1. Comparison of visual inspection using
acetic acid[VIA] and pap smear as a
method of cervical cancer screening in
low resource settings and prevalence of
cervical cancer in diseased population

2. • Carcinoma of cervix is the second most common cancer among
women worldwide. Worldwide carcinoma of cervix accounts for
about 500,000 new diagnosis and 273,000 deaths every year. Of
the new cases 80% occur in the underdeveloped countries[1]
• The pap smear remains the most common screening test for
cervical cancer, however many developing countries do not have
ample resources to implement cytology based prevention
programmes[2]
• An alternative of pap smear, a low cost test, visual inspection
using acetic acid(via) has emerged for use in low resource settings
where it can be performed by trained health professionals[3]
• Cervical cancer is preventable condition and with well organized
cervical cancer screening programmes, a major impact can be
made on the incidence of and mortality from ca- cervix[4]

3. • According to a study the invasive caner of cervix is the
third commonest malignancy among female population of
Pakistan[5]. By the time most patients appear to hospital
the cancer has already advanced to stages two or three[6]
• Objectives
• 1] comparison of efficacy of VIA and pap smear as a
method of cervical cancer screening in low resource
settings
• 2] to determine the proportion of women screened
positive with VIA and screened positive with pap smear
• 3]To compare the sensitivity, specificity, positive predictive
value and negative predictive value of VIA and pap smear
• 4]To determine the total number of CIN and CA-Cervix in
the study population

4. • Cervical cancer is very common among females of Pakistan
and also it presents at advanced stage, in spite of that there
is no affective as well as cost effective screening programme
in our country.pap smear is used in many developed
countries of the world as a screening test but difficult to
imply in our country because of its cost, time required for
interpretation of results and poor patient compliance. So in
these circumstances VIA seems to be a better choice which is
cost effective, results available immediately and no need of
follow up by patient. Studies have done at international level
that have also showed VIA as an affective screening approach
in less developed countries(7,8). Only one such study has
been done at lady wellington hospital Lahore , but it is first
kind of this study in my institute and it will help develop
better screening strategy in low resource settings of Pakistan
as it is cheap, acceptable to the patient, immediate
availability of the results and no need of patient compliance

5. • Inclusion criteria
o -age 25-60 years
o Non pregnant
o Multiparous
o having history of persistent vaginal
discharge, suspicious looking cervix, post coital
bleeding, intermenstural bleeding
• Exclusion criteria
•
•
•
•
Pregnancy
abnormal uterine bleeding
absent cervix e.g. having underwent TAH
Having visible gross cervical lesion of suspected
malignancy

6. • Operational definitions
1. Visual inspection with acetic acid(VIA)
It will be performed by applying 5% acetic acid solution
to cervix with a cotton swab and interpreting the
findings 1 minute after application by visualizing the
cervix
VIA positive;- if a well defined dense opaque acetowhite
lesion close to the squamocolumnar junction or acetowhite
area close to the transformation zone is observed , the
result will be labeled positive
VIA negative;- the result will be labeled negative if
•
No acetowhite lesion
• Faint and bluish white translucent acetowhite lesion
• White line indicative of squamocolumnar junction(SCJ)

7. • 2]Pap smear
• It is a screening test for cervical cancer and involves
taking scraping of cervical surface
• I will perform this test when my patient is not
menstruating ideally 2 weeks after day of her last
menstrual period and will advise her not to use any
vaginal medication 24 hrs before examination
• I will put my patient into lithotomy position, insert the
speculum, visualize the transformation zone. then insert
the Ayres spatula, rotate it to 360 degree and take
sample from transformation zone. After removing
spatula sample will be evenly spread on slide and fix
with an aerosol fixater before it gets dried and send for
cytological examination
•
Positive smear results;- I’ll use BATHESDA reporting
system to interpret the results

8. • 3]Bathesda reporting system(7)
• The classification uses the term
• ‘squamous intraepithelial lesions’(SIL) to encompass all
grades of CIN (cervical intraepithelial neoplasia) ,it is
subdivide into two categories
Low grade; which includes cellular changes associated
with human pappiloma virus(HPV) infection and CIN-1
High grade; which includes CIN2 and CIN3
• Atypical squamous cells have two categories
atypical squamous cells of undetermined
significance(ASC-US) and atypical squamous cells that
can not exclude high grade(ASC-H)

9. • 4]TRANSFORMATION ZONE

10. • Material and methods
•
study design;- cross sectional/ comparative
study
•
settings;- department of gynae and obs., PMC
affiliated hospital Dhq . FSD
•
Duration;- minimum of 6 months after
approval of my synopsis
•
sample size;- by using WHO sample size
calculator for 2 poportions

11. • Data collection procedure
After taking consent from the hospital ethical review
committee women attending outdoor department
fulfilling inclusion criteria will be included in the study and
informed consent will be taken from the patient. Exclusion
criteria will be strictly followed to limit confounding
variables. Demographic information will be collected in
computer based database. History, general physical
examination will be performed by me ,then I’ll put my
patient in dorsal position and perform gynecological
speculum examination. First I’ll take pap smear and then
5% acetic acid will be applied on cervix using cotton swab.
The test results will be divided into 2 categories VIAnegative and VIA-positive. All the data will be collected
and recorded by me on Performa attached at the end
Data analysis procedure