:245-9

How to cite this URL:
El-Khouly NI, El-Kelani OA, Mohamed AA, Hemida AS. Comparison of visual inspection with acetic acid and Pap smear for cervical cancer screening. Menoufia Med J [serial online] 2022 [cited 2024 Mar 29];35:245-9. Available from: http://www.mmj.eg.net/text.asp?2022/35/1/245/343131




  Introduction Top


Cervical cancer is the fourth most common cancer in women and the seventh overall, with an estimated 570 000 new cases in 2018 worldwide, most of these occurring in developing countries [1]. In Egypt, the incidence of cervical cancer is 969 per year and 631 die from the disease [2].

The most common risk factors of cervical cancer are human papilloma virus (HPV)-associated early onset of sexual activity, early age at first pregnancy, high parity, and multiple sexual partners, all of which are associated with the risk of HPV infection. Other risk factors include the presence of other sexually transmitted diseases, low socioeconomic status, cigarette smoking and immune suppression from any cause, vitamin deficiency, and long-term oral contraceptive use [3].

For several years, Pap smears have formed the basis of cervical tumor screening and detection programs in more advanced countries. Countries with national programs using the cytology-based screening technique have achieved a marked decrease in mortalities from cervical tumors [4].

Many developing countries do not have ample resources to implement cytology-based prevention programs, which necessitate well-organized laboratories to collect material and specialized pathologists to make the diagnoses. Therefore, cytology-based screening is effective, but beyond the capacity of health services in developing countries [5].

Visual inspection of the cervix after the 3–5% acetic acid (VIA) technique is a cheap, simple, and easy to learn method of cervical cancer screening. On exposure to this solution, abnormal cells of the cervical epithelium temporarily turn white and reveal acetowhite epithelium of the abnormal transformation zone. Several studies have shown the advantages of VIA, including its simplicity, high sensitivity, and instant results. VIA as a visual screening test that does not depend on laboratory services could be a promising alternative screening tool for early detection of cervical cancer [6].

This study aimed to compare the diagnostic value of VIA and Pap smear in screening for cervical cancer in women.


  Patients and methods Top


After approval of the local ethical committee and written informed consent were obtained, a comparative cross-sectional study was carried out on 420 patients. Participants were selected from those attending the family planning clinic, Alexandria, Egypt, from January 2019 to August 2020. The sample size was categorized after the recommendations of the Biostatistics Department in the Faculty of Medicine, Menoufia University. Inclusion criteria were as follows: patients in the age group of 20–60 years were included in the study and priority was given to patients who had had early marriage and early pregnancy. Exclusion criteria were as follows: unmarried patients, patients younger than 20 years and older than 60 years of age, patients with vaginal bleeding and active infection at the time of examination or women with frank invasive cervical cancer. All women in the study, after examination of the cervix, underwent a Pap smear test, a VIA and then visual inspection with Lugol iodine. Cervical smear was taken using Ayre's spatula and cyto brush. Pap smear tests were reported based on the Bethesda system.

Cytology was considered positive if it included atypical squamous cells of undetermined significance, low-grade intraepithelial lesion (LSIL), high-grade intraepithelial lesion (HSIL), or invasive cancer.

In the VIA method, the cervix was first smeared with a 3–5% acetic acid solution for 1 min and then observed under sufficient light. VIA was considered negative when no acetowhite lesion was observed, and polyp protruding from the cervix or nabothian cyst was found. VIA was considered positive if any acetowhite lesion fulfilled the following criteria: Persistent acetowhite lesion more than 2 min, diameter of lesion more than 2 cm, well-demarcated edges, extension of the lesion to the endocervical canal and positivity with Lugol's iodine. Lugol's iodine solution was applied to the cervix and the cervix was examined again by the naked eye.

VILI involves examination of cervix with the naked eye after application of lugol”s iodine was positive if mustard yellow iodine nonuptake was observed in the transformation zone and VILI was negative if normal cervix with squamous epithelium turned brown or black with Logol's iodine and columnar epithelium did not change color. The participants who showed a positive result with either Pap smear or VIA or both (98 participants) were referred to the women's health clinic for colposcopy-guided punch biopsy.

Punch biopsy was taken from the acetowhite area and in the absence of the acetowhite area, random biopsy was taken from four cervical regions.

Statistical analysis

All data were collected; tabulated and statistically analyzed using SPSS 22.0 for Windows (IBM Corp., Armonk, New York, USA) and MedCalc 13 for Windows (MedCalc Software bvba, Ostend, Belgium). Data were tested for normal distribution using the Shapiro–Wilk test. Qualitative data were represented as frequencies and relative percentages. The χ2 test and the Fisher exact were used to calculate the difference between qualitative variables as indicated. Quantitative data were expressed as mean ± SD. The diagnostic value indices including the specificity, sensitivity, positive predictive value (PPV) and negative predictive value (NPV) for the results of VIA and Pap smear were determined by the sensitivity of the test: the percent of positives by the test and the true positives. Specificity of the test: the percent of negatives by the test and the true negatives. PPV: the percent of the true positives and all the positives by the test. NPV: the percent of the true negatives and all the negatives by the test. Accuracy: the percent of agreement between the two tests. The sensitivity, specificity, PPV and NPV as well as accuracy are expressed as percentages.


  Results Top


In our study, 420 women were screened; the mean age of the participants was 36.31 ± 10.44 years, and the mean BMI is 26.92 ± 3.65 kg/m2. The most prevalent complaint found among the patients was persistent vaginal discharge (51.2%), followed by pelvic pain (27.6%), intermenstrual bleeding (11.4%), postcoital bleeding (7.6%), and postmenopausal bleeding (2.1%) [Table 1].
Table 1: Demographic data and Complaints among the participants

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Of the 420 patients screened using Pap and VIA, 57 were positive with VIA only, 26 were positive with Pap only and 15 were positive with both Pap and VIA. Therefore, 98 patients were referred to colposcopy-guided biopsy.

Biopsy revealed 36 true positive cases; 17 patients had CIN1, 13 patients had CIN2 and six patients had CIN3. Colposcopy-guided biopsy yielded 36 suspicious finding cases: 23 women had acetowhite lesion, four women had a mosaic pattern, punctuation was reported in six women and atypical vessels were reported in three patients.

Of 420 patients, 90.2% had a negative Pap smear; 5.95% of the patients were atypical squamous cells of undetermined significance, 2.6% were LSILs and 1.2% were HSILs. Thus, in total, 9.8% of Pap smears were reported to be positive [Table 2].
Table 2: Pap smear findings among the patients

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VIA was positive in 72 (17.14%) patients and 82.86% were negative [Table 3].
Table 3: Visual inspection with the acetic acid test findings among the patients

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The sensitivity, specificity, PPV and NPV of VIA were 86.11, 89.32, 43.05, and 98.56%, respectively, while the Pap smears had a sensitivity of 52.78%, a specificity of 94.27%, a PPV of 46.34%, and a NPV of 95.51% [Table 4].
Table 4: Diagnostic value of Pap smear and visual inspection with the acetic acid for colposcopy+biopsy

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VIA had detected 100% (6/6) of CIN3, 92.3% (12/13) of CIN2, and 76.5% (13/17) of CIN1 [Table 5].
Table 5: Distribution of histopathological findings based on visual inspection with the acetic acid test findings

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Comparison of VIA and Pap smear results showed that of the 72 women who screened positive on VIA, 15 had positive Pap smear, whereas 57 had a negative Pap smear. The kappa coefficient was 0.1611 (P = 0.0016) [Table 6].
Table 6: Comparison of visual inspection with the acetic acid and Pap smear results

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This study found biopsy-confirmed dysplasia in 8.6% of patients.

The biopsy detection rate of Pap smear was 4.5% and that of VIA was 7.4%. Therefore, VIA performed better in the detection of dysplasia [Table 7].
Table 7: Comparison of Pap smear and visual inspection with the acetic acid results according to colposcopy + biopsy findings

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The combination of Pap smear and VIA showed higher sensitivity than VIA or Pap smear alone [Table 8].
Table 8: Combined Pap smear+visual inspection with the acetic acid

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  Discussion Top


Various studies have been carried out worldwide to evaluate the diagnostic value of VIA and Pap smear in screening for cervical cancer, and different results have been obtained with respect to the studied population and the methodology. In some studies, VIA has been identified as an appropriate screening method and in others, given its low specificity, use of these two methods simultaneously for cervical cancer screening has been recommended [7].

The present study showed that 17.14% of patients were VIA positive. whereas positive VIA was 6% in study by mohamed et al.[8] and 50.59% by vahedpoor.[9]

The wide variation in rates in various studies is due to the different criteria used for screening and the different populations of women screened.

Goel et al.[10] found that VIA was positive in 29 (13.81%) patients, while the remaining 181 (86.19%) patients had normal VIA.

The current study showed that 41 patients had a positive Pap smear test, with a false-positive rate of 53.7%. The sensitivity of the Pap smear was 52.78%, the specificity was 94.27%, the NPV was 95.51% and the PPV was 46.34%, with an accuracy of 90.71%. Our results were confirmed by the study of El Sokkary [11], as they showed that in relation to histopathological results of suspicious findings of colposcopy-guided biopsy, for the Pap test, the sensitivity was 83.3%, specificity was 90.7%, PPV was 50.8%, NPV was 97.9%, and accuracy was 90%.

In the study of Albert et al. [12], two cases that were negative by Pap smear but positive by VIA were confirmed to be positive by biopsy histology, while all of those that were positive by Pap smear were confirmed to be positive by biopsy histology. These yielded a sensitivity of 60%, a specificity of 100%, a PPV of 100%, a NPV of 99.4%, and a diagnostic accuracy of 99.4%.

In our study, of 36 positive colposcopy and biopsy patients, 31 patients had a positive VIA test, with a false-positive rate of 56.95%. The sensitivity of the VIA test was 86.11%, the specificity was 89.32%, NPV was 98.56%, and PPV was 43.05%, with an accuracy of 89.05%. In the study of Keshavarzi et al. [13], of the six cases that were positive by VIA, three were confirmed to be negative with biopsy histology, while two of the cases that were negative to VIA but positive to Pap smear were confirmed to be positive with biopsy histology. These yielded a sensitivity of 60%, a specificity of 94.4%, a PPV of 50%, a NPV of 99.4%, and an accuracy of 98.6%.

Cancer of the cervix has been considered preventable because it has a long preinvasive state and availability of screening programs, and treatment of preinvasive lesions is effective. It is known that well-organized screening by cytology has markedly reduced the incidence of morbidity and mortality from cervical cancer in developed countries [5].

In the study of Consul et al. [14], VIA showed higher sensitivity compared with Pap smear, whereas VIA had lower specificity compared with Pap smear, which was similar to the Bhattacharyya et al.[15] study. The lower specificity of VIA when compared with Pap smear was due to the high incidence of suspected acetowhite epithelium, which might be inflammation, immature metaplasia, or latent HPV infection. The results from this study indicate that VIA is a promising method of cervical cancer screening as it showed higher sensitivity (86.11%) compared with Pap smear (52.78%). The majority of the studies showed that the sensitivity of VIA was higher than that of Pap smear; however, Pap smear had higher specificity than VIA. Their findings were similar to the pooled analysis of eleven studies carried out in Africa and India on cervical cancer screening tests. Talathi and Wagh[16] revealed that in the study group consisting of 200 women, 69% of women were VIA negative and 31% were VIA positive. Out of 69% VIA negative patient's Pap results were supporting its interpretation as all Pap tests were negative for precancerous and cancerous lesions of cervix. Out of VIA positive patients 66% were negative for intraepithelial lesion or malignancy and 34% were LSIL or HSIL.

In this study, the PPV (46.34%) of Pap smear was higher than the PPV of VIA (43.05%), but the NPV (98.56%) of VIA was higher than the NPV of Pap smear (95.51%). The reason for the low PPV of Pap and VIA is the low prevalence of disease, cervical biopsy and histology, the gold standard for the diagnosis of cervical neoplasia.

In Egypt, Abdel-Hady et al.[17] carried out a study to assess the performance of VIA as a screening test for detection of cervical carcinoma. Diluted acetic acid (5%) was applied to the cervix during routine gynecologic examination. Women with positive results were referred for colposcopy. Among the 5000 women who were screened using VIA, 409 were referred for colposcopy. The sensitivity and NPV of the VIA screening test was 97%.

Jeronimo et al.[18] found that of the 921 women, 132 (6.9%) had a positive VIA and 80 (4.2%) had a positive Pap smear (P = 0.0001). VIA positivity varied over the course of the study. It was 13.5% during the first quarter of the study, and then 4.8, 3.7, and 4.8% during the following three quarters. In contrast, Pap positivity did not vary over the study period. It is important to mention that 12 (0.6%) women had a positive result on both tests; that is, 120 (6.2%) women were only VIA positive and 68 (3.5%) women were only Pap positive.

Limitations of the study

There were several limitations to this study: cervical biopsy and histology, the gold standard for the diagnosis of cervical neoplasia, was not performed on all women. The results of VIA are operator dependent and may result in a large number of referrals. In addition, patients were called for a second visit for colposcopy, which led to various logistic problems. Also, the study sample size was small.


  Conclusion Top


VIA has the advantage of ease of learning, low cost, high sensitivity in comparison with Pap smear and immediate availability to assess results, and can be used as an alternative primary test to screen premalignant cervical intraepithelial lesions and subclinical early cancer of the cervix.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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Nessa A, Wistrand C, Begum SA, Thuresson M, Shemer I, Thorsell M, et al. Evaluation of stationary colposcope and the Gynocular, by the Swede score systematic colposcopic system in VIA positive women: a crossover randomized trial. Int J Gynecol Cancer 2014; 24:339–345.  Back to cited text no. 7
    
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Vahedpoor Z, Behrashi M, Khamehchian T, Abedzadeh-Kalahroudi M, Moravveji A, Mohmadi-Kartalayi M. Comparison of the diagnostic value of the visual inspection with acetic acid (VIA) and Pap smear in cervical cancer screening. Taiwan J Obstet Gynecol 2019; 58:345–348.  Back to cited text no. 9
    
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Goel A, Gandhi G, Batra S, Bhambhani S, Zutshi V, Sachdeva P. Visual inspection of the cervix with acetic acid for cervical intraepithelial lesions. Int J Gynaecol Obstet 2005; 88:25–30.  Back to cited text no. 10
    
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El Sokkary H. Comparison between Pap smear and visual inspection with acetic acid in screening of premalignant cervical intraepithelial lesion and subclinical early cancer cervix. Int J Reprod Contracept Obstet Gynecol 2016; 6:54–59.  Back to cited text no. 11
    
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]



 

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