VISUAL INSPECTION OF CERVIX WITH ACETIC ACID: A GOOD ALTERNATIVE TO PAP SMEAR FOR CERVICAL CANCER SCREENING IN RESOURCE LIMITIED SETING

Objective: Determine the diagnostic accuracy of visual inspection of cervix (VIA) by using 3% acetic acid as a screening test for early and timely detection of cervical cancer when histopathology taken as the gold standard of diagnosis. Methodology: This study was conducted at Nishtar Hospital, Multan, and the study design choose for conducting this study was Cross Sectional study method. Study was completed in one year duration from February 2018 to February 2019. All statistical data was entered and analyzed by using SPSS version 23. Frequencies and percentages were calculated and presented for qualitative variables like marital status. Parity, ethnic group and religion. Mean ± Standard Deviation (SD) was calculated for numerical variables like duration of marriage and age. The diagnostic accuracy, sensitivity specificity and positive predictive value (PPV) and negative predictive value (NPV) was calculated using two into two contingency table and histopathology was taken as the gold standard. Results: Overall, 100% (n=320) female patients were included, in this study. There were 87.2% (n=279) patients had poor socio-economic status, while 12.8% (n=41) had good socio-economic status. The sensitivity, specificity, positive predictive value, negative predictive value and accuracy of VIA and abnormal looking cervix were 81.7%, 80.7%, 51.5%, 48.5% and 81.3% respectively. Conclusion: Screening schedules are not planned and followed in Pakistan ever, so VIA is effective and always a useful diagnostic test for cervical cancer, pre-cancerous lesions can be detected at their early stage through VIA and mortality and morbidity can be reduced.

with Pap smear test. Dysplasia may be precancerous presentation of cervix. Another common pre-cancerous presentation is cervical intraepithelial neoplasia and can be diagnosed by biopsy test of cervix. Treatment of these two presentations (SIL and CIN) is usual and can stop the development of cancer. Aim of this study is to find out the cost effective diagnostic test which can be use as primary screening test to diagnose Cervical Cancer.

Methodology:
This study was conducted at Nishtar Hospital, Multan, and the study design choose for conducting this study was Cross Sectional study method. Study was completed in one year duration from February 2018 to February 2019. After getting Ethical approval study was started in Gynaecology and obstetrical ward of hospital. Females of reproductive age 18-60 years were studied after taking informed consent from study population. Medical history was taken in detailed way and then Physical examination session was also arranged to assess the Cervix by trained staff. Separate room was arranged for maintaining privacy standards of the study personnel's. Procedure was explained to the personnel's to reduce their anxiety level. Sample size was calculated openepi.com by using CI 95%, power of study 80% and diagnostic accuracy 95.6%.
Patients were positioned in Lithotomy position for Physical Examination of Cervix. Proper light stand was arranged in the examination room to make the inspection area visible. Acetic Acid swab was applied to the Cervix and then cervix area was observed for Acetowhite changes. Changes were noticed in duration of 1 minute. In Diagnostic labeling Acetowhite changes were considered as Positive Test and dull or no changes were considered as negative test for diagnosing Cervical Cancer.
Tissue Biopsy was taken from the positive diagnostic results personnel's and the samples were sent to histopathology lab for further investigation. To analyze the frequencies and percentages all the data was analyzed in SPSS-17. Categorical variables were formed on the basis of Age, Marital Status, religion and ethnic group. Sensitivity and the specificity of the diagnostic test were calculated according to positive predictive value and negative predictive value.
All statistical data was entered and analyzed by using SPSS version 23. Frequencies and percentages were calculated and presented for qualitative variables like marital status. Parity, ethnic group and religion. Mean ± Standard Deviation (SD) was calculated for numerical variables like duration of marriage and age. The diagnostic accuracy, sensitivity specificity and positive predictive value (PPV) and negative predictive value (NPV) was calculated using two into two contingency table and histopathology was taken as the gold standard.

Discussion:
Cervical Cancer is considered as one of the emerging health problem among females of reproductive age (10).
Every year thousands of cases appear. Its incidence is higher in the developing countries like Pakistan (10). In Pakistan its incidence is about 3.6% in every year. The most dangerous thing is, people have less awareness about cervical cancer, due to lack of awareness about disease sign and symptoms patients come late to the hospitals specially they approach hospitals at last stages (11).
Different diagnostic tests are performed to diagnose Cervical Cancers. The Diagnostic Test PAP Smear is the most common test in developed countries and can be use as primary diagnostic test for Cervical Cancer Screening in developed Countries, but in under developed countries due to lack of resources this test cannot be use commonly, so this test is not approachable in rural areas and under developed places (12). While Visual Inspection of Cervix after applying Acetic Acid (VIA) Test is use as a substitute of PAP smear in developing countries (13,14).
In our study VIA was positive in 81.2% patients and among VIA positive patients in which cervixes looking abnormal 134 (51.5%) have positive histopathologic finding and 126 (48.5%) have negative histopathology, similarly among VIA negative and abnormal looking patients 30 (50%) patients have positive and 30 (50%) have negative histopathology. In some previous studies VIA positive was reported in 1.7 to 29% patients (15,16,17).
VIA is a non-invasive test which provide quick results or it is less costly test. So it is a very useful test in developing countries to diagnose Cervical Cancer. This test can easily be performed in rural areas where hospitals do not have so many diagnostic resources. Due to its non-invasive approach this test can be perform easily without creating anxiety to patient. Reporting of this test is quick and based on visual assessment; this property encourages quick diagnosis of Cervical Cancer.