Review of screening and preventive strategies for cervical cancer in India

Cervical cancer is the commonest cancer among Indian women. The predominant risk factor is persistent infection with human papilloma virus (HPV) which is now well established. Despite being the commonest cancer, and the fact that it is a type of cancer, which can be detected early by sensitive screening methods there is no effective screening programme or preventive strategy for reducing its burden. This article reviewed the published studies that has been carried out in India during 1965-2005 on cervical cancer with emphasis on screening by Pap smear and other alternative methods. Conventionally, Pap smear cytology is the only method for screening; but recently various studies have been carried out to explore alternative methods like visual inspection methods. Due to the operational difficulties by Pap smear, these alternative screening methods could be more feasible for organized population based screening in a low resource country. There is therefore a need for initiating screening programmes within the existing health system in India.     

Cancer screening behaviors among U.S. women: breast cancer, 1987-1989, and cervical cancer, 1988-1989.

Data from the Behavioral Risk Factor Surveillance System (BRFSS) were used to examine trends in breast and cervical cancer screening behaviors among U.S. women in selected states. Data reported are from the 1987, 1988, and 1989 BRFSS for breast cancer screening (mammography) and from the 1988 and 1989 BRFSS for cervical cancer screening (Papanicolaou [Pap] smear). Results are presented as either state-specific or state-aggregate data for the years noted above. State-specific analyses indicated that self-reported mammography utilization increased between 1987 and 1989. Although whites and blacks reported similar mammography utilization rates both for screening and for a current or previous breast problem, disparities were evident among women of different ages and incomes. The proportion of women who reported ever having had a Pap smear and having heard of a Pap smear were extremely high and remained fairly consistent across the 2 survey years. State-aggregate analyses, however, showed that the percentage of women who had had a Pap smear within the previous year was negatively associated with age and positively associated with income. A higher proportion of blacks than whites obtained Pap smears. These results indicate that certain segments of the population are not taking full advantage of available breast and cervical cancer screening technologies. Public health strategies, such as those outlined in the Breast and Cervical Cancer Mortality Prevention Act of 1990 (Public Law 101-354), should enhance screening opportunities for these women.     

Factors associated with inadequate cervical cancer screening among lower income primary care patients

This study identified factors associated with cervical cancer screening patterns among lower income primary care patients. One hundred forty-one women completed a self-administered questionnaire before their medical visit. The results indicated that 71 percent had a Papanicolaou (Pap) test in the past year, 14 percent had one between 1 and 3 years ago, and 15 percent had not had a Pap test for 3 or more years. Advanced age was associated with a reduced likelihood of adequate screening; 21 percent of women aged 50-64 years and 39 percent of those aged 65 years and older had not had a Pap test in the past 3 years. Factors positively associated with screening included perceived susceptibility to cervical cancer and the belief in the efficacy of Pap tests and benefits of screening. Fear of finding cancer was a significant barrier to cervical screening in this population. Of those women who had not been screened adequately, 58 percent were interested in obtaining Pap tests in the primary care setting. The implications for promoting cervical cancer screening in primary care practices are discussed.     

Exploration of factors linked with high cervical cancer rates in women from the former Yugoslavia in Victoria,Australia

Objectives: The aim of the project was to identify the cervical screening rate and other factors that may be associated with high rates of cervical cancer in women from the former Yugoslavia compared to the general population in Victoria, Australia. Design: A cross-sectional survey was conducted by structured personal interviews of 42 Bosnian, 56 Croatian, 49 Macedonian, and 35 Serbian women, and 39 women who identified as Yugoslav or of mixed background. Self-report data were collected on Pap testing behaviour, estimated screening rate of each community, stage-based barriers to cervical screening, and women's theories about causes of cervical cancer within their community. Results: Women in this study had an acceptable screening rate, but barriers to cervical screening were similar to those of other groups. While Macedonian women believed more of their community had Pap tests than the other cultural groups, just under half were under-screened themselves. Smoking rates were very high for women in this study. The most common causes of cervical cancer suggested by women in the study were: a low screening rate, lifestyle stress, and chemicals. Conclusion: It is unlikely that the high cervical cancer rate in women from the former Yugoslavia is a result of under-screening, lifestyle stress, or chemicals. Smoking may well contribute to the cancer rate, however the most likely explanation is that cancers not previously detected in Yugoslavia are now being found, together with cervical abnormalities, within the systematic two yearly screening programme of PapScreen Victoria, in Australia.     

Perceptions of cervical cancer threat, benefits, and barriers of Papanicolaou smear screening programs for women in Iran

OBJECTIVES: The main purpose was to assess associations between HBM variables and participation in cervical cancer screening programs in a sample of Iranian women. METHODS: A total of 333 married women of childbearing age were recruited with cluster sampling. The study was conducted from spring 2002 to spring 2003 and a self-report questionnaire and structured interview were designed to measure the four HBM constructs and Iranian women's knowledge about Pap smear screening. RESULTS: A total of 68.5% reported having undergone at least one Pap test. Women were more likely to participate in Pap smears when they had access to knowledge about cervical cancer and screening programs. Furthermore, the perceived benefit and barrier variables of the Health belief model were two factors related to participation in Pap smear testing. CONCLUSIONS: Health care professionals must provide women with more information about cervical cancer and the benefits of participating in cervical cancer screening programs.     

Effect of a community action intervention on cervical cancer screening rates in rural Australian towns: the CART project

BACKGROUND. The effect of community action on cervical cancer screening rates was explored in 20 rural Australian towns. METHODS. Town quarterly Pap test counts, from the Australian Health Insurance Commission, were converted to town rates using Census populations. Pap test rates for 12 quarters before and after mobilization were examined. RESULTS. Wilcoxon-Mann-Whitney tests demonstrated significantly higher per capita Pap test rates pre- to postmobilization for intervention towns compared to matched control towns for women whose last Pap test was more than 2 years ago (P=0.008). Maximum efficiency robust tests examining the equality of mean differences (intervention-control) of per capita rates between pre- and post-mobilization periods also found significant differences for Pap tests where last procedure was between 1 and 2 years ago (R = 13.9, P = 0.039) and near significance for Pap tests where last procedure was less than one year ago (R = 10.6, P = 0.087). CONCLUSIONS. It appeared that underscreened women were more likely and overscreened women were less likely to have a Pap test in response to the intervention. The results indicate that a community action program can positively impact cervical cancer screening rates.     

Cervical cancer screening beliefs among young Hispanic women

OBJECTIVES: This study examined beliefs, attitudes, and personal characteristics that correlated with self-reported cervical cancer screening history among Hispanic women aged 18 to 25 years old in El Paso, TX, a large metropolitan area on the U.S.-Mexico border. METHODS: Data were collected through a cross-sectional, face-to-face survey. The study questionnaire was based primarily on the Health Belief Model, and included scales that measured perceived susceptibility and seriousness of cervical cancer, and perceived benefits and barriers to Pap test screening. The study questionnaire also included measures of acculturation, Pap test history, pregnancy and sexual history, use of birth control, type of medical insurance, and educational attainment. RESULTS: Sixty-nine percent reported ever having had a Pap test and 56% reported having had a test in the past year. Eighty percent reported that they were sexually active, and of these, 63% reported using birth control. Respondents understood the seriousness of cervical cancer, their susceptibility to cervical cancer, and the benefits of Pap testing; however, only 61% agreed that most young women whom they know have Pap tests. Greater acculturation and the belief that most young unmarried women have Pap tests were positively associated with ever having screening. The perception that the test would be painful and not knowing where to go for the test were negatively associated with ever having a Pap test. CONCLUSIONS: This study found suboptimal rates of screening for cervical cancer in a sample of young Hispanic women residing along the U.S.-Mexico border. Although women may understand the seriousness of cervical cancer and the benefits of screening, perceptions about Pap tests may pose barriers to undergoing screening. Efforts to increase screening also may need to focus specifically on women who are least acculturated, as they also were least likely to have had prior Pap tests.     

Pap smear use in California: are we closing the racial/ethnic gap?

BACKGROUND: Minority women continue to be disproportionately affected by cervical cancer. Minority population groups at high risk for cervical cancer may be failing to fully comply with screening recommendations. The use of Pap smears among women in California was evaluated to identify ethnic groups at higher risk for noncompliance with cervical cancer screening. METHODS: Cross-sectional analysis of 2001 California Health Interview Survey data. Logistic regression was used to assess the independent contribution of race/ethnicity to the use of Pap smears. RESULTS: Hispanic (aPR = 1.03, 95% CI 1.02-1.05) and Black (aPR = 1.03, 95% CI 1.001-1.06) women are more likely to report a Pap smear in the past 3 years as compared to White women. Asians were the least likely to report cervical cancer screening despite a more favorable sociodemographic profile. Screening rates varied among Hispanic or Asian subgroups; Mexicans, Vietnamese, Chinese, and South Asians are particularly underserved. CONCLUSIONS: In contrast to the country as a whole, Hispanic women in California are more likely to report a recent Pap smear as compared to White women. However, racial/ethnic disparities in Pap smear use persist; Asian women are the least likely to report cervical cancer screening as compared to any other group.     

Effective screening programmes for cervical cancer in low- and middle-income developing countries.

Cervical cancer is an important public health problem among adult women in developing countries in South and Central America, sub-Saharan Africa, and south and south-east Asia. Frequently repeated cytology screening programmes--either organized or opportunistic--have led to a large decline in cervical cancer incidence and mortality in developed countries. In contrast, cervical cancer remains largely uncontrolled in high-risk developing countries because of ineffective or no screening. This article briefly reviews the experience from existing screening and research initiatives in developing countries. Substantial costs are involved in providing the infrastructure, manpower, consumables, follow-up and surveillance for both organized and opportunistic screening programmes for cervical cancer. Owing to their limited health care resources, developing countries cannot afford the models of frequently repeated screening of women over a wide age range that are used in developed countries. Many low-income developing countries, including most in sub-Saharan Africa, have neither the resources nor the capacity for their health services to organize and sustain any kind of screening programme. Middle-income developing countries, which currently provide inefficient screening, should reorganize their programmes in the light of experiences from other countries and lessons from their past failures. Middle-income countries intending to organize a new screening programme should start first in a limited geographical area, before considering any expansion. It is also more realistic and effective to target the screening on high-risk women once or twice in their lifetime using a highly sensitive test, with an emphasis on high coverage (>80%) of the targeted population. Efforts to organize an effective screening programme in these developing countries will have to find adequate financial resources, develop the infrastructure, train the needed manpower, and elaborate surveillance mechanisms for screening, investigating, treating, and following up the targeted women. The findings from the large body of research on various screening approaches carried out in developing countries and from the available managerial guidelines should be taken into account when reorganizing existing programmes and when considering new screening initiatives.     

Variation in the duration of protection given by screening using the Pap test for cervical cancer

The duration of protection offered by Pap screening for cervical cancer was examined using data on 101 cases of invasive cervical cancer and 396 controls from a Maryland case-control study. Receipt of a Pap test up to 4 years ago afforded significant protection, compared to women screened 11 or more years ago, or never screened. Smoking, intercourse before age 19, and a history of sexually transmitted disease were significant risk factors for cervical cancer; barrier contraception use was protective. Variation in protection from Pap screening was examined by age, race, age at first intercourse, barrier contraception use, and source of last Pap test (obstetrician-gynecologist vs other provider type). Results showed older women, women with earlier age of first intercourse, and non-users of barrier contraception received slightly less protection from Pap tests, while women who received their last Pap test from an obstetrician-gynecologist received significantly more protection than women who did not. Issues of quality of screening and follow-up are discussed in regard to these results.     

A mobile unit: an effective service for cervical cancer screening among rural Thai women

BACKGROUND: We carried out a systematic screening programme using a mobile unit with the purpose of increasing use of Papanicolaou (Pap) smear screening among rural Thai women. The mobile unit campaign was carried out initially between January and February 1993 and then in 1996 in all the 54 rural villages in Mae Sot District, Tak Province, northern Thailand. METHODS: To evaluate the effect of the programme on changes in knowledge and use of screening, we compared the results of three interview surveys of women, 18-65 years old, in villages selected by systematic sampling for each survey; first in 1991 (before the operation of the programme), secondly in 1994 (one year after the first screening campaign), and last in 1997 (one year after the second campaign). This report also compares data on Pap smears taken by the mobile unit with other existing screening services in the study area. RESULTS: A total of 1603, 1369, and 1576 women respectively, participated in each survey. The proportion of women reported knowing of the Pap smear test increased from 20.8% in 1991 to 57.3% in 1994 and to 75.5% in 1997. The proportion of women who had ever had a Pap smear increased from 19.9% in 1991 to 58.1% in 1994 and to 70.1% by 1997. Screening by the mobile unit accounted for 85.2% of all cervical intraepithelial neoplasia (CIN) III and all invasive cancers identified among the Pap smears taken by screening services in the area between 1992 and 1996. The rate of CIN III was 3.5/1000 smears in this screening programme, which was 5.2 and 2.0 times higher than the rates in the maternal and child health/family planning clinic and the annual one-week mass screening campaign respectively. CONCLUSIONS: The use of a mobile unit may be an effective screening programme in rural areas where existing screening activities cannot effectively reach the female population at risk.     

The coverage of cervical screening in Hungary

The purpose of this study is to calculate the proportion of women having cytological examination (Pap smear) of cervix either within or outside of the Hungarian organized cervical cancer screening programme. METHODS: The data derive from the financial database of the National Health Insurance Fund Administration (OEP) of Hungary covering the period of 2000-2005. The period 2000-2002 was considered as a reference period of opportunistic screening, while 2003-2005 was the first screening circle of organized screening. RESULTS: Between 2000-2002 1 667 618 women underwent cytological examination of Pap smear, and it increased to 1 749 498 women between 2003-2005. In the age-group 25-64 years, the annual coverage varied between 22.0-23.3% in 2000-2002, and it increased to 23.4-24.3% between 2003-2005. In the target population the 3-years-coverage increased from 48.9% in 2000-2002 to 52.6% in 2003-2005 (+3.7%). CONCLUSIONS: The organized screening programme managed to increase moderately the coverage of target population. In order to realize the mortality decline due to cervical cancer, participation rate must be increased.     

Cervical cancer screening among South Asian women in Canada: the role of education and acculturation

Cervical cancer screening by Papanicolaou (Pap) smear lowers the incidence and provides early detection of cervical cancer and is a preventative health care measure that should be available on a regular basis to all women at risk. As the population of ethnic women increases, it is important to assess whether these women are aware of and are utilizing this health service. A self-administered questionnaire was completed by 124 South Asian women, aged 18 to 60 years. Sixty-two South Asian students were selected from a university setting and 62 Tamil women were selected from a community center for South Asian women. This study examined the knowledge and use of Pap smears in South Asian women in Canada, and whether their level of acculturation or formal education influenced whether they know about and receive Pap smears. Low level of knowledge about the Pap test and a low prevalence of Pap testing behaviour was significantly correlated (p < 0.001) with a low level of formal education, education taking place outside of Canada, and a low index of acculturation. South Asian students were significantly more acculturated than Tamil women (p < 0.001). In conclusion, there was a low level of knowledge and prevalence of cervical cancer screening among South Asian women. This study highlights the need for educational interventions in Canada directed to ethnic women especially from South Asia.     

Hispanic acculturation and utilization of cervical cancer screening in the US

BACKGROUND: Hispanic women have an incidence rate of invasive cervical cancer that is twice as high as that of non-Hispanic White women. Previous investigations have reported that Hispanics are less likely to utilize cancer screening services. Using data from the 2000 National Health Interview Survey, this study examined whether acculturation of Hispanic women was associated with cervical cancer screening. METHODS: The subjects included 2307 Hispanic women aged 21-70 who did not have a history of cervical cancer or a hysterectomy. Women were analyzed by acculturation level according to whether or not they ever had a Pap smear and had one in the previous year and previous 3 years. RESULTS: Acculturation levels tended to be inversely correlated with no Pap smear. Compared to lower acculturated women, women who were more acculturated were less likely to never had a Pap smear (OR = 0.86; 95% CI = 0.58-1.27 for moderate acculturated women and OR = 0.51; 95% CI = 0.29-0.89 for higher acculturated women). Similar results were found for having no Pap smear within the past 3 years (OR = 0.83; 95% CI = 0.61-1.13 for moderate acculturated women and OR = 0.73; 95% CI = 0.49-1.08 for higher acculturated women). CONCLUSION: The findings show that lower acculturation was associated with the under use of cervical cancer screening and suggest that these women might have barriers in accessing and utilizing Pap smears.     

Use of mammography and Pap smear in Estonia,a country without organized cancer screening

Summary Objectives: To analyze mammography and Pap smear status in Estonia where no organized population-based cancer screening is available. Methods: 5000 individuals (aged 16–64) were randomly chosen from the national population register; among them, 1755 women filled out postal questionnaires. Results: 50% of respondents aged 45–64 reported having taken a mammogram, 51% of women aged 25–64 had the Pap smear at least once in their lifetime. Corresponding figures for the past two years were 37% and 30%. Irrespective of age, women taking fewer tests over the past two years were rural workers, unemployed, and health behavior recommendations ignorers. In most cases, initiative for mammogram came from women, and from the physician in the case of Pap smear. Moderate increase in mammography use occurred after a project for early detection of breast cancer was launched. Conclusion: Women must continuously be informed that early detection of breast and cervical cancer is possible. Young women should be encouraged to ask for Pap testing. Knowledge of family physicians should be improved. Submitted: 13 February 2006; Revised: 4 October 2006; Accepted: 8 November 2006     

Effect of an antepartum Pap smear on the coverage of a cervical cancer screening programme: a population-based prospective study

Background  

Almost one-third of Norwegian women aged 25–69 years invited to have a Pap smear do not attend during the recommended period, and thus constitute a population with high-risk of cervical cancer (CC). Since the incidence of precancerous lesions of the cervix peak with occurrence of pregnancies within the same decade in women aged 25 to 35 years of age, antepartum care presents an opportunity to offer a Pap smear thereby increasing the coverage of the programme. The study objective was to describe the effect of the antepartum Pap smear on the coverage of a cytological CC screening programme.     

HPV and cervical cancer testing and prevention: knowledge, beliefs, and attitudes among Hispanic women

Cervical cancer is a preventable disease resulting from infection with high-risk types of sexually transmitted human papillomaviruses (HPVs). Public knowledge of HPVs and their link to cervical cancer is limited. Participation in cervical cancer prevention programs, including Pap and HPV screening and HPV vaccine acceptance, is crucial for limiting the incidence of cervical cancer. Hispanic women suffer the highest cervical cancer incidence rates in the United States. In this study, we conducted community-based focus groups with Hispanic women to explore knowledge and attitudes relating to cervical cancer, HPV, HPV testing, and HPV vaccination. Study findings suggest a need to increase public health literacy in relation to HPV, the link between HPV and cervical cancer, and HPV primary and secondary prevention options. Health care providers should be prepared to share information with patients that supports and promotes informed decision making about HPV testing and vaccines and their complementary roles in cervical cancer screening and prevention.     

Cervical cancer screening in hospitals: the efficacy of legislation in Maryland.

OBJECTIVES. The purpose of the study was to examine the efficacy of a Maryland law requiring Pap testing to be offered during hospital admissions. "In-reach" strategies emphasize cancer screening within existing health care contacts (such as inpatient stays) rather than additional visits solely for screening. METHODS. Data from a 1986 telephone survey of Maryland women were used to examine the effect of hospitalization on self-reported Pap testing in a 3-year period. The effect of hospitalization on screening was examined by age and income to assess whether inpatient screening was more prevalent among certain subgroups of women. RESULTS. For the group as a whole, the odds of Pap screening did not vary with hospitalization. However, among women aged 45 to 54 years with annual household incomes over $20,000, hospitalized women were more likely than nonhospitalized women to report recent Pap tests. For low-income women aged 75 years and older, hospitalization actually decreased the likelihood of reporting Pap tests. CONCLUSIONS. Despite legislation, inpatient cervical cancer screening appears to mirror outpatient patterns, leaving elderly and low-income women unscreened. Methods for increasing inpatient Pap testing for underscreened women are discussed.     

Coverage and focus of a cervical cancer prevention program in southern Brazil.

OBJECTIVE: To determine the coverage and focus of cervical cancer screening (Pap smears) in a population-based sample in Brazil. METHODS: Cross-sectional cluster survey covering 1730 women aged 20 years or older with a history of sexual activity. Information was collected on social, demographic and behavioral variables, knowledge of and use of the Pap test. RESULTS: Of women aged 25-59 years, who are the target population of the national cervical cancer screening program, 78.7% had had at least one Pap test in their lifetime, and 68.8% had had a Pap test in the last 3 years. Statistics for focus of the program showed that of the 637 women who reported having a Pap test in the last year, only 20.6% actually required one. The remainder were either outside the age range or had had another test less than 30 months previously. Prevalence of not having been tested in the previous 3 years was highest among black (41.7%) and low-income women (64.3%), and among those at greatest risk for cervical cancer (62.3% for women with three or more risk factors). Focus was inversely related to socioeconomic status. CONCLUSION: Coverage rates were similar to those reported in other national studies, but this is the first report to examine the focus of the national program. We show that 8 of every 10 Pap tests were not necessary. Coverage levels remain unacceptably low among women of low socioeconomic status and those at greatest risk for cervical cancer.     

Who is being screened for cervical cancer?

Data from the 1973 National Health Interview Survey, a probability sample of the United States population, are used to examine the relationship between Pap testing and four socioeconomic variables. It was found that women at highest risk of cervical cancer are least likely to have had Pap tests. The proportion of women who report never having had a Pap test is greater among Blacks, the poor, the elderly and nonmetropolitan residents. In particular, poor Black women in nonmetropolitan areas have extremely high proportions reporting no Pap test. However, high risk women are only slightly less likely to have visited a doctor in the two years preceding interview. These results suggest that improvement in Pap test coverage among high risk women could be attained by encouraging the use of the Pap test in regular ambulatory medical care.