Pap Smear Performance Among Women in Basrah Cervical Screening

Elaf Zuhair Mansoor; Lamis Aziz Hameed; Hayat Yahya Al Mousaw

doi:10.21070/acopen.10.2025.12703

Elaf Zuhair Mansoor ⁽¹⁾, Lamis Aziz Hameed ⁽²⁾, Hayat Yahya Al Mousaw ⁽³⁾

(1) M.B.Ch.B, C.A.B.M.S/FM. Abi Al-Khasib Primary Health Care Sector, Basrah Health Directorate, Iraq

(2) MBChB,FIBMS, Family Medicine Department of Family and Community Medicine, College of Medicine, University of Basrah, Iraq

(3) Family medicine specialist and clinical dietitian Al-Mawani Teaching Hospital, Basrah, Iraq

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Abstract:

General Background: Cervical cancer remains a leading cause of cancer-related mortality among women worldwide, particularly in developing countries where early detection programs are limited. Specific Background: The Papanicolaou (Pap) smear is a widely used, cost-effective screening method for detecting precancerous and cancerous cervical lesions. Despite its proven utility, misreporting and limited access continue to challenge accurate diagnosis in many regions. Knowledge Gap: There is limited data on the performance of Pap smear testing in Iraq, especially regarding sociodemographic factors influencing abnormal results. Aim: This study evaluates the performance of Pap smear tests among women attending the early detection cervical cancer screening center in Basrah and examines associations with sociodemographic characteristics. Methods & Results: A record-based cross-sectional study of 677 women from 2013–2015 showed 60.7% normal results, 18.8% LSIL, 4.3% HSIL, and 1–1.2% other abnormalities. Abnormal results were more prevalent in women aged 40 and above and were significantly associated with passive smoking, parity, and duration of marriage. Novelty & Implications: This study provides the first detailed insight into Pap smear performance in Basrah, highlighting population-specific risk factors that can guide targeted screening and early intervention strategies.

Highlights:

First evaluation of Pap smear performance in Basrah population.

Abnormal results associated with age, parity, and passive smoking.

Provides evidence for targeted cervical cancer screening programs.

Keywords: Pap Smear, Cervical Cancer, Screening Performance, Basrah, Women Health

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Introduction

Ten percent of cancer deaths in the US are from cervical cancer, which is the second most common cause of cancer death after breast cancer. [1] About 11270 new instances of cervical cancer were diagnosed in the US in 2009, and 4070 fatalities were attributed to the disease. [2].

Before the age of 35, half of women with cervical cancer receive a diagnosis. [3]. While the incidence is declining in industrialized nations, it is still increasing in emerging nations. [4] In developing nations, almost 80% of cervical cancer cases occur. [5]

The most popular and economical screening technique for cervical cancer detection is the Papanicolaou test, which has also proved successful in lowering the cancer's incidence as well as the rates of morbidity and death among women who have the disease. [6]. The incidence rates of cervical cancer have been reduced considerably with screening programs, which, in combination with HPV vaccination, may offer a promising way to lower the global burden of this disease [7].

Because cervical cancer has a lengthy pre-invasive phase, it can be avoided. [8] The Pap smear test is frequently used to diagnose cervical intraepithelial lesions, which typically show no clinical symptoms. [9] The sensitivity of cytology tests was 51% for detecting precancerous lesions, 47–62% for cervical intraepithelial neoplasia grades 1–2, and 59–60% for specificity. [10] Every year, almost 30% of new instances of cervical cancer are in women who had a Pap test, but the results were misreported as normal because of mistakes in sample, fixation, and interpretation. The resources required to perform the Pap smear as a screening method for cervical abnormalities are sometimes lacking in underdeveloped nations. [9] Due to the high incidence of cervical cancer, different methods have been pursued. Acetic acid Direct Visual Inspection (DVI) has been more popular recently. Patients will save money and time by using the DVI approach, which does not require laboratory facilities and yields results in a single visit. [9], in contrast to alternative methods. It had a sensitivity of 66–96% and a specificity of 64–98%. [11]

The risk of cervical cancer is high among 8.21 million women in Iraq who are 15 years of age or older. According to current estimates, 311 women receive a cervical cancer diagnosis each year, and 212 of them pass away from the disease. In Iraq, cervical cancer is the tenth most common type of cancer and the seventh most common among women aged 15 to 44. The estimated Age Standardized Incidence Rate (ASIR) /100000 women was 2.8. [12] While in Basra, cancer of the uterus and cervix ranked as the fourth female cancer over the period from 2005-2008, ASIR of cervical cancer was 5.4. [13]

Methods

A record-based cross-sectional study involving the records of all women who attended the cervical cancer screening center in Basrah for a year, extending from 1st of January 2013, to 31st of December 2015. An agreement of the Ministry of Health and the Research Committee of the Basrah Health Directorate was obtained before starting the study. The study was carried out in the cervical cancer

Table 1.
		Frequency	Valid Percent
Age (years) ≥ 19		15	2.2
20-29		143	21.2
30-39		244	36.2
> 40		272	40.4
Total		677	100.0

Occupation House wife
Occupation House wife		596	88.7
Employee		71	10.6
Retired		1	0.1
Others		4	0.6
Total		677	100.0
Marital status	Married	625	92.5
	Divorced	17	2.5
	Widowed	33	4.9
	Separated	1	0.1
	Total	676	100.0
Address City center		399	59.0
Al-Zubair Abu-Al-Khasib		150	22.2
Al-Zubair Abu-Al-Khasib		53	7.8
Shat Al-Arab		33	4.9
Al-Qurna		14	2.1
Al-Medainah		5	0.7
Al- Fao		6	0.9
Outside Basrah Center (Thiqar)		13	1.9
Maisan		3	.4
	Total	677	100.0
		677	100.0

screening center at the maternity and children’s hospital in Basrah.

The study population: Records of 677 women attended the center from 1st of January 2013, to 31st of December 2015. Data were collected from the records of all women who attended the cervical cancer screening center. The data include the referred place/ health center, age, occupation, education, socioeconomic status, and marital status of each referred woman.

Age at first marriage, duration of marriage, age at first delivery, sequence among husband’s wives, sequence of the current husband. History of passive smoking and parity. Also, information about pap smear (previous smears result), cervical appearance by inspection. The SPSS software (Statistical Package for Social Sciences, version 20) was used to do statistical analysis on the data. The outcomes were tallied. When the p-value was less than 0.05, the association was deemed significant. The chi-square test was used to determine whether there was any association between the variables.

Results

Table 1: Sociodemographic distribution of the study population

The highest percentage of the attending women were aged 40 and more, more than three quarters of them are housewives, more than half were from the Basrah center, and almost all of them were married.

Table 2. **The results of the pap smear test according to the referred center**
Center of referral	Normal	cin1	cin2-3	scc	Adenocarci- noma	ascus, agsus	inflammation	Total
Cervical cancer screening center	408	101	27	6	1	7	95	645
Cervical cancer screening center	63.3%	15.7%	4.2%	0.9%	0.2%	1.1%	14.7%	100.0 %
Al-Seef	1	7	1	0	0	1	0	10
Al-Seef	10.0%	70.0%	10.0%	0.0%	0.0%	10.0%	0.0%	100.0 %
Al- Gunainah	2	7	0	0	0	0	0	9
Al- Gunainah	22.2%	77.8%	0.0%	0.0%	0.0%	0.0%	0.0%	100.0 %
Al- Nahda	0	12	1	0	0	0	0	13
Al- Nahda	0.0%	92.3%	7.7%	0.0%	0.0%	0.0%	0.0%	100.0 %
Total	411	127	29	6	1	8	95	677
Total	60.7%	18.8%	4.3%	0.9%	0.1%	1.2%	14.0%	100.0 %

P= 0.000

There is a highly significant association between the site of referral and the results of the Pap smear test. The result of the Pap smear among 63.3% of women attending the screening center was normal.

Table 3. **Results of cervical appearance by inspection**
	Number of cases	Percentage (%)
Normal cervix	232	37.5
Bleeding on touch	316	51.1
Polyp	19	3.1
Hypertrophy	67	10.8
More than one abnormality	212	34.3

This table revealed that most women had cervical bleeding on touch, and only about 3.1% had a polyp, 34.4%had more than one abnormal finding by vaginal examination.

Table 4. **The result of cytological examination of cervical smear**
Cytological result	Frequency	Percent
Normal	411	60.7
CIN1	127	18.8
CIN2-3	29	4.3
SCC	6	0.9
Adenocarcinoma	1	0.1
ASC-us, AGS-us	8	1.2
Inflammation	95	14.0
Total	677	100.0

The table above shows that 60.7% of attending women had normal results, 23.1% had CIN, 1% had invasive carcinoma, ASC-US and AGS-US were the results in 1.2%, and inflammation was the finding in 14%. Inspection for cervical appearance was reported for 152 out of 171women with abnormal Pap smear results. The cervix was unhealthy in all of the patients with abnormal Pap smear results; examination showed that any or all of the following characteristics were present: hypertrophy, polyps, and hemorrhage.

Discussion

In this study, 677 women who visited the Basrah cervical cancer screening clinic had their Pap smear test results reported. The target population, or the population to which the study's primary findings will be applied, must be precisely defined for such a study. After that, a large representative sample needs to be chosen from a suitable source of the study population. [14] Women who qualify for the Basrah screening program are the study's target population. Every woman who had visited this center during the previous three years served as the population's exclusive source. The information and the results of the pap smear were obtained from the records prepared for the attending women; all smears were examined by a skilled cytopathologist in one of the labs that the center often uses for the screening program.

Sociodemographic and some other characteristics

In this study, the age of the study population ranged from 16 to 70 years; most of the investigated women (76.6%) were aged more than 30 years. The prevalence of CIN increases with an increase in age; the majority of CIN were diagnosed at age 40 and more (27.6%), which is similar to the results obtained by a study in Basrah, which revealed the risk of cervical intraepithelial neoplasia for women ≥35 years was nearly three times that for women in the age group 15-24. [15] It is also similar to a study in Saudi Arabia in which the most common age for women with CIN was between 40 and 50 years. [16] A study in China showed similar results; women diagnosed with CIN were aged 46–55 years. [17] In England in 2009, overall cervical cancer diagnoses in women aged 25–39 years. [18]

According to the current study, every patient with an abnormal smear who had their cervical appearance inspected had an abnormal appearance. According to a 2011 study conducted in Bangladesh, two-thirds of individuals with abnormal smears had a cervix that looked unhealthy. [16] On the other hand, a study in Saudi Arabia showed that it is well documented that a negative smear can be found in the presence of epithelial cell abnormalities. [19]

In this study, about 60.7% of the smears were normal,18.8 % LSIL, 4.3% HSIL, SCC and adenocarcinoma represented 1%, both ASC-US and AGS-US represent 1.2%, while inflammation was the result for 14% of all women. In contrast to prior studies conducted in Kuwait and the United Arab Emirates, which indicated a prevalence of abnormal smears of 4.3% (Kuwait) and 3.6% (United Arab Emirates), the Pap smear results in this study showed a very high incidence of abnormal smears. [20, 21]

The following prevalence rates of intraepithelial neoplasia were obtained by a study carried out in KSA, the rates were 17.3%, 7.9% and 5% for the western, south-western [22, 23], and eastern region [24] of KSA, respectively. [22, 23, 24]

In China in 2009, the corresponding prevalence rates for cervical cancer, CIN I, II, and III were 50.2, 34.0, 36.4, and 12.2 per 100,000. [25], which are higher than those estimated in the present study. Incidence rate of cervical cancer per year in the United States in 2008 was 6.6 cases per 100000 and varied with age. [26].

Conclusion

Women examined by the pap smear test had a comparatively high frequency of cervical intraepithelial neoplasia. As women became older, the incidence of cervical intraepithelial neoplasia rose. There is a need for future studies, especially with a large sample size and with an observational cohort design.

References

[1] P. J. Eifel, J. S. Berek, and M. A. Markman, “Gynecological Cancer: Cancer of Cervix, Vagina, and Vulva,” in DeVita, Hellman, and Rosenberg’s Cancer: Principles and Practice of Oncology, V. T. DeVita, T. S. Lawrence, and S. A. Rosenberg, Eds., 8th ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2008, ch. 42, pt. 3, sec. 2, pp. 2708–2729.

[2] R. S. Eisenstaedt, “Cervical Cancer,” in Hematology and Oncology, 16th ed. Abington, PA: Abington Memorial Hospital, 2013, p. 78.

[3] M. Vasa and J. E. Rosenberg, “Cervical Cancer,” in First Aid for the Internal Medicine Boards, T. Le, P. V. Chin-Hong, T. E. Baudendistel, and C. J. Lai, Eds., 3rd ed. New York, NY: McGraw-Hill, 2011, ch. 14, p. 577.

[4] G. G. Dark and A. R. Abdul Razak, “Cervical Cancer,” in Davidson’s Principles and Practice of Medicine, N. R. Colledge, B. R. Walker, and S. H. Ralston, Eds., 21st ed. Edinburgh: Churchill Livingstone, 2010, ch. 11, p. 276.

[5] National Cervical Cancer Coalition, “NCCC National Cervical Cancer Coalition,” 2008.

[6] L. Peirson, D. Fitzpatrick-Lewis, D. Ciliska, and R. Warren, “Screening for Cervical Cancer: A Systematic Review and Meta-Analysis,” Syst. Rev., vol. 2, no. 35, pp. 1–14, 2013, doi: 10.1186/2046-4053-2-35.

[7] R. Potter et al., “Gynecological Cancers,” in Oxford Textbook of Oncology, D. J. Kerr, D. G. Haller, C. J. H. van de Velde, and M. Baumann, Eds., 3rd ed. Oxford: Oxford Univ. Press, 2016, ch. 44, sec. 6, p. 576.

[8] J. S. Berek, Berek and Novak’s Gynecology, 15th ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2012, pp. 596–646.

[9] M. Emami-Naeini, Procedure of Pap Smear and Interpretation of Results. Tehran: Shahid Beheshti University of Medical Sciences, 2010.

[10] Z. Eftekhar, P. Rahimi-Moghaddam, F. Yarandi, and R. Brojerdi, “Accuracy of Visual Inspection with Acetic Acid (VIA) for Early Detection of Cervical Dysplasia in Tehran, Iran,” Asian Pac. J. Cancer Prev., vol. 6, pp. 69–71, 2005.

[11] L. Gaffikin, M. Lauterbach, and P. D. Blumenthal, “Performance of Visual Inspection with Acetic Acid for Cervical Cancer Screening: A Qualitative Summary of Evidence to Date,” Obstet. Gynecol. Surv., vol. 58, pp. 543–550, 2003, doi: 10.4103/0300-1652.149168.

[12] WHO/ICO Information Centre on HPV and Cervical Cancer, Human Papillomavirus and Related Cancers in Iraq: Summary Report 2010. Geneva: WHO, 2010.

[13] Basrah Cancer Research Group, Cancer in Basrah: Epidemiological Analysis of Incident Cancer 2005–2008. Basrah: Dar Al-Kutub, 2009.

[14] P. N. Baker and L. C. Kenny, Obstetrics by Ten Teachers, 19th ed. London: Hodder Arnold, 2011.

[15] International Agency for Research on Cancer (IARC), Cancer Epidemiology: Cross-Sectional Surveys, ch. 10, pp. 213–229, 2012.

[16] N. S. Manuel, N. A. Ajeel, and A. F. Al-Assady, “Cervical Intraepithelial Neoplasia Among Screened Women in Basrah,” Iraqi Board Dissertation, 2012.

[17] U. Banik, P. Bhattacharjee, S. U. Ahamad, and Z. Rahman, “Pattern of Epithelial Cell Abnormality in Pap Smear: A Clinicopathological and Demographic Correlation,” Cytojournal, vol. 8, p. 8, 2011, doi: 10.4103/1742-6413.86343.

[18] L. Tao, L. Han, and X. Li, “Prevalence and Risk Factors for Cervical Neoplasia: A Cervical Cancer Screening Program in Beijing,” BMC Public Health, vol. 14, no. 1185, pp. 1–10, 2014, doi: 10.1186/1471-2458-14-1185.

[19] V. Castanon, M. W. Leun, R. Landy, A. W. Lim, and P. Sasieni, “Characteristics and Screening History of Women Diagnosed with Cervical Cancer Aged 20–29 Years,” Br. J. Cancer, vol. 109, pp. 35–41, 2013, doi: 10.1038/bjc.2013.322.

[20] H. M. Al-Kadri, A. H. Hajeer, N. S. Al-Hawashim, and H. H. Salem, “The Significance of Documenting Clinical Appearance of the Uterine Cervix in the Cervical Cytology Form,” Saudi Med. J., vol. 27, pp. 447–451, 2006.

[21] K. Kapila et al., “Changing Spectrum of Squamous Cell Abnormalities Observed on Papanicolaou Smears in Mubarak Al-Kabeer Hospital, Kuwait, Over a 13-Year Period,” Med. Princ. Pract., vol. 15, pp. 253–259, 2006.

[22] S. Ghazal-Aswad et al., “Cervical Smear Abnormalities in the United Arab Emirates: A Pilot Study in the Arabian Gulf,” Acta Cytol., vol. 50, pp. 41–47, 2006.

[23] H. A. Elhakeem, A. S. Al-Ghamdi, and J. A. Al-Maghrabi, “Cytopathological Pattern of Cervical Pap Smear According to the Bethesda System in Southwestern Saudi Arabia,” Saudi Med. J., vol. 26, pp. 588–592, 2005.

[24] F. J. Altaf and S. T. Mufti, “Pattern of Cervical Smear Abnormalities Using the Revised Bethesda System in a Tertiary Care Hospital in Western Saudi Arabia,” J. Cytol., vol. 28, p. 173, 2011.

[25] M. H. Balaha, M. S. Al Moghannum, N. Al Ghowinem, and S. Al Omran, “Cytological Pattern of Cervical Papanicolaou Smear in Eastern Region of Saudi Arabia,” J. Cytol., vol. 28, no. 4, pp. 173–177, 2011.

[26] W. Xiang, F. H. Zhao, J. F. Shi, Z. X. Li, J. F. Ma, Y. L. Qiao, and Y. Wang, “Feasibility of Packaging Screening for Cervical Cancer, Breast Cancer, and Reproductive Tract Infection in a Rural Area in China,” Zhongguo Yi Xue Ke Xue Yuan Xue Bao, vol. 31, no. 5, pp. 616–619, 2009.

Universitas Muhammadiyah Sidoarjo

Academia Open

Section Clinical Research