Dr. Priya Ganeshkumar, Medical Director at Sainivas Healthcare and FOGSI's oncology committee chair, walks through three real cases that expose how easily cervical precancer hides, and how routine screening habits decide the outcome.
Case 1 - Spotting That Masked Stage IIIC Disease (00:06:29 - 00:09:56)
A 43-year-old presented with one month of intermittent spotting per vagina, regular cycles, and two prior full-term deliveries. An outside Pap had read as inflammatory, and she moved between clinics until a referring gynecologist found an eroded, unhealthy cervix on speculum exam. Colposcopy was technically inadequate from bleeding and scarring but showed dense acetowhite areas and abnormal vessels; biopsy confirmed invasive, large-cell non-keratinizing squamous cell carcinoma, HPV-16 positive. Imaging showed bilateral internal iliac nodal involvement and parametrial extension - stage IIIC - despite the patient feeling entirely well throughout. "This case could have easily been prevented had her HPV test been done systematically," the speaker noted: routine HPV screening from age 30, every five years, would likely have caught this a decade earlier, at a fully treatable precancerous stage.
Case 2 - When Biopsy and Colposcopy Disagree (00:09:56 - 00:13:55)
Persistent white discharge - a near-daily OPD complaint - brought in a patient referred with HPV-66 positivity from an unvalidated platform. A validated assay confirmed multiple high-risk strains; colposcopy showed an extending acetowhite lesion, Lugol's positive, Swede score 7 - but the punch biopsy showed only chronic cervicitis, and p16 IHC was negative. Trusting the colposcopy over the reassuring biopsy, the speaker proceeded to LEEP; final histology confirmed CIN3 with clear margins. Follow-up was set at six-monthly co-testing, then annual HPV testing to ten years and three-yearly beyond, since lesions can reappear even eight to ten years later.
Case 3 - The NILM Pap That Missed Adenocarcinoma (00:13:55–00:16:21)
A 42-year-old with post-coital bleeding and white discharge had a NILM Pap and was repeatedly advised to return in six months. When symptoms persisted, she sought another opinion: HPV came back 16-positive, and colposcopy showed a dense acetowhite area with rough surface, raised margins, inner border sign, and mosaic staining - Swede score 10. Biopsy confirmed well-differentiated adenocarcinoma. Pap carries roughly 40% false negatives, particularly for adenocarcinoma; the speaker's rule is firm - post-coital bleeding warrants colposcopy and HPV testing regardless of Pap result.
Across all three, the pattern repeats: cervical precancer is symptomless until it isn't, and by the time it speaks, years of a treatable window are gone. As the speaker puts it, the colposcope deserves to be treated as the gynecologist's stethoscope - routine, not reserved for when something already looks wrong.