This is the story of an expedition performed recently by three medical doctors including me, two anatomic pathologists and one general surgeon, supported by a young medical student, all from Milan, Italy, and volounteers of the Change onlus humanitarian organization, to the islands of Nosy Be and Sakatia in the northwestern part of Madagascar.
The aim of the mission was to test the incidence of pap-smear cytological abnormalities in a restricted female population which had never been screened before for cervical cancer and is at a presumed high risk of developing this malignancy.
We brought from Milan all the stuff which is required to collect, smear, and stain cytological samples including a light microscope for immediate on site interpretation. Our goal was to work together with a team approach trying to conclude the procedure of screening, including the release of all cytological reports, on a same-day basis.
Fig 1
Women had been invited in advance to be present for a clinical evaluation and pap smear sample collection in the days of September 14th, and 15th, 2010, at the Dispensaire of Sakatia (Fig 1), a first level health facility recently built up by Change onlus organization in that small island at just a 20 minutes boat ride from Nosy Be, and on September 16th, at the Infirmary facility of the Pecherie factory in Nosy Be island (see Fig. 2).
Fig 2
Fifty two women were seen in Sakatia and 42 women in the Pecherie Infirmary. The age ranged between16 to 57. Most of them were multiparous. After filling a questionnaire and providing her precise patient demographics, each woman had pelvic examination and pap smear sampling done. Smears were stained manually within two hours according to the Papanicolaou method (Figs 3 and 4).
Fig 3
Fig 4
Fig 5
Smears were then rapidly interpreted on site; the pathological report was generated according to the terminology of the 2001 edition of Bethesda System, using a portable personal computer.
Women’s attitude to the gynecological examination was very good and they reacted enthusiastically to our initiative. Fig 6 shows a group of them chatting outside the Sakatia Dispensaire and waiting for their turn.
Fig 6
Results
| Diagnosis (Bethesda) | Pecherie | Sakatia | Further work-up |
| HSIL | 1 | 1 | Colp+bp |
| AGC-neo | 1 | 1 | Colp+bp |
| LSIL | 2 | 2 | Colp+bp |
| ASCUS-HPV | 1 | 3 | Colp+ bp+ HPV test |
| ASCUS |
| 1 | P-smear repeat |
Legend to the figure: colp = colposcopy; bp = biopsy; P= pap.
HSILs were detected in two women aged respectively 27 and 37, while the women diagnosed as having AGC-neo lesions were 43 and 47 years’ old. The incidence of High grade (HSIL and AGC-neo) and Low grade (LSIL, ASCUS-HPV, and ASCUS) lesions cumulatively reached values which are rather high according to WHO’s estimates (see “Comprehensive Cervical Cancer Control. A guide to essential practice”, p. 40, World Health Organization, 2006) for previously unscreened population (see the following table)
| SIL | Pecherie | Sakatia | WHO |
| High Grade | 2 (4,76%) | 2 (3,84%) | 1-5% |
| Low Grade | 3 (6,97%) | 5 (9,61%) | 3-10% |
The 11 women who are candidates to further examination will be examined in November 2010 by a Gynecologist and colposcopist and the results of further tests, including biopsy and viral molecular tests, will be immediately reported on this blog.
Conclusion
Although the number of cases described in this report is fairly small, it is quite evident that women in Madagascar urgently need to be screened for uterine cervical cancer. Our effort will continue and we strongly hope that, under our guide and supervision, in few years the whole female population of the Nosy Be Island will be screened on the basis of a well organized plan and under the support of local Health authorities. We are deeply convinced that before starting to educate local health personnel and medical Doctors to the need of a well planned screening programme, and before teaching them to do theirselves, it is important to work hard locally as actively as possible to show the real advantages of it. In other words we still need to persuade them to the necessity of performing such screening procedure before trying to teach them how to do it. Our operative approach, consisting of a multidisciplinary team of physicians who intensively concentrated their efforts in few days, seems to be the best way to obtain such a result. In future expeditions also a Gynecologist will take part of the team with significant advantages in terms of speed of diagnosis and treatment. Doing first is, at least in this setting, much better than teaching first.
The Team. From left to right: Stefania Rossi, MD and MIAC, Anatomic Pathologist, San Paolo University Hospital, Milano; Sofia Bronzato, intern Medical Student at the San Raffaele University Hospital, Milano; Adolf, the local Nurse on duty of the Dispensaire of Sakatia; Franco Silva MD, General Surgeon and Interventional Radiologist, Fatebenefratelli Hospital, Milano; Liza, Translator and patient herself; Giorgio Gherardi, MD, Anatomic Pathologist and Head of Pathology, Fatebenefratelli Hospital, Milano, Italy. Photographs by Andrea Gherardi: website and blog
