Assessment of Two Mass Screening Campaigns for Pre-Cancerous and Cancerous Lesions of the Uterine Cervix using Colposcopy

  

    
Age at the first sexual intercourse
    
Résults of colposcopy
    
p
  
  

    
Normal
    
ATG 1 
    
ATG 2
    
 
  
  

    
< 20 ans
    
2 (15,4%)
    
2 (15,4%)
    
9 (69,2%)
    
0,39
  
  

    
= 20 ans
    
7 (35%)
    
3 (15%)
    
10 (50%)
    
 
  

Table 6: Results of colposcopy according to the patient age at the first sexual intercourse.

Discussion

During these two screening campaigns, we collected 50 colposcopies, 28 of which were performed at the Centre Médical Interarmées de Thiès and 22 at the Hôpital Institut d’Hygiène Sociale de Dakar. In our developing countries, where there is no policy of organised screening for cervical lesions, this strategy has several advantages but also some disadvantages. The strengths were as follows :

- the high attendance of these mass screening campaigns by women,

- easy performance of screening tests and the possibility of immediate colposcopy following a positive visual inspection

- accessibility of consultation sites,

- and the availability of medical consumables.

Areas for improvement were :

- follow-up of screened patients with colposcopic lesions who had undergone biopsy. Of the 20 patients who had received a biopsy, only 5 had returned the histology results; the other 15 were contacted by telephone and could not afford the cost of the histology examination;

- the lack of thermocoagulation and cryotherapy equipment for the immediate management of lesions detected according to the “screen and treat” strategy.

The epidemiological profile was that of a married woman, multiparous, in period of genital activity. The average age of the patients was 45 years with a first sexual intercourse around 22 years. These results are similar to those published by Dembélé [4] and Gassama [5] in Dakar and Ngekoum et al [6] in Cameroon who found an average age of 44.5, 43.6 and 43 years respectively. They are also comparable to those of Afoutou [7] in Dakar and Sonfack [8] in Mali. On the other hand, it appears to be higher than that found by Firnhaber in South Africa [9] and Sankaranarayanan in India [10] which were respectively 38 and 40 years old. The advanced age of the patients can be explained in part by the fact that this was a selected population recruited in the context of opportunistic or mass screening. In our country, as in developing countries, organised screening should be done at a younger age, given the incidence and average age of onset of cervical cancer in these countries [11]. Screening programmes vary from country to country. In the USA, screening is carried out from the age of 20 years; the same is true in Scandinavian countries, whereas in France screening is carried out from the age of 25 years [12]. In our study, colposcopy revealed 18 GAT 2 lesions (36%), 9 normal colposcopies (18%), 9 menopausal atrophies (18%), 9 ectropions (18%), 5 cases of viral colpitis (10%), 5 GAT 1s (10%), 5 cases of cervical polyps (10%) and one combination of GAT 1 and 2 (2%). Our results are comparable to those recorded by some African authors. Indeed, in his work in Dakar, Gassama found a GAT 2 lesion in 36.6% of cases, a GAT 1 in 31.5% and a viral colpitis in 10.4% of cases [5]. Iloki’s study of 150 women found GAT 2 in 36.7%, normal colposcopy in 17.3%, GAT 1 in 9.3%, GAT 2 + GAT 1 in 9.3%, cervical buds in 8.6% and colpitis in 19.3% [13]. On the other hand, our rate of GAT2 was higher than that found by Diallo [14] in a study carried out in Mali involving 5016 women, which was 15.1% GAT2. In our series, colposcopy was satisfactory in the majority of our patients (78%). Our results are similar to those of Gassama who found 78% of satisfactory colposcopy [5]. Nevertheless, we note that there seem to be more GAT 2 lesions in our developing countries than in developed countries. Indeed, Coupez and Barrasso in France found GAT2 in 8.4% of a population of 13,798 patients and viral colpitis in 13.2% of cases [15]. In our series, the majority of patients (72.2%) with a positive visual inspection with acetic acid and lugol had GAT 2. Patients with a positive visual inspection with acetic acid alone had a majority of normal colposcopies (71.4%). Patients who had only a positive visual inspection with lugol had 50% GAT 1 and 50% GAT 2. The visual inspection methods are based on naked eye examination aided by a magnifying glass and the results depend on the experience of the practitioner. These methods should be considered as a means of guidance and sometimes require further diagnostic examination. The performance of colposcopy is operator dependent. The most common diagnostic errors are due to similarities between the colposcopic appearance of various conditions: immature metaplasia and high-grade intraepithelial lesion, inflammation or infection and invasive cervical cancer, decidua and high-grade intraepithelial lesion, high-grade cytology and perimenopausal cervix. Hormonal imbalances are the cause of a large number of diagnostic errors. For example, in postmenopausal women, but also in adolescents, the squamocolumnar junction is frequently buried in the cervical os, making it difficult to explore. The prescription of oestrogens in the days preceding the examination usually allows this situation to be corrected and the squamocolumnar junction to be revealed. The examiner should therefore not hesitate to reconvene the patient to schedule the examination under better conditions [16]. In all cases, a presumptive diagnosis should always be avoided. If abnormalities are found, the next step is to perform a biopsy for histology, which is the only way to make a diagnosis and decide on an appropri ate therapeutic approach. In our study, 20 patients (40%) underwent colposcopy. Of these, only 5 (25%) had returned the results. These were CIN 2 and 4 normal results. The patient with CIN 2 had a hysterectomy. In our series, GAT 2 lesions were more frequent in patients aged 45 years and over (60%) (p=0.46), in primiparous women (100%) (p=0.62), in patients who had had first intercourse before 20 years (69.2%) (p=0.39) and in patients who had not used contraception (88.9%) (p=0.13). However, the small size of our sample does not allow us to establish a statistical relationship between these different parameters and the results of colposcopy.

Conclusion

Colposcopy is still not widely used in our developing countries where visual inspection methods are more accessible. However, it remains an essential examination in the diagnosis of precancerous and cancerous lesions of the uterine cervix, reliable and easy to perfor.

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