Sensitivity and Specificity of Visual Inspection by Acetic Acid of Cervical Lesion at Nyambu Village Kediri Tabanan GN Bayu Dalem

Putra, Ketut Suwiyoga, Mayun Mayura Department Of Obstetrics and Gynecology University of Udayana/Sanglah General Hospital Denpasar Bali
ABSTRACT Introduction : Cervical cancer is the second commonest cancer that affects women through out the world.. Its clinical manifestation through molecular and cellular changes are metaplasia and dysplasia. Visual inspection of the cervix by acetic acid ( VIA ) is one of the many screening tools to aid the diagnosis of dysplasia which are caused by HPV infection. Objective : To identify a positive visual inspection by acetic acid test with positive human papilloma virus test in cervical lession and a positive visual inspection test with negative human papilloma virus test in cervical lession. Subject and method : This research was a cross sectional study .One hundred and fifty samples were included in this study which were identified at the participating local community health center who agreed and are qualified. All samples were inspected and had the PAP Smear test thus the patient was examined by a qualified and trained personel to visual inspection by acetic acid. The result of the VIA test were then compared to the result of the PCR test which were then calculated with chi square and analysed by the t- independent test. Result : The average age of the sample who were VIA positive is 37,675,66 and with negative result were 34,968,19. Results from the t-independent test shows there was no statistical differences in the average age of the subjects (p>0,05). Analysis with the 2x2 table identified sensitivity of 72,73%; specificity 97,12%; negative prediction 97,83% positive prediction 66,67%; ratio of positive probability 25,27; ratio of negative probability 0,28% and an accuracy of 95,33%. Conclusion: Based on the research result above we may conclude that this simple test is spesific and sensitive in diagnosing dysplasia thus quiet reliable as a screening tool to detect cervical carcinoma in its early stages. Key word : Cervical cancer, Visual inspection by acetic acid (VIA) ABSTRAK Pendahuluan : Kanker serviks adalah kanker terbanyak kedua pada wanita di seluruh dunia. Manifestasi klinis timbul melalui perubahan molekuler dan seluler berupa metaplasia dan displasia. Inspeksi visual serviks menggunakan asam asetat (IVA) adalah salah satu dari berbagai metode skrining adanya displasia yang disebabkan oleh infeksi HPV. Tujuan : Untuk mengenali inspeksi visual positif mengunakan tes asam asetat pada lesi serviks dengan tes virus papilloma manusia positif dan inspeksi visual positif mengunakan tes asam asetat pada lesi serviks dengan tes virus papilloma manusia negatif. Subyek dan Metode : Penelitian ini merupakan studi potong lintang. Seratus lima puluh sampel yang diikutsertakan dalam penelitian ini diambil dari pusat kesehatan masyarakat setempat setelah menyatakan bersedia dan memenehi kriteria inklusi. Semua sampel diperiksa dan dilakukan PAP Smear oleh tenaga kesehatan yang terlatih dalam melakukan IVA menggunakan asam asetat. Hasil tes IVA selanjutnya dibandingkan dengan hasil tes PCR yang kemudian diuji menggunakan tes chi square dan analisa dengan uji t-independent. Hasil: Rerata usia sampel dengan IVA positif adalah 37,675,66 dan dengan IVA negatif adalah 34,968,19. Uji t-independent menunjukkan tidak ada perbedaan bermakna antara rerata usia subyek (p>0,05). Analisa pada tabel 2x2 menunjukkan sensitifitas sebesar 72,73%; spesifisitas sebesar 97,12%; prediksi negatif sebesar 97,83%; prediksi positif sebesar 66,67%; rasio probabilitas positif 25,27; rasio probabilitas negatif sebesar 0,28%; dan akurasi sebesar 95,33%. Simpulan: Berdasarkan penelitian diatas, kemi simpulkan bahwa tes sederhana ini spesifik dan sensitif dalam mendiagnosa displasia sehingga dapat digunakan sebagai alat skrining untuk mendeteksi karsinoma serviks pada tahap awal. Kata Kunci: Kanker serviks, Inspeksi Visual Asetat (IVA)

INTRODUCTION Cervical cancer is the second most common cancer affecting women through out the world. In the United States there have been reports of 14000 new cases and 5000 cervical cancer related deaths every year.1 Data retreived from the Indonesian Medical Department revealed that cervical cancer is the most common cancer in Indonesia . Efforts by the government by using Pap Smears as means of screening tools, which have been used by industrialized nations to lower the incidence of cervical cancer seems to have lower impact due to various aspects leading to a less than 5% screening rate compared to the ideal 80% target.2 One of the screening method which is still under research through out the world, especially in developing nations is the application of Visual Inspection by Acetic Acid (VIA) of the cervix which in certain ways has advantages such as its effectiveness ( similar to standard diagnostic test), cost effective and relatively simple to perform, instaneous results which deems no further visits, appropriate for mass screening and does not need pathology specialist to determine the results. These

conditions are more acceptable in the application as a screening tool in the developing nations.2,3 METHOD A cross sectional study was undertaken using one hundred and fifty samples whom were recruited at the Nyambu Village health Cente, Kediri Tabanan. Inclusion criteria are marrital status, has had previous sexual intercourse, age of no more than 60 years, willing to participate in the study confirmed with informed consent. Exclusuion criteria having menstrual period or abnormal uterine bleeding, the use of antiseptics or medications in the previus week and intercourse within 3 days before examination.This study was conducted at Nyambu Village, Tabanan within the time frame of August- September 2007. Data were analysed using Chi Square. RESULT Tabel 1 denotes the average age of positive VIA tests were 37,675,66, Negative VIA tests 34,968,19. Using the t-independent tests revealed that the average age between the group is not statistically different (p>0,05).

Table 1. Histopathological characteristics

VIA Characteristics Positive (n = 12) Negative (n = 138) P

effective

and

relatively

simple

to

perform, instaneous results which deems no further visits, appropriate for mass screening and does not need pathology specialist to determine the results. This is
0,246

Age ( years)

37,675,66

34,968,19

mor which

prefferable has of very

for

application

in

developing nations such as Indonesia few Pathological were 100

Table 2. Diagnostic test between VIA and HPV DNA/PCR
Group Positive Negative HPV DNA/PCR Positive Negative 8 3 4 135 P

specialist. Data in 2003 revealed that the number screeners specialists. The results of this study revealed a sensitivity and specificity which are similar to other studies which has a range of sensitivity and specificity of 76,7%-79% and 64%-87%

VIA

1,000

Analysis using the 2x2 table revealed a sensitivity Specificity = = 72,73%; positive 97,12%;

respectively. Positive predictive value and Negative predictive values are 97% and 40% respectively.. False postive value which accounts for 24,5%.of the result may be due to non specific aceto white reaction. 80% of these lesion are not associated with cervical which can intraepithelial neoplasia,

predictive value = 66,67%); Negative predictive value = 97,83%; Rtio of positive probability = 25,27; Ratio of negative probability = 0,28; and accuracy = 95,33%. DISCUSSION The current screening tool widely used through out the world is the Pap Test. As an alternative sreening tool, the VIA test has advantageous for application in developing nations compared to the Pap Test for early detection of cervical cancer such as its effectiveness ( similar to standard diagnostic test), cost

either be a physiological reaction and inflamation.4,5 False negative values of this study were 25,0%. Which may be due to the examiners perception to acetowhite reaction, less amount of lighting and lower concentration of acetic acid due to long storage hours.3,4,5

CONCLUSION Regarding the results above, we may conclude that the sensitivity and specificity of the VIA test compared to the Gold Standard PCR is 72,73 % and 97,12% respectively.

Serviks, dalam Media Medika Indonesia 43 2008) 116-120

5. Akinola,

O.I,

et

al.

2007.

Efficacy of visual inspection of the cervix using acetic acid in cervical cancer screening: A comparison with cervical cytology, in Journal of Obstetrics and Gynaecology, October 2007; 27 (7): 703-705. Available: http://www.informaworld.com

REFERENCE
1. Schellekens, M.C, et al. 2004.

Prevalence of single and multiple HPV types in cervical carcinomas in Jakarta, Indonesia, in Gynecologic Oncology 93 (2004): gyno 2. Suwiyoga IK, Kanker Serviks : Penyakit yang dapat dicegah, Maj Obstet Ginekol Indones 2007 ;31 :3-25 3. Suwiyoga Kanker IK. Serviks Perbandingan Antara Pap 49-53. Available: http://www.elsevier.com/locate/y

Akurasi Diagnostik Lesi Pre Smear dengan inspeksi visual asam asetat pada Lesi Serviks. Cermin Dunia Kedokteran,2004 ;145(1) : 5-8 4. Wiyono et al. 2008. Inspeksi Visual Asam Aseta (IVA) untuk Deteksi Dini Lesi Prakanker