## Cervical Cancer Screening — Investigation of Choice **Key Point:** Pap smear (conventional cytology) remains the gold standard and most appropriate initial screening test for cervical cancer in resource-limited settings and community screening programs in India. ### Why Pap Smear is the Answer **High-Yield:** Pap smear has the following advantages: - Cost-effective and widely available in India - Sensitivity ~80–90% for detecting precancerous lesions (CIN 2/3) - Specificity ~95% - Established infrastructure and trained personnel across India - Recommended by WHO and Indian guidelines (NACO, ICMR) as the primary screening modality ### Screening Algorithm for Cervical Cancer ```mermaid flowchart TD A[Asymptomatic woman age 21-65]:::outcome --> B[Pap smear screening]:::action B --> C{Cytology result}:::decision C -->|Normal| D[Repeat in 3 years]:::action C -->|ASCUS/LSIL| E[HPV reflex testing]:::action C -->|HSIL/SCC| F[Colposcopy + biopsy]:::action E --> G{HPV positive?}:::decision G -->|Yes| F G -->|No| D F --> H[Histology-guided management]:::outcome ``` ### Comparison of Screening Modalities | Investigation | Sensitivity | Specificity | Cost | Setting | Role | |---|---|---|---|---|---| | **Pap smear** | 80–90% | 95% | Low | Community/outpatient | **Initial screening** | | HPV DNA testing | 95–98% | 90% | High | Triage of ASCUS; primary screening (high-income) | Reflex test or adjunctive | | Liquid-based cytology | 85–95% | 95% | Moderate | Reduces air-drying artifact | Alternative to conventional Pap | | Colposcopy + biopsy | 95%+ | 98% | High | Hospital-based | **Diagnostic/confirmatory** | **Clinical Pearl:** In the Indian context, Pap smear screening every 3 years for women aged 21–65 years reduces cervical cancer mortality by ~80%. **Warning:** Colposcopy and biopsy are diagnostic, not screening tests — they are reserved for abnormal cytology findings, not initial population screening. [cite:Park 26e Ch 7]
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