Visual Inspection with Acetic Acid (VIA) Screening Program: 7 Years Experience in Early Detection of Cervical Cancer and Pre-Cancers in Rural South India

Cervical cancer continues to be a major public health problem in India in the absence of wide spread organised cervical screening programs. Visual inspection of the cervix with acetic acid (VIA) is an effective, inexpensive screening test that can be combined with simple treatment procedures for early cervical lesions, provided by trained health workers. We report 7 years experience in early detection of cervical cancer and pre-cancers using the VIA test in a community-based program in rural Andhra Pradesh, India where there are no existing organised cervical screening programs.

Materials and Methods:

Eligible women aged between 26 and 60 were opportunistically screened by trained health wor kers using the VIA test. Women who tested positive were further evaluated and those with cervical lesions were treated either by cryotherapy in the screening clinic or referred to a higher center.

Results:

A total of 18,869 women were screened by a single round of VIA testing with a positive rate of 10.75%. Biopsy proven high-grade squamous intraepithelials (HSILs) were 90 (0.48%) and low-grade squamous intraepithelials (LSILs) were 43 (0.28%). The overall prevalence of cervical intraepithelial neoplasia (CIN) 2+ lesion rate is 1.05%. A total of 312 (1.65%) cryotherapies were done and 49 women underwent hysterectomy.

Conclusions:

VIA by trained female health workers is a safe, acceptable, and effective test that can save lives from cervical cancer even in remote areas with few resources. These results have important implications for efficient service delivery in cervical screening programs in low-resourced settings.     

Abnormal Pap test results and the rurality factor

Objective: To review the published socio‐cultural determinants that put women in rural areas at greater risk of having an abnormal Pap test result. Design: Literature review. Conclusion: An Australian woman is at increased risk of developing cervical dysplasia if she lives in a rural area, identifies as an Indigenous Australian or is from a non‐English speaking country. Being aged over 50 years, increases the risk of cervical cancer but not cervical intra‐epithelial neoplasia (CIN) 1, which peaks in the 20–24 year age group. Other connections with cervical dysplasia relate to a woman or her partner's sexual history, her nutritional status and possibly even her personality type. Smoking, social isolation, high negative life change events and having lived a ‘troubled’ life are all identified in the literature as increasing a woman's risk of having an abnormal Pap test result. Receiving an abnormal Pap test result often leads to feelings of fear, anxiety, guilt, shock, vulnerability, powerlessness, depression, shame and feeling dirty for the woman concerned. Compounding these negative feelings are social, practical and financial difficulties that have to be addressed. It is argued that social and medical models of health must complement each other to improve the well being of rural women experiencing an abnormal Pap result. What is already known: Innumerable studies have verified that cervical screening significantly reduces the incidence of cervical cancer and the Pap test is promoted as a tool to prevent cervical cancer. However, preventative strategies used in addition to cervical screening have rarely been considered in the literature. What this study adds: This review concludes that optimum health outcomes for rural women are realised when socio‐cultural considerations are articulated with cervical screening programs. It suggests possible strategies for practitioners to use to use to help reduce the incidence and impact of cervical pathology for rural women.     

'I do not need to… I do not want to… I do not give it priority…'– why women choose not to attend cervical cancer screening

Objective  To describe and interpret why women with no cervical smear taken during the previous 5 years choose not to attend a cervical cancer screening (CCS) programme. Background  CCS programme is a service for early detection of cervical cancer. Today, some women choose not to attend the programme. Design  Data were collected by tape‐recorded interviews and analysed by qualitative inductive content analysis. Setting and participants  Purposive sample of 14 women in southeast Sweden, who had chosen not to attend CCS during the previous 5 years. Findings  The following themes were revealed: I do not need to…, I do not want to… and I do not give it priority…. The women had a positive attitude to CCS but as long as they felt healthy, they chose not to attend. A negative body image, low self‐esteem, feelings of discomfort when confronted with the gynaecological examination and fear of the results also influenced their non‐attendance. The women prioritized more important things in life and reported various degrees of lack of trust in health‐care. Conclusion  Women’s choice not to attend CCS were complex and influenced by present and earlier intra‐ and inter‐personal circumstances. They had a positive attitude to CCS, but other things in life were more important. Health‐care professionals have to facilitate a co‐operative discussion with the women in order to contribute to a mutual understanding for the perspectives of the women and the professionals.     

Improving survival disparities in cervical cancer between Māori and non‐Māori women in New Zealand: a national retrospective cohort study

Objective: Māori women in New Zealand have higher incidence of and mortality from cervical cancer than non‐Māori women, however limited research has examined differences in treatment and survival between these groups. This study aims to determine if ethnic disparities in treatment and survival exist among a cohort of Māori and non‐Māori women with cervical cancer. Methods: A retrospective cohort study of 1911 women (344 Māori and 1567 non‐Māori) identified from the New Zealand Cancer Register with cervical cancer (adenocarcinoma, adenosquamous or squamous cell carcinoma) between 1 January 1996 and 31 December 2006. Results: Māori women with cervical cancer had a higher receipt of total hysterectomies, and similar receipt of radical hysterectomies and brachytherapy as primary treatment, compared to non‐Māori women (age and stage adjusted). Over the cohort period, Māori women had poorer cancer specific survival than non‐Māori women (mortality hazard ratio (HR) 2.07, 95% confidence interval (CI): 1.63–2.62). From 1996 to 2005, the survival for Māori improved significantly relative to non‐Māori. Conclusion: Māori continue to have higher incidence and mortality than non‐Māori from cervical cancer although disparities are improving. Survival disparities are also improving. Treatment (as measured) by ethnicity is similar. Implications: Primary prevention and early detection remain key interventions for addressing Māori needs and reducing inequalities in cervical cancer in New Zealand.     

What Australian women want and when they want it: cervical screening testing preferences,decision‐making styles and information needs

Background New testing technologies and human papillomavirus (HPV) vaccines have recently brought changes to cervical cancer screening. In 2006, the Australian government also changed the protocol for managing abnormal Pap smears. Australian women’s attitudes and preferences to these changes are largely unknown. Quantitative data on information needs and community attitudes to informed decision making in screening in Australia are also limited. Objective This national study measures women’s preferences for testing and management of abnormal screening results, preferred decision‐making styles and information needs for cervical cancer screening. Design A randomly selected sample of Australian women aged 18–70 participated in a structured telephone questionnaire, exploring testing preferences, information and decision‐making needs. Results A total of 1279, of 1571 eligible women, participated in the study with an overall response rate of 81.4%. Half of the women (n = 637) preferred having their Pap smears at least annually, and 85% wanted concurrent HPV testing. A large proportion of women preferred to be involved in decision making for both routine Pap smears (87%) and follow‐up for abnormal results (89%). The majority of women wanted information on screening risks (70%) and benefits (77%); of these 81 (85%) wanted this information before screening. However, 63% of women only wanted information about follow‐up examinations if they had an abnormal Pap test result. Conclusion Australian women want to be involved in decision making for cervical cancer screening and require information on the risks and benefits of Pap testing prior to undergoing any screening.     

A comparison of two visual inspection methods for cervical cancer screening among HIV-infected women in Kenya

Objective

To determine the optimal strategy for cervical cancer screening in women with human immunodeficiency virus (HIV) infection by comparing two strategies: visual inspection of the cervix with acetic acid (VIA) and VIA followed immediately by visual inspection with Lugol’s iodine (VIA/VILI) in women with a positive VIA result.

Methods

Data from a cervical cancer screening programme embedded in two HIV clinic sites in western Kenya were evaluated. Women at a central site underwent VIA, while women at a peripheral site underwent VIA/VILI. All women positive for cervical intraepithelial neoplasia grade 2 or worse (CIN 2+) on VIA and/or VILI had a confirmatory colposcopy, with a biopsy if necessary. Overall test positivity, positive predictive value (PPV) and the CIN 2+ detection rate were calculated for the two screening methods, with biopsy being the gold standard.

Findings

Between October 2007 and October 2010, 2338 women were screened with VIA and 1124 with VIA/VILI. In the VIA group, 26.4% of the women tested positive for CIN 2+; in the VIA/VILI group, 21.7% tested positive (P < 0.01). Histologically confirmed CIN 2+ was detected in 8.9% and 7.8% (P = 0.27) of women in the VIA and VIA/VILI groups, respectively. The PPV of VIA for biopsy-confirmed CIN 2+ in a single round of screening was 35.2%, compared with 38.2% for VIA/VILI (P = 0.41).

Conclusion

The absence of any differences between VIA and VIA/VILI in detection rates or PPV for CIN 2+ suggests that VIA, an easy testing procedure, can be used alone as a cervical cancer screening strategy in low-income settings.     

Travel time and distance to health care only partially account for the ethnic inequalities in cervical cancer stage at diagnosis and mortality in New Zealand

Objective: To investigate whether travel time or distance to the nearest general practitioner (GP) and/or cancer centre accounts for the ethnic differences in cervical cancer screening, stage at diagnosis and mortality in New Zealand (NZ). Methods: The study involved 1,594 cervical cancer cases registered between 1994 and 2005. Travel time and distance to the GP and cancer centre were estimated using a Geographical Information System. Results: Adjustment for travel time or distance made almost no difference to ethnic differences in screening rates. Adjustment for travel time reduced the excess risk for late‐stage diagnosis in Māori (the odds ratio (OR) reduced from 2.71 (95%CI 1.98–3.72) to 2.59 (1.88–3.56), a 7% decrease) and 33% in Pacific (the OR reduced from 1.39 (0.76–2.54) to 1.26 (0.68–2.33)) women. Adjustment for travel time reduced the excess risk for mortality by 3% in Māori (the hazard ratio (HR) reduced from 1.59 (1.21–2.08) to 1.57 (1.19–2.06)) and 13% in Pacific (the HR reduced from 1.92 (1.20–3.08) to 1.80 (1.11–2.91)) women. Similar findings were observed when using travel distance rather than travel time. Conclusions: Travel time and distance are only weakly associated with cervical cancer screening, stage at diagnosis and mortality in NZ. However, travel time may account for a small proportion of the ethnic differences in stage at diagnosis, and to a lesser extent mortality, particularly for Pacific women. Implications: The findings suggest that there may be ethnic variations in access to treatment or treatment quality, which may be related to travel time.     

Knowledge about Cervical Cancer Risk Factors,Traditional Health Beliefs,and Pap Testing Among Vietnamese American Women

Introduction: The objective of this paper was to examine knowledge about cervical cancer risk factors and traditional health beliefs in relation to Papanicolaou (Pap) testing among Vietnamese women. Methods: A population-based survey was conducted in Seattle (n<352, response rate=82%) during 2002. Results: The proportions of women who knew that older age, not getting regular Pap tests, and Vietnamese ethnicity are associated with an elevated cervical cancer risk were only 53%, 62%, and 23%, respectively. The majority (87%) incorrectly believed poor women’s hygiene is a risk factor for cervical cancer. Approximately two-thirds (68%) of the women had received a Pap test during the preceding three years. Knowing that lack of Pap testing increases the risk of cervical cancer was strongly associated (p<0.001) with recent Pap smear receipt. Conclusion: Our results confirm that Vietnamese women have lower levels of cervical cancer screening than non-Latina white women. Intervention programs addressing Pap testing in Vietnamese communities should recognize women’s traditional beliefs while encouraging them to adopt biomedical preventive measures into their daily lives.     

The screening history of women with cervical cancer in the Rotterdam area

Objective: In order to gain insight into the diagnostic effectiveness of the screening program on cervical cancer in the Rotterdam area, the history of women with cervical cancer was studied. Three questions were asked: (1) What percentage of women were invited to the screening program, and what percentage participated. (2) What percentage of women had had a negative smear within 3 years before cancer was diagnosed, and (3) What percentage of women encountered inadequate follow-up. Methods: All the cytological and histological results of women who were diagnosed with cervical carcinoma between 1992–1994 were studied. Results: Within 3 years of the diagnosis, 42% of the 165 women with cervical cancer were invited for the cervical screening program. A total of 47% were too old to be invited and 10% were too young. A total of 37% of the women who were invited participated in the screening program. A total of 33 (20%) of 165 women with cervical carcinoma had had a negative smear within three years preceding the diagnosis. For women under 34 years of age this was 41% (n = 7), and for women over 56 years 8% (n = 6). A total of 7% of all women with cervical cancer encountered inadequate follow-up. Conclusion: Many women with a diagnosis of cervical cancer are too old to be invited for the cervical screening program. Relatively few of the women with cervical cancer who were invited for the screening program actually participated in this program.     

An examination of sociocultural factors associated with cervical cancer screening among low-income Latina immigrants of reproductive age

The purpose of this study was threefold: 1) to examine whether low-income Latina immigrants were less likely to receive a Pap smear than low-income non-Latinas; 2) to examine ethnic differences regarding cervical cancer knowledge; and 3) to examine the sociocultural factors associated with cervical cancer screening among low-income Latina immigrants. Participants included 225 low-income women of reproductive age attending a WIC (Women, Infants, and Children) clinic (50% Latina immigrants and 50% non-Latinas). Latina immigrants were less educated, less likely to have health insurance, and more likely to be married or living with a partner than non-Latinas (ps < 0.05). All non-Latinas had a Pap smear in the past compared to 81.3% of Latina immigrants (p < 0.001). Latina immigrants displayed significantly less knowledge regarding cervical cancer than non-Latinas (ps < 0.01). Latina immigrants tended to display culturally based knowledge and beliefs regarding cervical cancer and screening that may influence getting a Pap smear.     

Risk of Intestinal Malignancy in Patients With Short Bowel Syndrome

Background: Postresection intestinal adaptation is an augmented self‐renewal process that might increase the risk of malignant transformation in the intestine. Furthermore, patients with short bowel syndrome (SBS) have other characteristics that might increase this risk. Our aim was to determine the incidence of new intestinal malignancy in SBS patients. Methods: We reviewed the records of 500 adult SBS patients identified from 1982–2013. There were 199 men and 301 women ranging in age from 19–91 years. Follow‐up from the time of diagnosis of SBS ranged from 12–484 months. A total of 186 (37%) patients were followed >5 years. Results: The cause of SBS was postoperative in 35% of patients, malignancy/radiation in 19%, mesenteric vascular disease in 17%, Crohn's disease in 16%, and other in 13%. Twenty‐eight (6%) patients received growth stimulatory medications. Fifteen percent of patients had a prior total colectomy. Twenty‐eight (6%) patients underwent intestinal transplantation, and 115 (23%) patients had a previous abdominal malignancy, including colorectal cancer in 43 patients. Thirty‐six (7%) received radiation therapy. Recurrent colon cancer was found in 2 patients, one at a stoma and the other with lung metastases. New colon cancer was found in 1 patient (0.2%), a 62‐year‐old woman with long‐standing Crohn's disease. Conclusion: The incidence of colon cancer in this heterogenous group of patients with SBS was similar to that of the normal population. This suggests that the risk of developing a new colon cancer in patients with SBS is not increased.     

Cervical cancer sociodemographic and diagnostic disparities in Florida: a population-based study (1981–2013) by stage at presentation

ABSTRACT

Objective: Florida has one of the highest cervical cancer mortality rates and socioeconomically diverse populations in the United States. We used statewide population-based cancer registry data to assess disparities in cervical cancer stage at diagnosis.

Design: Primary invasive adult female cervical cancer patients in the Florida Cancer Data Registry (1981–2013) were linked with 2000 United States Census data. Early (localized) and advanced (regional and distant) stage at diagnosis was assessed by age, race, ethnicity, neighborhood socioeconomic-, marital-, and smoking- status. Univariate and multivariable logistic regression models were fit to identify factors associated with the risk of advanced cervical cancer stage at diagnosis. Adjusted odds ratios (aOR) and corresponding 95% confidence intervals (95%CI) were calculated.

Results: Of 18,279 women (mean_age 51.3 years old), most were non-Hispanic (83.5%), white (79.1%), middle-low neighborhood socioeconomic status (NSES) (34.7%), married (46.0%), and never smoked (56.0%). Higher odds of advanced stage was observed for blacks (aOR: 1.42, 95%CI: 1.30–1.55, p?<?0.001) compared to whites, Hispanics (1.15, 1.06–1.25, p?=?0.001) compared to non-Hispanics, and middle-low (1.13, 1.02–1.25, p?=?0.02) and low NSES (1.42, 1.28–1.57, p?<?0.001) compared to high NSES. Previously (1.30, 1.21–1.39, p?<?0.001) and never married (1.37, 1.27–1.48, p?<?0.001) had higher odds of presenting with advanced stage versus married women. Never smokers had decreased odds of presenting with advanced stage compared to women with history of (1.41, 1.32–1.52, p?<?0.001) or current (1.29, 1.18-1.42, p < 0.001)smoking status.

Conclusions: There are cancer disparities in women of black race, Hispanic ethnicity and of middle-low and lowest NSES in Florida. Evidence-based interventions targeting these vulnerable groups are needed.

Abbreviations: HPV: Human Papilloma Virus; CDC: Center for Disease Control and Prevention; SES: socioeconomic status; FCDS: Florida Cancer Data System; NSES: Neighborhood Socioeconomic Status; NPCR: National Program of Cancer Registries; IRB: Institutional Review Board; ACS: American Community Survey; SEER: Surveillance, Epidemiology and End Results; OR: Odds Ratio; CI: Confidence Interval     

Associations of Dietary Glycemic Index,Glycemic Load and Carbohydrate with the Risk of Cervical Intraepithelial Neoplasia and Cervical Cancer: A Case-Control Study

Background: The association of dietary glycemic index (GI) and glycemic load (GL) with the risk of cervical cancer has never been investigated. Thus, we aimed to find evidence of any association of GI and GL with the risk of cervical intraepithelial neoplasia (CIN) and cervical cancer. Methods: In this hospital-based case-control study, we included 1340 women (670 controls and 262, 187 and 221 patients with CIN1, CIN2/3, and cervical cancer, respectively) from the Korean human papillomavirus cohort study. Completed demographic questionnaires and semi-quantitative food-frequency questionnaires were collected. The association of dietary GI and GL with CIN and cervical cancer was estimated using a logistic regression model. Results: The multivariate odds ratios (OR) of the highest compared with the lowest quintile of GL for CIN1 were 2.8 (95% confidence interval (CI) = 1.33–5.88). Dietary GI and GL were not associated with CIN2/3 and cervical cancer. Stratified analyses by body mass index (BMI) indicated a positive association between GI and GL and CIN 1 risk among women with a BMI (in kg/m²) <23 (OR = 2.94; 95% CI = 1.32–6.53; p for trend = 0.031 for GI and OR = 3.15; 95% CI = 1.53–6.52; p for trend = 0.013 for GL), but not among those with a BMI of ≥23. A stratification analysis by menopausal status showed that the highest quintile of GI and GL was significantly associated with the risk of CIN1 (OR = 2.91; 95% CI = 1.43–5.96; p for trend = 0.005) (OR = 2.96; 95% CI = 1.53–5.69; p for trend = 0.023) among premenopausal women. Also, in HPV positive women, dietary GL showed significant CIN1 risk (OR = 2.61; 95% CI = 1.09–6.24; p for trend = 0.087). Conclusion: Our case-control study supports the hypothesized associations of dietary GI and GL with increased risk of CIN1. Thus, the consumption of low GI and GL foods plays a significant role in the prevention of cervical carcinogenesis.     

多种检测方法在子宫颈癌及癌前病变筛查中的应用评估

目的评估多种检测方法在子宫颈癌及癌前病变筛查中的应用价值及可行性，为子宫颈癌筛查方案提供依据。方法对子宫颈癌高发区江西省修水县大桥乡妇女进行以人群为基础的研究，对已登记的2499名年龄为30～49岁农村已婚妇女分别做人乳头瘤病毒（HPV）检测、新柏氏薄层液基细胞学（TCT）、醋酸染色后肉眼观察（VIA）、碘染色后肉眼观察（VILI）以及电子阴道镜检查。全部检查方法均以独立、双盲方式进行。对VIA、VILI及电子阴道镜三项检查中任何一项存在子宫颈可疑病变的妇女行子宫颈活检；对以上三项检查均未发现可疑病变，但子宫颈脱落细胞HPV阳性或TCT结果阳性（ASCUS以上级别）的妇女，2周后给予子宫颈活检。观察HPV、TCT、VIA、VILI、电子阴道镜等筛查方法单独使用或联合使用进行子宫颈癌及其癌前病变筛查的敏感度、特异度、阳性预测值、阴性预测值。宫颈组织病理诊断均经国际癌症研究所病理确诊。筛查时将病理诊断为子宫颈上皮内瘤变（CIN）1级（CINl）纳入阴性结果，将CIN2以上（包括CIN2）病变纳入阳性结果。宫颈细胞学按TCT（thinprep cytology test）标准制片，细胞学诊断按照2001年TBS（The Bethesda System）细胞病理分类标准判读诊断。结果2499名受检妇女中，2432名纳入研究（67名妇女因HPV或TCT阳性未行活检故未列入统计），其中HPV阳性妇女387例；TCT阳性妇女153例。宫颈活检病理诊断共检出CIN及子宫颈癌99例，其中CIN237例，CIN359例，宫颈癌3例。HPV、TCT、HPV＋TCT、VIA、VILI、VIA＋VILI、阴道镜检等筛查方法的敏感度分别为96．67％、89．47％、97．98％、56．57％、36．36％、63．64％、39．39％。特异度分别为85．00％、96．91％、86．97％、94．60％、96．23％、92．97％、98．14％。结论HPV＋TCT用于宫颈癌及癌前病变筛查的敏感度高于其他筛查方法。     

Encouraging Underscreened Women to Have Cervical Cancer Screening: The Effectiveness of a Computer Strategy

Background.Computers that collect data from patients and provide both patients and practitioners with printed feedback on a range of health risks are a tool for assisting general practitioners with preventive care. This study assessed the impact of computer-generated printed feedback on cervical screening among women who were underscreened for cervical cancer.Method.Female attenders at two Australian general practices were randomly allocated to Experimental or Control groups. Women in both groups completed a health risk survey on a touch screen computer prior to their consultation. Those in the Experimental group received printed pages summarizing their results, including their eligibility for cervical screening and last Pap test, for themselves and their doctor. The number and proportion of underscreened women who had a Pap test in the 6 months after completing the computer survey, as determined by pathology records, were examined.Results.Of the 679 participants, 139 were classified as underscreened on the basis of self-report (74 Experimental, 65 Control) and 272 on the basis of their pathology records (148 Experimental, 124 Control). Overall about one-third of women had a test in the 6-month period, and the differences between the groups were not significant for women overall (18–70 years) or for women 18–49 years. Among women 50–70 who were underscreened based on self-report, those receiving the printout were more likely to have a Pap test in the next 6 months (P< 0.05). This pattern was also evident, but did not reach statistical significance, for older women who were underscreened based on pathology records.Conclusions.We are unable to draw conclusions regarding the effectiveness of the computer system due to the modest proportions of women screened, the small numbers, and the fact that the computer survey may have created an intervention effect in the Control group. As the study suggests the computer system is acceptable to women and may be effective for encouraging screening among older women, further exploration of the system is desirable.     

Risk Factors Associated with Invasive Cervical Carcinoma among Women Attending Jimma University Specialized Hospital,Southwest Ethiopia: A Case Control Study

Background

Cervical cancer is a more serious public health problem than other cancers in women in Sub-Saharan Africa in general and in Ethiopia in particular. Thus, this study assessed risk factors related to invasive cervical carcinomas in southwestern Ethiopia.

Methods

Unmatched case control study was conducted in Jimma University Specialized Hospital from April 1 to September 30, 2010. The study consisted of 60 cases (women who had cervical cancers based on histopathologic examination) and 120 controls (women with no cervical cancers). Semi-structured questionnaire was utilized for data collection. Vaginal examinations often visualized with speculum insertions were done for both cases and controls. Punch cervical biopsies were then performed for the suspected cases at Jimma University Hospital that serves about 15 million people in a catchment radius of 250 kms. Data were analyzed using SPSS version 13.0 software. Univariate and multivariate analyes were done to describe and identify independent predictors of cervical cancer.

Results

The mean ages of cases and controls were 47.7 (SD=10.8) and 35.5 (SD =10.5) years respectively. Older women (40–59 years), (OR= 4.7; 95%CI= 2.3–9.6), more than one husband (OR= 2.0; 95%CI=1.0–3.9), as well as more than one wife in lifetime, (OR= 3.0; 95% CI= 1.5–5.9), women who had more than 4 children, (OR =10.3, 95% CI= 3.6–29.0), and age greater than 25 years at first full term delivery, (OR= 8.8; 95% CI= 3.5–22.0) were statistically significant and the latter two were independently associated with invasive cervical cancer. Only 7(11.7 %) of cases and 58(48.3%) of controls ever heard of cervical cancers; however, 2(3.3%) of cases and 7(5.8%) of controls had ever had history of papaneocolous (pap) smear tests done.

Conclusion

Poor knowledge on cervical cancer was observed that required more work to be done to increase knowledge of mothers on cervical cancer and on associated risk factors. Behavioral communication activities and establishment of cervical cancer screening programs for the young could help reduce the advancement of cervical cancer particularly among the less knowledgeable, older and grand multiparous women in our parts of the world.     

宫颈癌危险因素病例对照研究

目的 探讨宫颈癌高发区的相关危险因素。方法 采用以住院患者为基础的病例对照研究方法，对129名经病理确诊的宫颈癌患者和143例非肿瘤病人对照进行有关月经、婚育史、性行为与避孕史、个人卫生习惯等因素的调查。结果 在单因素分析的基础上进行多元Logistic回归分析，最终引入回归方程的变量为家庭经济收入、首次性交年龄、洗澡设施、妇科病史、产次和绝经，而结婚年龄、首次发生性行为和孕育年龄、孕产次等生殖因素，则与宫颈癌发生的危险性呈剂量一反应关系。结论 经济收入低、首次发生性行为的年龄小、既往有妇科病史、孕产次多可增加宫颈癌发生的危险性，特别值得注意的是洗澡和清洗阴部少等不洁卫生习惯可能是导致当地该病高发的原因之一，绝经后妇女宫颈癌发生的危险性较低。     

A mixed methods,community‐based investigation on women's cancer awareness in Haiti

Despite a high number of cases, the awareness of breast and cervical cancer in Haiti and other low and middle‐income countries (LMICs) remains relatively unknown. The objective of the research was to understand perceptions and attitudes towards breast and cervical cancer in Haiti through community‐engaged research. We report Haitians perceptions of breast and cervical cancer symptoms, diagnosis, complications, treatment, community support and access to medical services. Five non‐governmental Haitian organisations performed a large survey across the country of Haiti in 2015. The survey and focus groups addressed demographics, reported knowledge of women's cancer, infrastructural issues and barriers to care, communication and media channels. The mixed quantitative and qualitative surveys with open‐ and closed‐ended questions were administered to 414 participants aged 13–65 (75% of whom were women). A separate, smaller survey on community support and gender‐based violence was conducted in 50 breast cancer patients and survivors as well. The quantitative data indicate low levels of knowledge about cancer across all geographic regions of the country amongst men and women. After coding participants' qualitative responses as “accurate” or “not accurate”, we determined the percentage of accurate responses related to knowledge. Data are reported broken down by geographic region, education, economic status and sex. Approximately one in five respondents reported knowing how a woman contracts breast or cervical cancer. Only 30% reported to know complications of breast cancer and 22% the complications of cervical cancer. When asked if they knew where to get a test for breast cancer, 20% said yes and 33% said they knew where to get a test for cervical cancer. The wealthiest and best educated generally had the most knowledge, but the poorest consistently had the second best. Forty percent of cancer patients reported to be victims of on‐going gender‐based violence. Further investigation should be undertaken examining the role of gender‐based violence and to address the knowledge of the working poor.     

The Impact of Near‐Universal Insurance Coverage on Breast and Cervical Cancer Screening: Evidence from Massachusetts

This paper investigates the effect of expansion to near‐universal health insurance coverage in Massachusetts on breast and cervical cancer screening. We use data from 2002 to 2010 to compare changes in receipt of mammograms and Pap tests in Massachusetts relative to other New England states. We also consider the effect specifically among low‐income women. We find positive effects of Massachusetts health reform on cancer screening, suggesting a 4 to 5% increase in mammograms and 6 to 7% increase in Pap tests annually. Increases in both breast and cervical cancer screening are larger 3 years after the implementation of reform than in the year immediately following, suggesting that there may be an adjustment or learning period. Low‐income women experience greater increases in breast and cervical cancer screening than the overall population; among women with household income less than 250% of the federal poverty level, mammograms increase by approximately 8% and Pap tests by 9%. Overall, Massachusetts health reform appears to have increased breast and cervical cancer screening, particularly among low‐income women. Our results suggest that reform was successful in promoting preventive care among targeted populations. Copyright © 2015 John Wiley & Sons, Ltd.