Challenges In Pap smear screening: A qualification assessment of Provincial Health System Network
aDept Pediatrics & Infectious Diseases, Health Care Center, Fars Province, Shiraz, bDept of Obstetrics and Gynecology, Shiraz University of Medical Sciences, Fars Province, Shiraz, cHealth Care Center, Fars Province, Shiraz, Iran
Aim: To evaluate the quality of Pap Smear screening, detection of preinvasive & early stages of cervical cancer at a health system network. Methods : In a cross sectional study from Mar.-Sep. 2002 , Pap smears taken by conventional method were collected from 12 localities covered by a provincial health network system in Iran. The slides are evaluated through a double blinded study at the Pathology Department of Shiraz University of Medical Sciences and results are compared with the previous local reports. The evaluation criteria was : 1-Adequacy of slides by presence of enough endocervical or metaplastic cells 2- Spreading of cells on the slides 3- Slides obscurity due to presence of blood & exudates 4- Methods of fixation : air dried slides or cells wash out by inappropriate distance of fixator 5- Method of staining 6-Interpretation of pap smear RESULTS:865 slides were reviewed: Unacceptable% Moderately acceptable% Acceptable% Slide Spreading 82.6 15.3 22.1 Method of Fixation 19.3 22.3 57.4 Method of Staining 30.7 31 38.3 Mounting of slides 23.4 10.8 65.8 Evaluation of obscurity of slides by presence of blood indicated that 85% had trace or none, 3.7% had less than 50.5%of surface covered with blood, 1.4% had 50-70% of surface covered with blood & none of them with more 70% . 98.7% of slides were free of blood or covered with less than 50%. 9.8% covered by profuse amount of exudates. The majority of slides (80.4%) had moderate amount of exudates & 9.8% had minimal. 83.5% of questionnaires contain necessary clinical information & 96.7% had adequate valuable cells. 6.2% of slides didn't have any foreign body. 59.7% of samples had adequate endocervical but 51.9% of them had been primarily reported. 82.4% of slides had benign changes but only 41% of them were reported. In 43% of slides microorganisms were present that 9.5% were reported. Koilocyte and changes due to herpes simplex viruses were not seen in any of the slides. ASCUS was reported in 3.7% of samples that only 0.6% of them were reported. All cases of HSIL and LSIL were reported correctly. Only one sample had malignant cell that was reported correctly. There was 6.1% overestimation and 55% underestimation in final diagnosis. There were no acceptable slides from two centers. CONCLUSION: It is obvious that improvement in the conventional Pap test technique is necessary. In this study we came to the conclusion that there are shortcomings in sampling, preparation of slides & also in cytological interpretation. For example, spreading of the cells on the slides was the major problem with the P value of zero. In two cities all the specimens were unacceptable. So there is a need for continuous technical education at different levels from health care personnel to cytology technicians. There is also a need for continuous evaluation of performance of health care personnels in the network during taking samples, preparation and interpretation with a gold standard set by the central medical organization.
Paper presented at the International Symposium on Predictive Oncology and Intervention Strategies; Nice, France; February 7 - 10, 2004; in poster session 992 (Screening & detection).