Original articlesCervical Screening in Africa: Discordant Diagnosis in a Double Independent Reading
Introduction
Cancer of the cervix is an important public health problem in Africa with regard to its high prevalence; it is the most common female malignancy 1, 2 and the leading cause of cancer death in African women [3]. In many developing countries, cervical screening programs are almost nonexistent or at the development stage. In Côte d'Ivoire, West Africa, following a prevalence study on cervical dysplasia-neoplasia in relation to human immunodeficiency virus (HIV) infection [4], discussion on a cervical screening program is in progress, including the issue of quality control monitoring.
The current concept in the field of cervical dysplasia, introduced with the Bethesda system [5], separates low-grade squamous intraepithelial lesions (LSILs), which are manifestations of productive human papillomavirus infection and serve as markers for women who are at risk of developing de novo high-grade lesions, and high-grade squamous intraepithelial lesions (HSILs), which are truly precancerous lesions [6]. The distinction between LSILs and HSILs is of great importance because the management of these two lesions is very different [7]. Interobserver variation in the cytological [8] or histopathological 9, 10, 11 diagnosis and grading [12] of dyskaryosis in cervical specimens justifies the setting up of a quality control in public health screening programs [13], in order for the screening strategy to minimize, in particular, false-negative results [14].
We assessed the frequency of discordant diagnosis or grading between two independent cytopathologists during a prevalence study on cervical dysplasia in gynecology clinics in Abidjan.
Section snippets
Methods
Women were recruited from three outpatient gynecology clinics of Abidjan: One is a community-based clinic, and the two others are located within university teaching hospitals [4]. Enrollment was continuous in these centers during the study period. Nonpregnant women between 20 and 50 years of age, without a history of lower genital tract neoplasia and accepting HIV test were included. A signed informed consent was obtained. The study was approved by the Ethical Committee of the Ministry of
Results
Between April 1995 and February 1996, 2281 women were asked to participate in the study; 83 of them (3.6%) were not included because they refused the HIV test. Among the 2198 women enrolled, a Papanicolaou smear could not be performed in 28 instances (1.3%) because of cervical bleeding at the time of enrollment (menses in 17 cases, intermenstrual bleeding in 11 cases), and these 28 women failed to return to the clinic for screening. Thus, a cervical screening was performed for 2170 women; a
Discussion
This study has shown a poor interobserver agreement in the cervical screening of dysplasia-neoplasia performed in the African context of gynecology clinics. Consistency of cytological reporting between two cytopathologists, assessed by kappa statistics, was fairly good for the most serious cervical lesions requiring curative treatment (high-grade and invasive lesions) but poor for less pejorative lesions (low-grade lesions) and null for lesions of undetermined significance (ASCUS). This
Acknowledgements
We are indebted to Roger Salamon for advice and criticism in the preparation of the manuscript. Supported in part by the Agence Nationale de Recherches sur le SIDA (France) and the French Ministry of Cooperation.
References (43)
- et al.
Sources of interobserver variation in histopathological grading of cervical dysplasia
J Clin Epidemiol
(1992) - et al.
Interobserver variation in the assessment of the sampling quality of cervical smears
J Clin Epidemiol
(1993) - et al.
Observer agreement on interpreting colposcopic images of CIN
Gynecol Oncol
(1995) - et al.
The association between human papillomavirus deoxyribonucleic acid status and the results of cytologic rescreening tests in young, sexually active women
Am J Obstet Gynecol
(1991) - et al.
Cancer incidence in Conakry, GuineaFirst results from the cancer registry 1992–1995
Int J Cancer
(1997) - et al.
Estimates of the worldwide frequency of sixteen major cancers in 1980
Int J Cancer
(1988) - et al.
Estimates of the worldwide incidence of eighteen major cancers in 1985
Int J Cancer
(1993) - et al.
Squamous intraepithelial lesions of the cervix, invasive cervical carcinoma, and immunosuppression induced by human immunodeficiency virus in Africa
Cancer
(1998) The 1988 Bethesda system for reporting cervical/vaginal cytologic diagnoses
JAMA
(1989)- et al.
A critical review of the morphologic classification systems of preinvasive lesions of the cervixThe scientific basis for shifting the paradigm
Papillomavirus Rep
(1994)
Interim guidelines for management of abnormal cervical cytology
JAMA
Interobserver variation in the diagnosis and grading of dyskaryosis in cervical smearsSpecialist cytopathologists compared with non-specialists
J Clin Pathol
Observer variation in histopathological diagnosis and grading of cervical intraepithelial neoplasia
BMJ
Pathologist variation in reporting cervical borderline epithelial abnormalities and cervical intraepithelial neoplasia
J Clin Pathol
Inter- and intra-observer variation in the histopathological reporting of cervical squamous intraepithelial lesions using a modified Bethesda grading system
Br J Obstet Gynaecol
Diagnostic reproducibility of Pap testing in two regions of MexicoThe need for quality control mechanisms
Bull Pan Am Health Organ
Improving the screening of cervical precancerous lesions by improving laboratory quality assurance in cytology
J Lower Genital Tract Dis
The Bethesda system for reporting cervical/vaginal cytologic diagnoses
Acta Cytol
The measurement of observer agreement for categorical data
Biometrics
Reproducibility study of cervical cytopathology in MexicoA need for regulation and professional accreditation
Diagn Cytopathol
A quality control system involving peer review of abnormal cervical smears
Cytopathology
Cited by (0)
- †
The DYSCER-CI Group comprises S. Anongba, I. Bobo, M. Koné, N. Messou, G. Moket, S. Mothebesoane-Anoh, Z. Sidibé, M. Sissoko, K. Touré-Coulibaly and C. Welffens-Ekra (gynecologists, Abidjan, Côte d'Ivoire); M. Diomandé, A. Ehouman, and I. Mensah-Ado (pathologists, Abidjan); C. Bergeron and J. Rivel (pathologists, France); D. Bonard, P. Combe, M. Dosso, H. Faye-Ketté, F. Sylla-Koko, C. Montcho, and B. You (microbiologists, Abidjan); G. Orth (virologist, France); F. Dabis and V. Leroy (epidemiologists, France); A. Boka-Yao, I.M. Coulibaly, G. La Ruche, and R. Ramon (epidemiologists, Abidjan).