Indian Journal of Cancer Medknow Publications on behalf of Indian Cancer Society ISSN: 0019-509X EISSN: 1998-4774 Vol. 48, Num. 1, 2011, pp. 40-46

Indian Journal of Cancer, Vol. 48, No. 1, January-March, 2011, pp. 40-46

Original Article

Correlates of cervical cancer screening among underserved women

YD Chankapa¹, R Pal², D Tsering²

¹ Department of Health Care, Human Services & Family Welfare, Govt. of Sikkim, Gangtok, Sikkim, India
² Department of Community Medicine, Sikkim Manipal Institute of Medical Sciences and Central Referral Hospital, 5th Mile, Tadong, Gangtok, Sikkim, India

Correspondence Address:
R Pal
Department of Community Medicine, Sikkim Manipal Institute of Medical Sciences and Central Referral Hospital, 5th Mile, Tadong, Gangtok, Sikkim
India
ranabirmon@yahoo.co.in

Code Number: cn11007

Abstract

Keywords: Age, caste, literacy, per capita monthly family income, pregnancy, religion

Introduction

Cervical cancer is the fifth most common cancer in the world. Of the estimated 460,000 new cases each year, three quarters occur in developing countries. In India, annually 16% of the world′s total cases occur and only 5% are reported in the early stages. ^[1] Cervical cancer is the main cancer among women in sub-Saharan Africa, India, and other parts of the developing world. Evaluation of screening performance of effective, feasible, and affordable early detection and management methods is a public health priority. ^[2] Cervical cancer is both a preventable and a curable disease - preventable because the pre-invasive stage can be detected by screening and curable because the very early stage can be cured. The incidence and mortality from this disease in developing countries is very high. Women of low socioeconomic status and minority women are at particular risk for not adhering to recommended cancer screening guidelines. ^[3] Country-specific decisions regarding the best strategy for cervical cancer control will need to rely on data from many sources and take into account complex epidemiologic, economic, social, political, and cultural factors, and be made despite uncertainty and incomplete information. A rigorous decision analytic approach using computer-based modeling methods enables linkage of the knowledge gained from empirical studies to real-world situations.^[4] The concept of cervical intraepithelial neoplasia (CIN) was introduced in 1968 as an equivalent to the term dysplasia, which means abnormal maturation. Cervical cancer progresses slowly from pre-invasive CIN to invasive cancer, and therefore, screening for dysplasia is an important public health effort worldwide, given the accessibility of the primary organ site, the acceptability of current screening methods, and the long pre-invasive period in which to detect disease and successfully intervene. ^[5] Cervical cancer is a disease most frequently found in poverty-stricken communities and reflecting a problem of equity at both levels: gender and regional, and this, is not only due to social and economic development inequalities, but also due to the infrastructure and human resources necessary for primary care. ^[6] Almost half a million new cases of cervical cancer are diagnosed each year worldwide. Human papillomavirus is recognized as one of the leading causes and is associated with 90% of cases. However, other risk factors (e.g., age of first sexual contact, number of sexual partners, multi-parity, diet, genetic predisposition, and environment) are also associated with cervical cancer. ^[7] Cervical cancer is a preventable disease due to screening for precursor lesions using the Papanicolaou cytological testing (Pap smear), which is simple, cost-effective, and a useful test for identifying those at risk of developing cervical cancer, holds the potential to be used as a tool to identify women at risk for subsequent development of cervical cancer. There is an imperative need for continued efforts to ensure that medically underserved minority women have access to cancer screening services. ^[8] The goal of cytological screening is to sample the transformation zone, the area where physiologic transformation from columnar endocervical epithelium to squamous (ectocervical) epithelium takes place and where dysplasia and cancer arise. A meta-analysis of randomized trials supports the combined use of an extended tip spatula to sample the ectocervix and a cytobrush to sample the endocervix. ^[9] Simple and inexpensive methods based on visual examination of the cervix are currently being investigated as alternative methods for cervical screening. ^[10] Visual inspection of the cervix after application of 3%-5% acetic acid (VIA) and magnified visual inspection after application of acetic acid (VIAM) had significantly higher sensitivity than cytology in our study; the specificity of cytology was higher than that of VIA and VIAM. ^[11] The study was undertaken to find out the magnitude of precancerous lesions among women in the age group 15-60 years and to identify the various socio-demographic and reproductive risk factors of cervical cancer among those with cervical lesions in this remote north-eastern hill state of Sikkim. So far, there has not been any study done in this field in this state and to the horizon of our knowledge and this was one of the first studies from North-East part of India.

Patients and Methods

This was a population-based descriptive cross-sectional study in a cervical cancer screening camp at the East Sikkim conducted during 1st September to 30th November 2006 on 968 adult women selected in the age group 15-60 years by multistage random sampling with no interventions. The data collection tool used for the study was an interview schedule that was developed at the health care facility with the assistance from the faculty members of the Institute and other experts from health department of Government of Sikkim. The close-ended questionnaire contained questions relating to correlates of cervical cancer that was related to the socio-demographic situation prevailing in Sikkim. By initial translation, back-translation, re-translation followed by pilot study the questionnaire was custom-made for the study. The pilot study was carried out at another primary health center (PHC) among general patients following which some of the questions from the interview schedule were modified. The main outcome measures were the extent as well as socio-demographic and reproductive variables of cervical cancer in the population under study. The state of Sikkim had four districts namely East, West, South, and North. East District was selected by lottery method. There were eight PHCs in the east district out of which Machong PHC was selected by lottery method. The ethical permission to conduct the study in the primary health centre was taken from the office of the Chief Medical Officer, East Sikkim, Department of Health Care, Human Services and Family Welfare, Government of Sikkim. The PHC covered a population of 9966 (males: 5077 and females: 4889). The health workers at the five sub-centers under the PHC had counseled and motivated the female folk above 15 years to attend the screening camp in the preparatory phase. On the day of screening, all the participants were explained about the purpose of the study and were ensured strict confidentiality, and then verbal informed consent was taken from each of them before the total procedure. The participants were given the options not to participate in the study if they wanted. All the adult women in the age group 15-60 years, who participated in the study were screened by one qualified gynecologist clinically followed by Pap smear test. Anyone of the cardinal physical signs was taken as clinical changes in our study: (a) bleeding on touch, (b) friability, (c) loss of mobility of the cervix, and (d) indurations. These clinical examinations and the cytopathological investigations were carried out in the designated pathology laboratory, under National Cancer Registry Programme (ICMR) - Population-Based Cancer Registries under North Eastern Regional Cancer Registry. The principal investigator collected the information on socio-demographic and reproductive variables by interview method using the questionnaire. Information on cervical cancer was disseminated in health education sessions to complement the findings of study. We graded the alteration in the cervix as cervical changes (CC), cervical changes with inflammation (CCI), low-grade squamous intraepithelial lesion (LSIL) and high-grade squamous intraepithelial lesion (HSIL).

The collected data were thoroughly cleaned manually and entered into Microsoft Excel (version 7.5) spreadsheets and analysis was carried out. The procedures involved were transcription, preliminary data inspection, content analysis, and interpretation. Chi-square test was applied to find out the differences significance in the proportions and percentages of the correlates in this study.

Results

Out of the total of 968 women in the study population highest (33.78%) was from 30 to 40 years of age group, followed by 15-30 years of age group (30.27%). [Table - 1]

Overwhelming majority 921 (95.15%) of women had no cervical lesion. Only 47 (4.85%) were found to have changes in their cervical epithelium. Cervical smear were taken from these 47 women by Pap smear test. None was proved malignant on cytopathological screening.

More than half (53.2%) of the women with cervical inflammation were in the age group of 21-30 years followed by 31-40 years age group (31.7%). Cervical inflammation was mostly evident among the younger counterparts with 34.1% among 21-30 years and 14.9% among 31-40 years. However, it was negligible among 41-50 years and none in the age group of 51-60 years. Whereas the percentage of younger women (21-30 years and 31-40 years women) decreased as the grading of cervical inflammation increased, it was vice versa for older women (41-50 years and 51-60 years). Intraepithelial lesions was seen more among the higher age groups, 100% for women 51-60 years. We compared the pooled data of the cervical changes (CC) and cervical changes with inflammation (CCI) with that of low-grade squamous intraepithelial lesion (LSIL) and high-grade squamous intraepithelial lesion (HSIL) regarding age variables; no significant difference was noted among those with or without lesions among women upto 30 years of age with those 31 years and above [P = 0.4671, Chi-square 0.5409 with Yate′s correction, d.f. = 1, relative risk (RR) 1.15 {confidence interval (CI) 0.8976-1.473}. [Table - 2]

The socio-demographic variables in relation to the various grades of inflammation were investigated among 47 women whose adequate smear samples have been examined. Most of the women with cervical inflammation were illiterate (34.1%). However, as the literacy level increased, fewer number of women showed cervical inflammation (17.0% for 41-50 years and 2.1% for 51-60 years). Similarly, an inverse relation was seen between income and grades of cervical inflammation where almost two-third of the women (74.6%) with varying grades of cervical inflammation was found among women where the per capita monthly family income was upto Rs. 500. In contrast to it, cervical inflammation was negligible (4.2% for income greater than Rs. 1500) among higher income women. We compared the pooled data of the cervical changes (CC and CCI) with that of cervical lesions (LSIL and HSIL) regarding sociodemographic variables. No significant difference in cervical lesion was noted among illiterate women with literates [P = 0.1, Chi-square 2.706 with Yate′s correction, d.f. = 1, RR 0.6908 (CI 0.4611-1.035)]. No significant difference was noted among women with per capita monthly family income (PCMFI) upto Rs. 500 compared to those women having PCMFI more than that [P = 0.6291, Chi-square 2332 with Yate′s correction, d.f. = 1, RR 0.8727 (CI: 0.6880-1.107)]. All the women with cervical lesions (LSIL and HSIL) belonged to Hindu religion. No cervical lesion (LSIL and HSIL) was noted among women participants belonging to the Buddhist and Lepcha religions. Our findings show that as cervical inflammation was more common among the lower socioeconomic group. [Table - 3]

In reproductive history of the women with cervical lesion in our sample, most of the women with cervical inflammation did not have a history of abortion (74.4%), and the percentage of women with cervical inflammation decreased as the number of abortions increased (one abortion: 16.9%, two abortion: 6.3%, three abortion: 2.1%). Women who were married earlier in life showed increase in cervical inflammation. Nearly half of the women (42.6%) were married as early as 12-17 years. It may be due to sexual contact at an early age. In contrast, cervical inflammation was quite less among women married at age 24-29 years. A considerable number of women had their first pregnancy in earlier period of life (<18 years: 31.9% and 19-24 years: 51.5%). In comparison, the percentage of women with cervical inflammation decreased as the age at first pregnancy increased (25-30 years: 12.7% and 31-36 years: 2.1%). This shows that earlier age at coitus and first pregnancy shows more percentage of cervical inflammation.

We compared the pooled data of the cervical changes (CC and CCI) with that of cervical lesions (LSIL and HSIL) regarding reproductive variables. No significant difference in cervical lesion was noted among women with age at marriage less than 18 years with those above [P = 0.7510, Chi-square 0.1007 with Yate′s correction, d.f. = 1, RR 1.043 (CI 0.8064-1.349)]; no significant difference was noted among women with pregnancy less than 18 years, 18-24 years and with more than that [P = 0.8155, Chi-square 0.4080 with Yate′s correction, d.f. 2]. However, abortion and still birth was significantly related with cervical lesions (LSIL and HSIL) [P = 0.0287, Chi-square 4.785 with Yate′s correction, d.f. 1, RR 1.567 (CI 0.9612-2.556)]. [Table - 4]

Discussion

Out of 968 women in our study population of East Sikkim, overwhelming majority had no cervical lesion. Of the cervical smear taken from these clinically suspected women, varying grades of inflammation was evident. None was proved malignant on cytopathological screening of the cervical smear. No significant difference was noted among those with or without lesions among women below 30 years of age with those above, among illiterate women with literates, in PCMFI difference, age at marriage and child birth. Cervical lesions were associated with Hindu women and with history of abortion and stillbirth.

In the study population that included all married women in the age group of 35-59 years in two villages of south India, chronic cervicitis accounted for the largest proportion of the cases (44.8%). In all, three cases were diagnosed as suspected cases of cancer cervix. On cytology, three cases (1.5%) turned out to be malignant. ^[12]

In a study at Lucknow, India, incidence of SIL was found to be 5.9% in the series, while cervical malignancy was seen in 0.6% of cases. The study highlighted the immense utility of cytological screening in minimizing the incidence of carcinoma cervix in the segment of the urban population screened, as the incidence dropped down to 0.5% in the second half from 1.1% noticed in the first half of the screening period. The study also emphasized the utility of clinically downstaging the cervical cancer as 7316 women showing clinical lesions of cervix were found to harbor SIL in 15.3% and carcinoma cervix in 1.3% of cases as against the incidence of 2.5% for SIL and 0.6% for frank cancer in women with normal cervix. The incidence of SIL and cancer cervix showed a rise with increasing age and parity and prolonged sexual period. The incidences of both cervical cytopathologies were also higher in women of low socioeconomic status, while religion was found to have no bearing on the occurrence of the disease. Herpes simplex was found to have strong affinity with both SIL and carcinoma cervix, while only SIL incidence was high with HPV infection. The study emphasizes the need for proper education to women of low socioeconomic class for creating awareness regarding hazards and risk factors of cervical cancer as well as management and cure of the disease. ^[13] In a study to find the trends in the incidence rate of cervical cancer for the Indian population from the data published in Cancer Incidence in Five Continents for various Indian registries, it was observed that cancer of the uterine cervix was the second most common cancer among women in the world after breast cancer. It was the most common cancer among Indian women. The age-specific incidence rates (ASIR) for cervical cancer revealed that the disease increases from 35 years and reaches a peak between the ages 55 and 64 years. For women beyond 64 years, the disease incidence showed an increasing trend or minimal decrease. It was also noted that most of the cervical cancer cases were detected with regional spread of the disease and a very small proportion were diagnosed at a localized stage. In India, an organized mass-screening program with Pap smear for early detection of cervical cancer is not in practice. The data suggest an urgent need for initiation of community screening and educational program for the control and prevention of cervical cancer. ^[14]

In cervical screening, a number of studies of visual inspection with various aids and studies of human papillomavirus (HPV) testing are in progress. Long-term follow up of these will inform policy on cervical screening in limited resource countries. ^[15] Cervical cancer continues to be an important cause of avoidable cancer deaths in older women. Despite the benefits of screening in reducing morbidity and mortality, older patients are under-represented in screening programs. Most professional groups recommend an annual Pap smear for all women, with no upper age limit. In most cases, women can safely undergo triennial screening after several annual negative smears. Screening is well accepted among older patients, as up to 92% will accept a Pap smear offered in a clinical setting. To insure that screening is cost-effective, use of sensitive and specific testing methods and limit screening to appropriate candidates. ^[16]

Significant disparities in cervical cancer incidence and mortality rates among minority groups have been documented in the United States, despite an overall decline in these rates for the population as a whole. Differences in cervical cancer screening practices have been suggested as an explanation for these disparities, as have differences in treatment among various racial and ethnic groups. Strategies to reduce the factors of cervical cancer disparities need to be employed in order to reverse these trends in differences. ^[17] There are major differences in cancer burden across socioeconomic classes, as is evident from the data for cancer incidence and mortality from Greater Mumbai, India, requiring a specific awareness of psychological profiles. ^[18]

Cervical cancer can be detected at an early stage through regular advantage of screening. A qualitative descriptive study was conducted with female members of an urban Sikh community in Canada to explore perspectives on cervical cancer screening. Lack of knowledge about the importance of prevention, influence of family and community, and health-provider issues affected the women′s access to screening. ^[19] The effectiveness of cervical cancer screening programs differs widely in different populations. A nationwide audit of the effectiveness of the Swedish cervical cancer screening program depicted that the screening program was equally effective for women of all ages, and was also effective against non-squamous cancers. ^[20]

In India, most women presented with cancer of the uterine cervix extending beyond the cervix. The majority of women belong to the lower socioeconomic status, are rural, aged between 35 and 64 years and highly noncompliant for complete treatment and follow-up. Opportunistic screening with cytology, colposcopy, and test for human papilloma virus and appropriate treatment are available on payment at urban private medical centers, but are not available at urban and rural government health centers that are accessed by women of the lower socioeconomic status who need these most, as the cytology screening in the government health measures is not feasible. The ′′social vaccine′′ of health empowerment along with visual inspection and appropriate referral by the rural and urban health personnel (Department of Health and Family Welfare); with an additional input of health awareness and motivation by Anganwadi Workers (Department of Women and Child Development), elected women representatives in the Panchayats (Department of Rural Development and Panchayati Raj) and non-governmental development agencies could be a collaborative effort toward "downstaging" cervical cancer. This could lay the foundation for the introduction of cytology screening when resources are available. ^[21]

The cost-effectiveness cervical cancer screening and emphasis on important qualitative themes to consider in designing cervical cancer intervention policies may have saved million from this preventable malignancy. There is a need for changes on cervical cancer screening policies, standards, quality control, monitoring and evaluation, and integration of new screening alternatives: (a) to address unprivileged rural women; (b) ensuring extensive coverage as well as a comparable quality of coverage in every state; and (c) to use screening strategies matching health care resources. In countries like India, with a great regional heterogeneity regional centers had be set up as a strategy, Finally, the screening program should have meet the expectations of its beneficiaries, and inculcate behavior change communication (BCC) in cervical cancer-related matters. It holds the potential to be used as a tool to identify women, at risk for subsequent development of cervical cancer.

Carcinoma of the cervix continued to be an important cause of avoidable cancer deaths in older women in the developing countries including India. There was an imperative need for identifying prevalence of asymptomatic cervical dysplasia in all population. Low cost methods for cervical cancer prevention have a place in reducing the incidence of this deadly disease. Substantial subgroups of Indian women, specifically those of ethnic minorities, had not been screened for cervical cancer or are not screened at regular intervals. We screened all women in the reproductive age group in our population for other reasons also, viz., to sensitize the female population regarding cervical cancer, its risk factors and the test available for early diagnosis of precancerous lesions, which was a reason for including young females too. Moreover, adolescent marriages are common in rural areas of Sikkim. Most of the study population was married at an early age, which made it necessary to include them as their coital activity and child bearing start early which is a risk factor for cervical cancer.

We had several limitations. In spite of our best efforts, the study sample was less as we had to face a tough opposition to screen apparently healthy women folk. Moreover, sparsely spread population in hilly terrains was another hindrance, and even after constant motivation by the health workers, few women did not participate in the screening camp.

Given the findings in the present study, few recommendations are made. First, BCC needs to improve knowledge about cervical cancer particularly with lesser educational level among the people in general and women in particular by improving educational tools preferably based on audiovisual techniques. We have to create wider awareness about the importance of early detection and encourage more people for screening of cervical cancer. Second, we should have some productive advertisements to motivate the general mass for the cervical cancer in to focus on the relations of the cervical cancer with early marriage, early pregnancy, repeated childbirth as well as unhygienic lifestyle and above all on the importance of screening. Third, the continuity of obtaining better health care services and receiving recommendations from physicians remain the core motivating factors that are significantly associated with the success of the screen and treat philosophy in cancer. Making people aware of recent findings, e.g., frequent and regular screening is associated with a lower risk of cancer progression will be added advantage.

References

Copyright 2011 - Indian Journal of Cancer

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