uterine cervical cancer in the population of Nosy Be, Madagascar

Pathologist at the microscope and local staff reviewing the cytological reports

In a previous post I described the results of a medical mission we made in september 2010 to promote secondary prevention of uterine cervical cancer by pap smear cytological screening in women living in Nosy Be Island, Madagascar. The mission was repeated in April 2011 and took place at the Dispensaire of the Organisation Medicale Interenterpresises of Nosy Be (OMINO) in Hellville. The data we collected confirm our previous results that in the population of Nosy Be the incidence of uterine cervical carcinoma and its precursor lesions is significantly high. 
So far, we have examined cumulatively 278 women aged 16 to 57. In both missions we managed to perform pap smear evaluation with immediate reporting and immediate colposcopy and biopsy on a same-day basis. To summarize, pap smear sampling started early in the morning and was performed by two physicians, then slides were immediately stained and interpreted by a Pathologist who was able to release a cytopathological report at the end of the morning. Then, women bearing abnormalities in their pap smear were invited to undergo immediate colposcopy which was performed in the  early afternoon. Biopsy samples were then collected and processed for histological evaluation. Histological processing was completed in Italy at the department of Pathology, Fatebenefratelli Hospital, in Milano, Italy. 

women waiting for their turn for pap smear sampling

Immediate cytological reporting allowed for women with pap smear abnormalities to undergo immediate colposcopy thus preventing the risk of patients’ drop out in the screening programme. This is the most rewarding result for our efforts because women in these countries often fail to show up again when they are subsequently (i.e. many days or even months later) invited to undergo further evaluation, and the screening procedure thus fails to confirm cervical lesions by colposcopy and histology. 
Overall, we detected 5 women with high grade lesions according to the Bethesda System, 2001, and three of them were diagnosed as having squamous cell carcinoma in situ on biopsy examination.  Low grade lesions were found in other 25 women who are going to be re-evaluated within 6 months after the first pap smear. The overall cumulative incidence of pap smear abnormalities in this population is 10.79%, and this value is higher than the World Health Organization’s estimates of 10% (see "Comprehensive Cervical Cancer Control. A guide to essential practice", p. 40, World Health Organization, 2006) for the previously unscreened population in Madagascar. The above value is about 5-fold to 8-fold higher than the incidence of abnormalities in the screened population living in countries of the high-income developed world.

In un precedente post ho parlato della missione medica da noi eseguita in settembre del 2010 e finalizzata a promuovere la prevenzione del carcinoma della cervice uterina nella popolazione residente di Nosy Be, in Madagascar. Tale missione è stata ripetuta in Aprile 2011 e ha avuto luogo presso il Dispensario della Organisation Medicale Interenterprises di Nosy Be (OMINO) a Hellville, il capoluogo dell'isola. I dati raccolti confermano la nostra precedente impressione che l’incidenza di questa neoplasia in quell’area geografica è decisamente elevata. Abbiamo esaminato in tutto 278 donne e identificato 5 casi con lesioni ad "alto rischio" di cui 3 con carcinoma. Sono state identificate inoltre 25 donne portatrici di lesioni a “basso rischio” che verranno sottoposte a controllo ravvicinato. In entrambe le missioni abbiamo provveduto a eseguire la lettura immediata del pap test allo scopo di poter sottoporre le pazienti che necessitavano di colposcopia e biopsia nello stesso giorno. Questa modalità operativa ha consentito di annullare la quota di casi che solitamente non si ripresenta al controllo quando le pazienti vengono riconvocate a distanza di tempo dal pap test e ciò ha ottimizzato gli effetti dello screening. L’incidenza di lesioni riscontrate, pari al 10,79%, appare decisamente elevata se si pensa che l’Organizzazione Mondiale della Sanità stima un’incidenza massima del 10% per la popolazione del Madagascar. L’incidenza è da 5 a 8 volte superiore a quella riscontrata nella popolazione femminile sottoposta a regolare screening nei paesi occidentali.