|Year : 2022 | Volume
| Issue : 1 | Page : 20-25
Evaluation of colposcopy in screening of suspicious-looking cervix using swede score and its correlation with the histopathological findings
Neelima Agarwal, Manisha Gupta, Alpana Agrawal, Karisma Tekta
Department of Obstetrics and Gynecology, Santosh Deemed to be University, Ghaziabad, Uttar Pradesh, India
|Date of Submission||19-Apr-2022|
|Date of Acceptance||25-Apr-2022|
|Date of Web Publication||21-Jul-2022|
K-24, Sanjay Nagar, Ghaziabad, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Background: Cervical cancer is a global health problem. It ranks as the fourth-most common leading cause of female cancer in the world and the second leading cause of female cancer in India. Different methods are used for its screening as it has a long latent phase. Colposcopy-guided biopsy of suspicious unhealthy-looking areas is taken as the gold standard in the diagnosis of intraepithelial lesions. However, a new scoring system of colposcopy called the Swede score has a high specificity and can omit the need of biopsy.
Objective: The objective of this study is to evaluate the diagnostic efficacy of colposcopy using Swede score in unhealthy cervix and to determine the degree of correlation between colposcopy scores and histopathological findings.
Materials and Methods: The study was conducted in the Department of Obstetrics and Gynecology, Santosh Medical College and Hospital, Ghaziabad, Uttar Pradesh, India, from January 1, 2020, to June 30, 2021. Ninety-eight patients fulfilling the inclusion and exclusion criteria were selected for the study.
Results: It was evident that colposcopy using a Swede score of >5 and even more of >7 is definitely more sensitive and accurate in the screening of unhealthy-looking suspicious cervix in the Indian population and can be considered to use for performing a direct excisional procedure or cryotherapy as a “see and treat” method at this cutoff point, avoiding the need for cervical biopsy for histopathological confirmation.
Conclusion: Swede score performed well in this hospital-based study on a selected population coming to gynecology OPD with complaints of lower abdominal pain, discharge per vaginum, dyspareunia, abnormal uterine etc. referred to the colposcopy clinic in view of unhealthy- looking suspicious cervix.
Keywords: Cervical biopsy, cervical cancer, colposcopy, Swede score
|How to cite this article:|
Agarwal N, Gupta M, Agrawal A, Tekta K. Evaluation of colposcopy in screening of suspicious-looking cervix using swede score and its correlation with the histopathological findings. Santosh Univ J Health Sci 2022;8:20-5
|How to cite this URL:|
Agarwal N, Gupta M, Agrawal A, Tekta K. Evaluation of colposcopy in screening of suspicious-looking cervix using swede score and its correlation with the histopathological findings. Santosh Univ J Health Sci [serial online] 2022 [cited 2022 Aug 11];8:20-5. Available from: http://www.sujhs.org/text.asp?2022/8/1/20/351570
| Introduction|| |
Carcinoma cervix is an important cause of female mortality in our country. India alone accounts for one-fourth of the worldwide burden. It is estimated that cervical cancer occurs in approximately 1 in 53 Indian women during their lifetime as compared to 1 in 100 women in developed world, and India accounts 18% of the invasive cancer cervix in world. The squamo-columnar junction represents the transformation zone and the area where atypical metaplasia with abnormal nuclear changes marks the precursor for dysplasia and malignancy. Human papillomavirus (HPV) is central to the development of cervical neoplasia and can be detected in 99.7% of cervical cancers. The most common histologic types of cervical cancer are squamous cells (70% of cervical cancers) and adenocarcinoma (25%).
Cervical cancer has a very long latent phase, and methods including Pap smear, HPV DNA testing, per speculum cervical examination using acetic acid (visual inspection with acetic acid [VIA]), and (visual inspection Lugol's iodine [VILI]) can be used for screening. In low-resource settings, it has been difficult to execute cytology-based screening programs because it is laboratory based and requires expensive equipment with strong technician support and needs highly skilled personnel for preparation and interpretation of the slides. Cytology needs to be repeated at regular intervals to be effective., VIA has been suggested as an alternative to cervical cytology due to inadequate or suboptimal cytology screening and high burden of cervical cancer disease in developing countries. VIA is inexpensive and its results are immediately available. However, the reproducibility and accuracy of VIA has been questioned in recent years., For assessing the validity of all the screening procedures, colposcopy still remains the reference gold standard. It is an outpatient department (OPD) procedure, simple, noninvasive, and helps in determining the location, size, margins, vascularity, and extent of abnormal cervical lesions. Colposcopy-guided biopsy of suspicious unhealthy-looking areas is taken as the gold standard in the diagnosis of intraepithelial lesions., The limiting factor of colposcopy is its accuracy which is directly related to the experience of its operator performing it.
Reid Colposcopic Index proposed by Reid and Scalzi is a well-known scoring system to grade the severity of premalignant lesions and to make colposcopy diagnosis less subjective. It includes color of acetowhiteness, margins, vascular pattern, and iodine staining. A new scoring system has been devised by Strander et al., the Swede score, which includes lesion size as a variable, in addition to the above four colposcopic signs along with the modifications to definitions of the scores for the remaining variables. The Swede score is simple to use, with no major learning curve, and it can also be used by any grade of colposcopist. Their results showed that the specificity for a total score of 8 or higher was 90% and that no lesion of cervical intraepithelial neoplasia (CIN 2) or higher resulted in a score of <5. Hence, the objective of this study was to evaluate the diagnostic efficacy of colposcopy using the Swede score in the unhealthy cervix and to determine the degree of correlation between colposcopy scores and histopathological findings.
| Materials and Methods|| |
The present cross-sectional study was conducted in the Department of Obstetrics and Gynecology, Santosh Medical College and Hospital, Ghaziabad, Uttar Pradesh, India, from January 01, 2020, to June 30, 2021. Women fulfilling the following inclusion and exclusion criteria were selected for the study.
- Women aged 25–60 years with complaints of lower abdominal pain, persistent vaginal discharge, postmenopausal bleeding per vaginum, or postcoital bleed
- Women with unhealthy cervix
- Women with Pap smear reports of inflammatory, atypical squamous cells of undetermined significance (ASCUS) or low-grade squamous intra-epithelial lesions (LSIL) after routine screening.
- Frank cervical cancer or obvious growth
- Posthysterectomy status
- Previous procedures on the cervix, for example, excision biopsy, cryotherapy, and conization
- Severe debilitating disease
- Unsatisfactory colposcopy.
Informed consent was obtained from all subjects.
Approval was obtained from the Ethical Committee of Santosh University.
Detailed history, general physical examination, per speculum, and bimanual examination were done. All women were screened for cervical cancer by VIA, VILI, and Pap smear. Women with cytology reports of inflammatory, ASC-US, and LSIL were also subjected to colposcopy, and biopsy was taken in the presence of abnormal sites. Patients in whom colposcopy was normal, the biopsy was taken from the cervix within the transformation Zone. The findings of colposcopy and histopathology were correlated.
The data were collected and tabulated. The observations were described in terms of percentages and proportions. Data were compiled and statistically analyzed using the Chi-square test, Student's t-test where applicable. P < 0.05 was considered statistically significant.
| Results|| |
Out of 102 women who were included in the study, four were lost to follow-up, and hence, 98 total patients were studied.
Abnormal cervical biopsy findings (CIN-1 or squamous cell carcinoma) were found in 10% of cases [Table 1] and [Figure 1].
|Table 1: Distribution of the patients according to cervical biopsy findings|
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|Figure 1: Distribution of the patients according to cervical biopsy findings|
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Among the study group, 84 women were in the age group of 35–60 years. Among them, 90% were proved on histopathology as preinvasive and invasive lesions. Seventy percent of the women with abnormal histopathological findings had a prolonged duration of marriage of at least 20–30 years which came out to be statistically significant with a P = 0.033. Incidence of CIN was found to be maximum among women married having two or more children [Table 2].
|Table 2: Correlation of sociodemographic parameters with cervical biopsy findings|
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Majority of the patients with abnormal bleeding patterns per vaginum as a presenting complaint had abnormal histopathological findings, which was found to be a statistically significant finding with a P < 0.001 [Table 3].
About 23% (23/98) of the total women had a Swede score of 5 or more, out of which 43.47% (10/23) were found to have preinvasive or invasive lesions with a significant P < 0.001 [Table 4] and [Table 5].
Swede score of 7 or higher had a specificity of 100% for CIN 2 or worse, with a sensitivity of 80% with an improved accuracy rate of 97.96%, whereas lowering the cutoff to 5 improved the sensitivity at the expense of specificity (sensitivity = 100% and specificity = 85.23%) and lowered accuracy rate to 86.73% [Table 6].
| Discussion|| |
Cervical cancer is the second-most common leading cause of female cancer in India and in other developing countries as well. Although it is a preventable condition because it is associated with a long precancerous stage making it amenable to screening and treatment, but still due to a lack of resources, effective screening programs, and poorly organized health system aimed for detecting precancerous lesions, the mortality rates are very high making carcinoma cervix the major cause of cancer-related deaths in Indian females.
In our study, screening was done in 102 women out of which 4 were lost to follow-up, and hence, 98 total patients in the age groups from 25 to 60 years with the complaints of lower abdominal pain, discharge per vaginum, abnormal uterine bleeding, backache, and dyspareunia were included in the study.
The sociodemographic parameters and patient profile of the present study were very similar to that of other studies. The mean age was 41.5 years which is comparable to all the other studies,, except Ravindranath et al. where the mean age was 35 years, including women from 25 to 59 years of age group. More than half of the subjects with CIN1 lesions were >40 years of age. Maximum incidence (87.5%) of CIN was found among 30–45 years of age group. Kushtagi and Fernandez, in their study, showed that the prevalence of CIN was higher in women over 30 years. Vaidya showed in his study that CIN was more prevalent in the age group of >35 years. Shalini et al. showed that the mean age of patients with cancer cervix was 35 versus 32 in patients with benign pathology in the cervix, supporting the fact that as the age increases, the incidence of preinvasive and invasive lesions also increases. It also collaborates the fact that sexually active women in the reproductive age group have a higher chance of having an unhealthy cervix.
Duration of marriage and time of sexual exposure has a distinct role in the genesis of CIN. In this study, the incidence of CIN was 70% among women who were married for more than 20 years which was comparable to other studies like Kushtagi and Fernandez and Karya et al. which also demonstrated that the severity of underlying CIN increased with the prolonged duration of marriage and early age of sexual exposure and hence the exposure to HPV.
The utility of Swede score as a useful marker for predicting the severity of the cervical lesion has also been demonstrated by Strander et al. and Bowring et al., who found that a score of 8 or higher had a specificity of 95% for CIN 2 or worse with a sensitivity of 38%, whereas lowering the cutoff to 6 improved the sensitivity at the expense of specificity. Lower scores showed high-negative predictive values; a score of 3 or less resulted in a negative predictive value of 90%.
Strander et al. showed that the specificity for a total score of 8 or higher was 90% and that no lesion of CIN2 or worse resulted when the score was <5. They also found that 70% of larger lesions scoring the maximum two points had CIN2 at least on histological diagnosis. In the present study, 8 subjects (42.1%) of CIN2+ were scoring more than 2 score for lesion size. Bowring et al. found that a score of 8 or higher had a specificity of 95% for CIN2 or worse with a sensitivity of 38%, whereas lowering the cutoff to 6 improved the sensitivity at the expense of specificity (sensitivity = 65% and specificity = 82%). Lower scores showed high-negative predictive values; a score of 3 or less resulted in a negative predictive value of 90%. In the present study, specificity for Swede score at a score of 8 or more was 100% (92.32–100) and sensitivity was 36.84% for CIN2+lesions, which was better than the results reported by Bowring et al. Lowering the cut off to 5 increased the sensitivity to 100%, while the specificity became 91.30%, which was better than the results reported by Strander et al.
On taking the cutoff value of Swede score as <5 and >5, the positive predictive value (PPV) was found to be 43.48% and negative predictive value (NPV) was 100%, with an accuracy of 86.73%, whereas if the cutoff for Swede score was taken as a value of <7 or >7, the accuracy significantly increased to 97.96% with a PPV of 100% and NPV of 97.78%.
| Conclusion|| |
Early diagnosis and treatment is the best tool for the prevention of carcinoma cervix, thus making an earlier diagnosis of CIN in adult women a desirable goal as it is the most common preventable cancer because of its long preinvasive stage (CIN), during which early diagnosis can be made by various screening modalities and detecting the patient before the disease gets invasive. Hence, diagnosis of CIN lesions and early invasive cancers should be managed at an early stage by routine screening for commencing appropriate management.
Thus, it is concluded from this study that Swede score performed well in this hospital-based study on a selected population coming to gynecology OPD with complaints of lower abdominal pain, discharge per vaginum, dyspareunia, abdominal pain, discharge per vaginum, dyspareunia, abnormal uterine etc. referred to the colposcopy clinic in view of unhealthy- looking suspicious cervix. From the present study, it is evident that Swede score of 7 or more has 100% specificity and 80% sensitivity with an accuracy of 97.96%; Swede score of 5 and more has a sensitivity of 100% and specificity of 85.23% with an accuracy of 86.73% and can be used for performing direct excisional procedure as a “see and treat” method at this cutoff sparing the need for cervical biopsy. This can be the preferred method for the treatment of high-grade CIN as it reduces the number of visits to the clinic and failure to receive appropriate treatment preventing loss to follow-up cases as well.
The main strength of the present study is that cervical biopsies were performed in all subjects irrespective of the Pap's smear findings or presence or absence of a lesion on colposcopy, hence eliminating the verification bias. However, a larger study may help to determine the most appropriate cutoff for use in population-based screening programs.
I extend my sincere thanks to my co-authors for their support in data collection and technical assistance.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]