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Indian Journal of Cancer
Medknow Publications on behalf of Indian Cancer Society
ISSN: 0019-509X EISSN: 1998-4774
Vol. 40, Num. 1, 2003, pp. 15-22
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Indian Journal of Cancer, Vol. 40, No. 1, (January - March 2003) , pp.
15-22
Review Article
A Survey on Risk Factors Associated
with Cervical Cancer
Juneja A, Sehgal
A,* Mitra AB,* Pandey A
Institute for Research in Medical Statistics (ICMR), Ansari Nagar, New Delhi
- 110029, India; and *Institute of Cytology and Preventive Oncology (ICMR), Maulana
Azad Medical College, BSZ
Marg, New Delhi - 110002, India.
Correspondence to: Atul Juneja. E-mail: atul_juneja@hotmail.com
Code Number: cn03002
ABSTRACT
Carcinoma of the cervix is one of the leading malignancies in the developing
countries including India. In view of this health care program might have to
be redefined. Most of the data are available from the developed countries,
which rely mainly on cytology screening on regular basis. This however may
not be feasible in developing countries because of various constraints. Thus
alternative approaches are needed based on risk reduction modalities. This
article while dealing with the control approaches based on secondary prevention,
reviews several risk factors associated with cervical cancer. The various articles
were approached through Medline search including cross-references. The important
life styles associated with cervical cancer and which are amenable to primary
prevention strategies through health education, behavioral interventions, legislative
approaches and modifying the health care seeking behavior were identified through
the review process. These factors mainly pertain to early sexual debut, multiple
sexual partners, menstrual hygiene and unprotected sex. Role of male partners
has also been delineated in the process of cervical carcinogenesis. These factors
are essentially conducive to the transmission of an etiological agent; the
high-risk types human papillomaviruses, the more proximal cause in the web
of causation. Barrier method of contraception and prophylactic vaccine in future
could help to check the transmission of the virus. Role of smoking and oral
contraceptives has also been discussed. Till the facilities for mass scale
screening are developed in developing countries the primary prevention approaches
could certainly help to check the incidence of the disease.
Key Words: Cervical cancer, Cervical neoplasia, Cytology
screening, Primary prevention.
Introduction
There has been a tremendous change in the demographic profile
of the country. The birth and death rates have declined and the life expectancy
of birth has also increased to 62 years as a result of betterment in health
services. The increase in the expectation of life has brought about the change
in the disease pattern of the population. In the midst of already existing
communicable diseases, non-communicable disease like cancer has become a major
cause of morbidity. Realizing the threat of cancer in a developing country
like India, cancer control activities got due attention. Realizing the
importance of this disease, Indian Council of Medical Research (ICMR) initiated
a network of cancer registries under National Cancer Registry Programme (NCRP)
in December 1991 to establish the database of magnitude of problem of cancer
in different parts of the country. This move also recognized the need to augment
and strengthen the existing registries. In the process, Bombay Cancer Registry
under Indian Cancer Society, which has been providing data on cancer incidence
since 1963 also became part of National Cancer Registry Programme. The population
based cancer registries in India are working on active system of registration.
These
are based at Bangalore, Bhopal, Chennai, Delhi, Mumbai
and rural registry at Barshi Maharashtra.These registries which
represent different parts of the country are providing incidence and mortality
data on cancer according to different factors. In addition there are hospital
based cancer registries at Chandigarh, Dibrugarh and Trivandrum, which provide
information mainly on relative frequencies of various cancers to help the planners
to prioritize the control measures. The quality control for data collection
and validation procedures is based on the international standards. The Indian
data as available from NCRP is represented in the Cancer Incidence in five
Continents published by International Agency for research in Cancer.1 As
per the information generated through this programme, the cancer of the uterine
cervix and the breast are the leading malignancies seen in Indian women where
as tobacco related cancers are dominating in males.2 In view of
the natural history of the cancer of the uterine cervix and availability of
effective screening technique tool-PAP Test, the cancer of the uterine cervix
gets priority in terms of control activities.
Squamous cell carcinomas usually arise from the squamocolumnar
junction of the cervix and preceded by precancerous stages CIN I, CIN II and
CIN III, (Cervical intra epithelial neoplasia) When abnormal cells occupy lower
one third of the epithelium, the cytological reporting is termed as CIN I where
as it falls in the category of CIN II when half of the total thickness is occupied
by abnormal cells. When neoplastic cells replace the entire thickness of epithelium
except the basement membrane, the stage is cytologically reported as CIN III
(Severe Dysplasia and CIS). Invasive carcinomas occur when malignant epithelial
cells break through the basement membrane and invader the stroma, continued
growth results in visible lesions that involve more of tissues.3,4 The
disease in stage CIN III and micro invasion can be easily diagnosed by exfoliative
cytology and colposcopy. A leading study from Canada revealed that the disease
in the in situ stage (CIN III), on an average takes about 10-12 years to enter
in the invasive stage i.e. the time gap between detectable pre clinical phase
and the clinical phase is quite long so that it provides enough opportunity
to administer management when complete cure is possible.5 Hence
it is justified to keep the cervical cancer as one of the priority areas for
cancer control activities.
In view of the natural history of the disease, cervical cytology
screening continues to be the main stay for the control of cervical cancer.
The treatment of disease in its pre clinical phase will result in higher cure
rate than if a disease is permitted to progress to a higher grade.
Exfoliative cytology in spite of certain limitations, is an
efficient method to detect the disease in pre invasive stage. Various studies
have demonstrated
reduction in morbidity and mortality from the disease.6 The situation
in developing country is entirely different. There is no organized screening
activity because of lack of resources including trained manpower. It has
been accepted that there are primary health care deficiencies, as a result
there
cannot be referral system networking for cervical cancer screening for years
to come. Even when the disease is detected in preinvasive stage there is
no system to recall the patient for further investigation and treatment.
The facilities
for treating the precursors are also limited. In a country like India, the
screening is only institution based and caters to a limited group. Hence
there is there is need to look at the alternate strategies for mass screening.
In view of the logistic difficulties of cytological screening,
alternate strategies have been advocated for developing countries. One of
the strategies is based on the down staging of the disease by visual inspection
of cervix.7,8 It has also been demonstrated that paramedical health
workers could be trained to pick abnormal cervix.9,10 Visual inspection
of cervix by application of acidic acid (VIA) is another approach for cervical
cancer screening, where in addition to detecting early stage cancer, even
pre cancerous lesions can also be picked up. This technique helps to identify
changes
in the transformation zone. It has been demonstrated in Indian settings and
has yielded encouraging results. The high false positivity is matter of concern
with this approach.7,11
The focus of screening is now shifting towards HPV testing
in screening programs. Recent studies have reported HPV testing to be highly
sensitive for detecting high-grade lesions.12 An effort has been
made to study the HPV screening in Indian rural settings, the results confirm
to the studies conducted in West.13 It has to be mentioned that
the HPV testing in conjunction with Pap smear would again be non-economical
affair for a setting with limited resources. However the strategy could be
employed for institutional based screening. There is also need to consider
inducting primary prevention module into the control programme. Considering
the above mentioned facts it becomes very important to review the various studies
that evaluated the risk factors associated with cervical cancer in different
parts of the world and the scenario in the Indian context. This would help
to formulate the strategies for the control of cervical cancer in India and
other developing countries.
The present paper aims to review various studies of risk
factors associated with the development of cervical cancer or
carcinoma in situ (CIN III) in the developed and developing countries including
India. An exhaustive search through Medline was carried out to reach at the
various articles (published in English) related with various issues of screening
and risk factors of cervical cancer. The articles were further cross-referred
based on the Medline search. This included the classical papers, which formed
the basis of the research on cervical cancer. Different relevant reports were
procured from the libraries.
The studies on risk factors of cervical cancer were available
since early seventies.14,15 Most of the studies recruited invasive
cancers reporting to cancer clinics. No information was available for early
cancerous or pre cancerous lesions (CIN I-III). The Institute of Cytology and
Preventive Oncology (ICMR) New Delhi launched the first study, involving pre
cancerous and early cancerous lesions in 1976. The study was first of its kind
in India since it had recruited the subjects based on the cytology screening
program carried out through the gynecology departments of major hospitals of
the Delhi. The study examined the biological behaviour of precancerous lesions
and the effect of certain sociodemographic and biological factors on progression
of dysplasia to higher grades.16,17 The study was under the strict
supervision of the scientific advisory committee. Various modifications were
incorporated in the study based on the recommendations of the committee from
time to time. The study was carried out in different phases and segments. In
one of the segments, women revealing severe dysplasia and malignancy and further
confirmed on biopsy were considered for case control comparison (WHO Classification
was used for cytological diagnosis). Indepth information on various socidemographic
factors, sexual behaviour, obstetric, menstrual and hygienic practices was
elicited by the trained field worker on cases as well as controls to carry
out the risk factor analysis. Women revealing normal or inflammation in cytology
during twice in a month were recruited as controls. The results of the study
have already been published.18,19 The results have been discussed
along with other Indian studies in relation to the studies carried out in the
developed world.
Sociodemographic factors
Data from the cancer registries indicate that more than 75%
of cervical cancers develop in women above the age of 35 years.20 Most
of the studies in developing countries indicate that average age of women with
CIS or CIN III was between 35 to 44 years. The age
parameter defines a `high risk' group relevant for
the screening activities and providing health care
facilities. It has been observed that that incidence of cervical
cancer varies widely according to the geographic
distribution. The highest rates have been reported from
Latin America and low rates are observed in US whites
and Jewish women in Israel. It has also been reported
that women belonging to the lower social class are at
much higher risk of development of cervical cancer. A
recent study analyzed 127 low and medium developed countries where the rates
varied from 3 to 61 per 100,000 females, identified geographical area
and religion as the independent factors associated with
the cervical cancer rates.21 The rates due to racial differences are
also considered; the magnitude of the risk in black diminished when adjusted
for socio economic
status.22 Various studies have tried to analyze the variables associated
with low socio economic status (education, income etc.) with the other life style
practiced by them such as sexual and hygienic practices. In most of the studies
low socio economic status has been observed
to be the confounding factor.23
Sexual behavior
Domenico Rigoni-Stern in the middle of 19th century, who was
an Italian Chief Physician of Verona Hospital and an instructor at University
of Padua, first raised the issue of relationship of cervical cancer and marriage.
He had observed for the first time that more uterine cervical cancer is found
in married than unmarried based on mortality records. The relationship of cervical
cancer with sexual behavior is supported by the fact that disease is rare in
nuns.24,25 The first review of literature on the risk factors associated
with sexual behavior was published in 1967, which reviewed nine studies.26
According to Martin the epidemiology of cervical neoplasm
is based on three fundamentals, which are
(i) near absence of neoplasms among nuns (ii) Near absence
of neoplasms among other species other than humans, (iii) Extremely low incidence
of disease among virgins. The main factors explored were early age at marriage,
marital dissolution and remarriage. Rotkin also presented a review of different
studies related with sexual behaviour in the process of cervical carcinogenesis.27 In
all the studies the percentage of women having married before 20 years was
significantly higher than controls. The studies clearly demonstrated that early
coitus, marital dissolution and remarriage occur more frequently in cases than
controls. Studies conducted in 1990s have highlighted early age at consummation
of marriage as an important risk factor after adjusting for confounding variables.28-30 Attempts
have also been made to study the risk patterns in
cancer cervix in Indian situation. The first major study
was carried out from 1960-63 in Agra.14 The study suggested that risk
of development of cervical cancer increased with the onset of sexual activity.
The results revealed that average age of women was 13.6 years for cases of cancer
cervix where as it was 15.6 years for the control group. Jayant has also shown
through the age cohort analysis that incidence of cervical cancer shows a decline
if the age of marriage
increases.31 In depth studies were carried out in the city of Bombay
to identify role of sexual risk
factors.15 It was observed that risk factors associated were of the
same order as prevailing in the developed countries. Recent Indian studies also
have also been made to study the risk patterns in cancer cervix in Indian situation.
The first major study
was carried out from 1960-63 in Agra.14 The study suggested that risk
of development of cervical cancer increased with the onset of sexual activity.
The results revealed that average age of women was 13.6 years for cases of cancer
cervix where as it was 15.6 years for the control group. Jayant has also shown
through the age cohort analysis that incidence of cervical cancer shows a decline
if the age of marriage
increases.31 In depth studies were carried out in the city of Bombay
to identify role of sexual risk
factors.15 It was observed that risk factors associated were of the
same order as prevailing in the developed countries. Recent Indian studies also
highlighted sexual behavior as an important contributing factor in the process
of
cervical carcinogenesis.32,33
Multiple sexual partners have also been the focus of attention
of researchers as regards cervical cancer is concerned. The odds ratios ranged
from 1.6-2.9 for the different studies reviewed by Rotkin. Based on the lead
provided by the earlier studies, the research on sexual behavior continued
in 1980's with focus on multiple contacts and Human Papillomavirus. The risk
associated with 10 or more partners has been reported to be nearly three to
four times higher than associated with one partner. The population attributable
risk that can be associated to having two or more partners is approximately
36%.34,35 It has also been hypothesized that age at first coitus
and number of sexual partners may be correlated hence attempts have also been
to study their independent effect. Some of the studies have found independent
effect of early age at marriage and multiple sexual partners.34-36 The
risk of development of cervical cancer is elevated by 2 to 4 times if a women
reports having more than one contact.26,37-39 The study by Brinton
et al (1987) has a special significance because it included five geographical
areas reporting to comprehensive cancer patient data system. To ensure proper
representation of the population into sample, different racial groups were
also included.
Attempts have also been made to study the role of multiple
sexual partners in Indian situation by providing specialized training to the
interviewers.40 Indian study conducted by ICPO (ICMR) highlighted
extramarital relations (more than one partner) as significant variable in the
development of high-grade lesion (sev dysplasia and above). (Ph.D. Thesis by
A. Juneja, MD University Rohtak 1998-unpublished). It is important to mention
that Indian studies did not include Human Papillomavirus in the analysis because
of the lack of availability of the data on substantial number of cases
for subjecting to indepth multi variate
analysis. A limited analysis has revealed that the magnitude of
odds ratios associated with sexual promiscuity and age
of onset of sexual activity diminished when adjusted
with status of HPV 16/18.41 Male behaviour
The risk of cervical cancer is influenced not only by woman's
sexual behaviour but also by male behaviour. This hypothesis is based on the
observations that there have been clusters of cervical and penile cancers and
husbands of cervical cancer patients reported significantly more sexual partners.42 Poor
penile hygiene of male partners has also been hypothesized as a risk factor
for cervical cancer. The role of male behaviour in the genesis of cervical
cancer was also examined in India. It was observed that risk of cervical cancer
was about three times higher in women whose husbands reported sexual contacts
with more than one woman during their lives other than wife. The results were
adjusted for possible confounding factors.43 Hence the control strategies
should also focus on male partners.
Menstrual/Reproductive/Hygienic factors
Attempts have also been made to study the relationship of
cervical cancer with the age at menarche or menopause but it did not result
in any statistical significance.27,30,34,44 The study carried out
by ICMR also did not get any significance with the age of menarche.19 The
type of material used is one of the important components associated with menstrual
practice and has a direct concern with menstrual hygiene. Some of the studies
carried out in west did not reveal any association between type of material
and cervical neoplasia.45,46 The Indian study revealed that risk
associated with the use of unclean cloth was 2.5 fold higher for the development
of CIN III and malignancy as compared to the use of clean cloth or use of sanitary
napkins. The factor remained statistically significant even after adjustment
with other factors such as age, age at marriage, promiscuity and education,
thus highlighting the importance of menstrual hygiene. It was observed that
if any of the deliveries were conducted by untrained personnel (untrained dai)
the women were at significantly higher risk of development of severe dysplasia
and malignancy (CIN III) further emphasizing the role of hygiene. Women who
abstained for less than forty days after delivery were also at elevated risk
of development of disease highlighting the importance of this social practice.
The odds ratios were adjusted for other obstetric practices, age at Ist pregnancy,
education etc18,47 A very recent study in Mali also highlighted
the
use of home made napkins as a statistically
significant risk factor in the development of cervical cancer. It
is important to mention that poor hygiene was
observed to be a co factor for cervical cancer with prevalent
HPV infection.48 A report from WHO also suggests genital hygiene to
be an important component associated
with cervical neoplasia.49 These factors may not be of relevance in
the developed countries. Abstinence from sex during periods as a factor in the
process of cervical carcinogenesis has not been studied in the reports from the
developed countries. Indian study also did not reveal any important finding for
this
variable.19
The role of multi parity has also been explored in the development
of cervical cancer. It was hypothesized that multi parity could be one of the
confounding variables. This variable is highly correlated with other marital
factors. However some of the recent studies have revealed multiparty to be
an independent risk factor.28,29,50
Frequency of sexual contact
The role of frequency of sexual contact on the risk of development
of cervical is a difficult area of research, yet efforts have been in this
direction to explore this sensitive variable. Earlier studies carried out did
not reveal any statistical significance of enhanced frequency of sexual intercourse.26,27,44 The
research on this aspect still continued because of hypothesis of association
of sexual behavior with cervical cancer. The study by Herrero et al (1990)
stated that frequency of coitus was a significant factor only for women reporting
multiple exposures before 20 years supporting the hypothesis of vulnerable
cervix. An attempt was also made to study this sensitive parameter in Indian
situation. The frequency of contact did not emerge as a significant variable
through a multiple logistic model after adjusting for possible confounders
such as age, age at consummation of marriage, extramarital affairs.19 The
recent studies are not evaluating this parameter possibly for the reasons mentioned
above.
Family planning practices
Several investigations have studied the effect of different
contraceptives practices on the risk of cervical cancer. One of the most common
practices adopted for family planning is the use of oral contraceptives particularly
in West. Recent investigations have raised concern for the long term users.
Majority of the studies have revealed high risk of cervical neoplasia with
increasing use of pill.45 Recent studies are focused on interactive
effect oral contraceptive and HPV infection.29,51 Barrier method
of contraception has been recommended as the
preventive measure for cervical cancer possibly
because it offers against some of the STDs. Very
limited information was available from Indian studies on
the role of contraceptive methods in the development
of cervical cancer. In one of the studies the cases
reporting OC use were too little for subjecting them to
statistical analysis. However protective effect was reported
in relation to the use of barrier method of
contraception and (Ph.D. Thesis by A. Juneja, MD University
Rohtak 1998-unpublished).
Smoking
Tobacco use has also been considered as an important candidate
responsible in the process of cervical carcinogenesis. Winkelstein was the
first person to set up the hypothesis that cigarette smoking could be one of
the candidates responsible in the process of cervical carcinogenesis. His hypothesis
was prompted by the high correlation in the geographic distribution of cancer
of the cervix and the cancer of the lung in the third national cancer survey.52,53 Cigarette
associated tumors are predominantly squamous cell tumors like lung or esophagus.
It was hypothesized that smoking effect is most manifested by squamous cell
oncogenic response. Hence cancer of the cervix could possibly be associated
with cigarette smoking. An exhaustive review of the literature, examining the
relationship of smoking with cervical neoplasia, revealed positive association
between the factor and the disease. Most of the studies reported dose response
relationship further supporting the theory.54 It was observed that
studies which did not reveal positive association had some bias in the selection
of the controls. One of the studies tried to explore the effect of smoking
cessation on the lesion size.55 The study revealed that women who
had completely stopped smoking showed a reduction in size of lesion by at least
20% revealing a high degree of statistical significance. A recent study from
Sweden observed smoking to be an important risk indicator. Most of the variables
had lost significance after adjusting the role of human papillomavirus but
the odds ratios associated with smoking retained their statistical significance.51
The Indian study conducted by ICMR revealed a high degree
of statistical significance with role of smoking for the development of severe
dysplasia and malignancy even after adjusting with sociodemographic factors
and variables associated with sexual behavior. In this study the comparison
was made between ever smoker and non-smoker. There were only 20% of the women
who had reported history of smoking as compared to 4% in controls. Role of
smoking in husbands was also evaluated for risk of development of cervical
cancer. It
was observed that an elevated risk of CIN III and
was reported for the women whose husbands were
smokers. However the risk diminished when adjusted for
other confounding factors. As per the results available
till date, the tobacco habit including passive smoking
could be considered as an important variable for
primary prevention.18,19
Dietary factors
Diet has also been under consideration of this important research.
Vitamin C and Beta-carotene have been considered as the protective agents against
cervical cancer.46 Various studies have been carried out in developed
countries on dietary pattern based on diet recall and level of micronutrients
in the blood. Study from China had indicated that intake of green vegetables
had protective role for cancer cervix.56 A study by Ziegler had
expressed a weak relation between the risk of both cervical cancer and in situ
disease and intake of carotenoids, vitamin C, folate, fruits and vegetables.
Vitamin A was not found to be statistically protective factor.57 Not
much information is available from the developing countries including India.
There is a need to take up the research on this important aspect for considering
this important component of diet for primary prevention strategy.
Viral etiology
The association of cervical neoplasia and the sexual risk
factors has inspired the research for a search of venereal agent. The attention
was initially focused on Herpes Simplex Virus type II (HSV II). The relationship
of HSV II with the risk of cervical cancer was of immense interest in 1960s.
The interest in the oncogenic potential of HSV II was reduced when HSV II DNA
protein were not detected consistently in tumors. The Indian study at also
failed to establish any direct relationship between HSV II and cervical neoplasia.58 The
recent investigations focus on possible role of Human Papilloma Virus. Various
types of HPV infect the cervix producing flat condyloma (genital warts) or
koilocytoic atpia, which resembles mild or moderate dysplasia. Presently around
100 HPV geno types have been identified and one third have been sequenced.
HPV types 16 and 18 are considered to be high risk type and HPV 6 and 11 are
low risk types. The role of HPV in the process of carcinogenesis is further
established by the presence of infections in the cancers of oral cavity esophagus
and larynx. The oncogenic potential of the virus is attributed to its E6 and
E7 genes. The detailed review has been published else where.59 It
has been possible to demonstrate structural
HPV antigen in all grades of dysplasia and
carcinoma in situ, including invasive carcinoma.
The evidence for causal role of HPV in the development of
cervical neoplasia comes from observational and epidemiological studies. The
epidemiological data strongly support that HPV infection is primary risk factor,
playing a significant role in development of in development of cervical neoplasia.
The past or present infection may be an indicator for sexual promiscuity and
would act as a surrogate variable. Majority of the studies have revealed that
HPV infection of type 16 and 18 is emerging as a primary risk factor for cervical
cancer even after adjusting for other confounding factors.60 Recent
studies have indicated that high parity becomes a risk factor in the development
of CIN III or invasive lesions in the presence of HPV. Among HPV +ve women,
dose response relationship were observed for education and age at onset of
sexual activity and among HPV _ve women, number of partners and parity were
associated with cervical cancer.61 There is a need to generate data
on HPV collating it with the other factors in developing countries. Controlling
Genital infections is another area, which could lead to prevention of this
deadly disease. Studies have generated information on this aspect.62
It is well known that immune system of the body controls the
viral infections by neutralizing the virus with antibodies or killing the virus.
The recent studies are indicative of important role of immune system in controlling
HPV infections. The recent attempt to control HPV induced diseases are targeted
to develop preventive immunotherapies and HPV vaccines to prevent infections
with high risk genotype.63
Methodological issues
The present exercise attempted to review the work related
with the development of cervical neoplasia specifically high-grade lesions
(CIN III and invasive cancer). The studies reviewed here had to elicit the
information on various sensitive parameters, which might have been a difficult
exercise, the quality and the extent of information might be different in the
studies leading to the difference in the results. Most of the studies reviewed
were of case control approach. The `case control' methodology is most suited
for evaluation of risk factors for cancer, as it is a rare disease. The cohort
approach might not yield substantial number of cases for the analysis for a
defined time period. However some of the studies have adopted nested case control
approach from the cohort generated. There is a special advantage of these studies
as it includes only
incident cases and possibility of recall bias in eliciting
of information is minimum.
All the studies under consideration had applied unconditional
logistic regression analysis to study the effect of potential confounding variables
to elicit the effect of independent risk factors in the process of cervical
carcinogenesis. For the very obvious reason classical method of analysis was
just not possible because of low sample size in stratum. None of the studies
had applied conditional logistic regression since it was difficult to recruit
the subjects in matched pairs. It might be quiet difficult to consider matching
factors because the disease is of multifactorial etiology. It may also not
be possible to study the control for the same investigations. Incomplete information
in any of the parameters may render the matched set useless for the analysis.
These are some of the issues, which make the matched analysis difficult. Most
of the studies had considered age matching (for unconditional logistic regression
analysis) although it being an important determinant of the disease, the interest
was focused on other risk factors.
Control strategies
Control of cancer of uterine cervix forms a major thrust area
of National Cancer Control Programme through secondary prevention approach.64 As
discussed earlier, there is severe constraints concerning organized mass scale
screening in India, hence the alternatives need to be worked out. It may be
mentioned that before the advent of wide scale application of cytology screening
in West, before 1960s, much of the mortality from cervical cancer could be
brought down through health education of masses, training of professionals
and changing the health care seeking behaviour of women.65 These
issues are in active focus again in view of the circumstances. There is a definite
possibility of carrying out primary prevention approach by modifying life style.
Various factors have been discussed which are directly or indirectly associated
with the development of cervical cancer. It is possible to modify variables
associated with life style through health education, which could help to bring
down the incidence of cervical cancer. These include increase in age of marriage
through health education and strictly enforcing the legislation. Health education
campaign against smoking habits should also target cervical cancer including
passive smoking. There is a need to strengthen the Maternal and Child Health
Services. This would help in taking care of pelvic infections and nutritional
status during anti natal period. It would also encourage deliveries conducted
through trained personnel, thus providing better hygiene and facilities. There
is also a
need to rope in male partners in the programme
for health education on sexual promiscuity and
smoking. Facilities need to be developed for screening and
treating the husbands for any genital infections so as to
prevent transmission. Women revealing cervical erosion
or cervicitis need to be treated appropriately. Since OC
users have been considered at an elevated risk of
development of cervical cancer, they should be screened for
cervical cancer at regular intervals. Early detection through
VIA or cytology could form as an important strategy for
early detection of cervical cancer for masses in
developing countries. The recent thrust of research on cervical
cancer points towards Human Papillomavirus. Thus
HPV screening for the high risk group could also
be considered for screening. The research on HPV vaccination would definitely
get encouraging results and could form an important measure for prevention
of
this deadly disease. The various studies on this disease
have enlightened scientist of different dimensions, but still it
is long way to go.
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