Call for Systematic Population-Based Cervical Cancer Screening: Findings from Community-Based Screening Camps in Tamil Nadu,India

Background: In India, systematic cervical cancer screening under the national programme is yet to cover the entire population and therefore opportunistic or camp based approach is commonly practiced screening mode currently. This study presents the proportion of screen-positive women [positive visual inspection of the cervix with acetic acid (VIA) and/or Papanicolaou (Pap) smear results] and its associated factors from a rural community-based cervical cancer screening conducted in a service setting. Methods: In this cross-sectional study involving record review, data was drawn from free screening camps conducted by a non-governmental organization in two rural districts of Tamil Nadu, India between March 2015 and March 2017. The associations were assessed using adjusted prevalence ratio with 95% confidence interval. Results: A total of 5,207 women were screened from 307 camps. The mean age was 39.5 years (SD: 8.6). At least one symptom was observed among 2,245 women (43.1%). Of 5,207 women, 19.4% (n=1,009, 95% CI: 18.3%, 20.5%) were screen-positive. Screen positivity in women     

A Descriptive Study of Different Methods of Cervical Cancer Screening among Ever-Married Women in 35-Year and 45-Year Cohorts in Kalutara District,Sri Lanka

Objective: Screening for cervical cancer in Sri Lankan females with Pap smears (conventional cytology) has shown no marked reduction in cervical cancer incidence over the past two decades. The study aims to compare the efficacy of Pap smear, with other screening tools such as Liquid Based Cytology (LBC) and Human Papilloma Virus/deoxyribonucleic acid (HPV/DNA) (using cobas 4800) in detection of underlying cervical intraepithelial neoplasia (CIN) and cervical cancer among 35 and 45 year old ever married women in Kalutara districtin Sri Lanka. Methods: Women from 35-year cohort and 45-year cohort were selected from all Public Health Midwife areas (n=413) in Kalutara district by random sampling. Pap smear, LBC, and HPV/DNA specimen were collected s from women who attended the Well Woman Clinics (WWC) . Women with positive results from any method were confirmed by colposcopy.  Results: Of the, 510 and 502 women in the 35-year cohort and 45-year cohort, respectively, included in the analysis, nine women among 35-year cohort (1.8%) and 7 women among 45-year cohort (1.4%) had cytological abnormality (positive results) with Pap smears. Thirteen women among 35-year cohort (2.5%) and 10 women among 45-year cohort (2%) age groups had cytological abnormality (positive results) with Liquid Based Cytology reports. Total of 32 women among 35-year cohort (6.2%) and 24 women among 45-year cohort (4.8%)  were positive for HPV/DNA test. Of  the women tested positive on screening, colposcopy revealed that HPV/DNA method was superior to Pap and LBC for detecting CIN while the results of latter two were comparable. Conclusions and Recommendations: The CIN detection rate by colposcopy was high with HPV/DNA screening with cobas 4800, whereas the detection rate by LBC was insignificantly higher than Pap smears.     

Understanding Barriers and Facilitators of Breast and Cervical Cancer Screening among Singapore Women: A Qualitative Approach

Objective: The uptake of breast and cervical cancer screening services among women in Singapore remains inadequate. Little is known about how gender norms influence women’s decision to undergo these screening services in a multi-ethnic Asian context. This research aimed to explore how gender-based qualitative factors influence women’s decision to screen. Methods: Qualitative data were collected using semi-structured interviews from 40 racially diverse women aged 25 and above who had visited polyclinics for their chronic disease management. Women were recruited using a purposive maximum variation sampling strategy to ensure representation of their views from the three major ethnic groups and based on inclusion criteria. Interviews were conducted either face-to-face or via telephone call. Interviews were audiotaped and lasted 30 minutes on average. Interviews were conducted until data saturation was reached. The data was transcribed and analysed thematically. Results: Gender norms and gender non-concordance with the healthcare professionals did not inhibit women from undergoing breast and cervical cancer screening services to a large extent. Women were empowered and had a central role in decision-making for screening services. Healthcare initiatives such as subsidies and mobile health applications facilitated the uptake of breast and cervical cancer screening services but can be improved further. Some of the barriers reported by Malay Muslims were not dissimilar to previous qualitative studies with women in this ethnic and religious group. Conclusion: Gender socialisation, empowerment, and healthcare initiatives did not inhibit our study participants’ decision to undergo breast and cervical cancer screening services. However, new initiatives and strengthening of the existing healthcare initiatives are needed to overcome any remnants of gender-related nuances and convert non-doers into doers.     

Educational Interventions for Cervical Cancer Screening Behavior of Women: A Systematic Review

Background: Cervical cancer is the second most common cancer in women worldwide; early detection can playa key role in reducing the associated morbidity. The objective of this study was to systematically assess the effects ofeducational interventions on cervical cancer screening (CCS) behavior of women. Methods: In this review the Cochranelibrary, Web of Science, Science Direct, PubMed, Scopus and search engine of Google scholar were searched for allinterventional studies (trails, pre- and post-test or quasi-experimental) published in 2000-2017 for a systematic review,The search was based on the following keywords: cervix cancer, uterine cervical neoplasms, screening, prevention andcontrol, Papanicolaou Test, pap test, pap smear, education, intervention, systematic review. Due to the heterogeneityof the data, a qualitative analysis was performed. Results: Thirty seven articles with 15,658 female participants indifferent parts of world were included in the review. About three quarters of the articles covered behavior changeinterventions. About one fourth of the articles were based on health education methods. The heath belief model isthe most popular used framework for cervical cancer screening interventions. The results of our study showed thatdifferent health education methods (such as calls, mailed postcards, mother/daughter education. consultation sessions,picture books, videos, PowerPoint slides, small group discussions, educational brochures, radio broadcast education,lecture presentations, tailored counseling and a fact sheet, Self-learning package, face-to- face interviews and etc) areeffective in modifying cervical cancer screening behavior of women. Conclusions: Our results showed that the differentinterventions and health behavior change frameworks provide an effective base for cervical cancer prevention. Heathproviders can chose educational methods based on the particular client situations.     

Exploring the Barriers to Cervical Cancer Screening through the Lens of Implementers and Beneficiaries of the National Screening Program: A Multi-Contextual Study

Background: Cervical cancer is a major reason for morbidity and mortality in Low and Middle income countries. The National Programme for Prevention and Control of Cancers, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS) sets out broad national guideline to implement Cervical cancer screening. However, an implementation strategy for cervical cancer screening is not in place for districts. Although opportunistic screening takes place, implementation is hindered by psychological and physical barriers for women, as well as insufficient capacity on the part of implementers. This qualitative study aims to identify the specific barriers that prevent the uptake of cervical cancer screening. Methods: Women who could benefit from cervical cancer program were interviewed to explore the factors that influenced their uptake of the cervical screening offered. Key informant interviews were conducted with implementers of the NPCDCS and with public health staff of three States (Himachal Pradesh, Meghalaya and Karnataka), to understand their perception of determinants of the utilization of screening services. Results: The general health concern among the participants was low, and routine check-ups were considered unimportant. Poor knowledge about cervical cancer, benefits of screening service availability, as well as a general sense of well-being, embarrassment or anxiety related to the screening procedure, fear of being judged for lack of modesty, and stigma were common barriers to screening uptake. In addition to a general unawareness of cervical cancer geographical inaccessibility of screening as a barrier to participate in cervical cancer screening, in certain regions. Conclusion: It is essential to increase the knowledge on cervical cancer and on the benefits of screening among Indian women. Providing information and cues to action by health workers and professionals can facilitate the decision to participate. Implementers need to be involved to ensure context specific implementation of the National programme to overcome these barriers.     

Opportunistic Screening for Cervical Cancer in a Tertiary Hospital in Karnataka,India

The incidence and mortality of cervical cancer remains high in India even after sixty years of introductionof the Pap smear (cervical cytology) which is an effective means of identifying preinvasive lesions of carcinomacervix. The morbidity and mortality due to cervical cancer has come down drastically in countries with wellestablished screening programmes at national level. This study aims at screening women for cervical canceropportunistically during their visit to hospital and to study various types of neoplastic and non-neoplastic lesionsof the cervix by cervical smear study (Pap smear study). In the present study, a total of 350 cervical smearswere studied. The age of patients ranged from 19 years to 80 years with mean age being 37.5 years. Out of 350cases, the diagnosis of neoplasia was given in 43 cases and 258 cases were diagnosed as inflammatory smears.Forty-cases were normal and 9 cases were inadequate to evaluate. Forty-three patients who were found to haveneoplastic lesions on cytology were referred for further investigations like colposcopy and biopsy to confirm thediagnosis and avail proper treatment. Limitation of the present study was small sample size as all female patientsaged between 20 and 60 years visiting hospital were not included in the screening, other screening tests like VIA(visual inspection with acetic acid test) and HPV DNA (human papilloma virus) tests were not done. Until thetime centrally organised screening programmes for cervical cancer are established in India, arrangements shouldbe made for hospital based opportunistic screening for all women attending hospital. The cost effectiveness ofdifferent screening tests for cervical cancer should be evaluated.     

The Pap-Smear Test Experience of Women in Turkey: A Qualitative Study

Objective: The study was planned with the purpose of examining the attitude of women who have pap-smeartest for the early diagnosis of cervical cancer, factors affecting their decisions and their feelings and experiencesduring this period. Materials and Methods: A phenomenological method was used. Data were collected betweenMarch 2012 and April 2012 using standard and purposive samplings from 17 women. A detailed interview withwomen were held in their houses and recorded. The data collection tool consisted of two parts, one of which isinformation form with 17 questions identifying sociodemographic and cervical cancer risk factors of women andthe second part is made up of semi-structured interview form with 15 alternative questions taking literature andthe pap-smear test into consideration. Collected data were put into a written document. Content analysis washeld by loading the documents into NVIVO 8 Statistical Programme. Results: The study comprised themes suchas cervical risk factor, decision of taking pap-smear test, taking pap-smear test, knowledge about pap-smear test,relieving factors during pap-smear test, obstructive factors during pap-smear test, gynecological examinationand feelings of women during and after pap-smear test while waiting for the results. Conclusions: As womenperceive gynaecological examinations differently from other examinations, they have different feelings in eachprocess of the Pap smear test. Medical staff should advise women more clearly on the nature and advantages ofthe Pap-smear test.     

Opportunities and Barriers to Breast Cancer Screening in a Rural Community in Coastal Karnataka,India: A Qualitative Analysis

Background: Breast cancer is reported to be the most common cancer among women in India with a high mortality to incidence ratio. Late presentation, driven by lack of awareness and limited accessibility to health services are some of the stated reasons for this. Given this context, this qualitative study was carried out to understand the perception of rural women towards the disease and factors that influenced utilization of available screening services among them. Methods: Forty-four rural women aged 20-60 years from a coastal province in southern India participated in four Focus Group Discussions (FGDs) that were conducted to understand their perception, attitudes and barriers towards breast cancer screening. Participants were identified from the community through purposive sampling and constituted of home makers and working women. The FGDs were led by trained facilitators and the discussions recorded. Ideas and concepts that emerged were listed as codes. Related and similar codes were grouped to form six themes. Results: Women in the study belonged to low- and middle-income households with a mean age of 42.8 ± 7.8 years and almost all had attended school. Although the respondents exhibited fairly good knowledge about the disease, cultural inhibitions, forgetfulness, economic constraints and apprehension towards tertiary health care facility were some of the barriers reported in the uptake of screening services. Participants hailed the role of female health care providers as motivational figures and stressed the need for easily comprehensible information dissemination strategies besides expecting an equal participation of men in issues involving women’s health. Conclusion: Involving cancer survivors as educators and empowering men on women’s health in addition to the felt need of a patient advocate to improve accessibility were some of the highlights of the discussions. Addressing these could go a long way in improving the cancer care continuum in the region.     

Awareness Level about Breast Cancer Risk Factors,Barriers, Attitude and Breast Cancer Screening among Indonesian Women

Background: Globally, breast cancer is the second most common cancer in women and is a leading cause of mortalityin Indonesia. Raising awareness of breast cancer is particularly important to help at risk women seek medical treatmentfor this disease. This study aimed to comprehensively investigate the Indonesian women’s level of knowledge aboutbreast cancer risk factors, barriers, attitude and breast cancer screening. Methods: This population-based cross-sectionalstudy administered the breast cancer awareness Indonesian scale (BCAS-I) to 856 Indonesian women. Samples wereselected in rural and urban combinations from three provinces by stratified random sampling. The ordinal logisticmodel was used to investigate the clustering effect of the participant’s characteristics in this study. Results: Of thewomen, 62% lived in rural areas and 38% lived in urban areas. Living in an urban area was significantly associatedwith a lower knowledge of the risk factors. However, living in an urban area was significantly associated with betterattitudes and healthier behaviours related to breast cancer awareness. Women with higher education levels had 70%worse attitudes toward breast cancer awareness. Women living South of Sumatera, women living in Yogyakarta, andunmarried women were 5.03, 3.84, and 1.56 times as likely to have higher perceived barriers, respectively. Conclusion:Urban women had a poorer level of knowledge of breast cancer risk factors compared to women living in more ruralareas. The result of this study may reflect inadequate breast cancer awareness campaigns or a lack of breast cancerawareness campaigns. These findings suggest that additional education programs aiming to increase awareness andeducate the public are needed.     

Determinants of Breast Cancer Screening Practice among Women in Indonesia: A Nationwide Study

Background: Breast cancer remains the leading cause of death for women globally, including in Indonesia. Breast cancer screening plays a vital role in reducing deaths caused by breast cancer. However, breast cancer screening rate is still low and studies on determinants for breast cancer screening is limited in Indonesia. This study aimed to identify the determinants of breast cancer screening among women in Indonesia. Methods: This population-based study was conducted among 827 women who lived in either rural and urban areas, using a stratified sampling design where were based on province and locality combinations. Data were analysed using a binary logistic regression model to assess the associations between independent and dependent variables. Results: As many as 827 women with an average age of 29.91 (± 11.14) years old participated in this study. The overall breast cancer screening among women was 18.74%. Knowledge of breast cancer risk factors, signs, and symptoms (adj.OR = 1.75, 95%CI: 1.20 – 2.56), age of 35 to 39 years old (adj.OR. = 1.52, 95% CI: 1.02 – 2.26), and household income of ≥6,000,000 IDR (≥457 USD) (adj.OR. = 5.19, 95%CI: 1.43–18.84) were associated with breast cancer screening attendance. In contrast, Christian women had a significantly lower breast cancer screening rate that women from other religions (adj. OR. = 0.45, 95%CI: 0.24 – 0.85). Conclusion: The overall breast cancer screening attendance was poor among Indonesian women population. Age, household income, religion, and knowledge of breast cancer risk factors were identified as the determinant factors for breast cancer screening.     

Barriers to Cervical Cancer and Breast Cancer Screening Uptake in Low-Income and Middle-Income Countries: A Systematic Review

Background: Cervical cancer (CCa) and breast cancer (BCa) are the two leading cancers in women worldwide. Early detection and education to promote early diagnosis and screening of CCa and BCa greatly increases the chances for successful treatment and survival. Screening uptake for CCa and BCa in low and middle - income countries (LMICs) is low, and is consequently failing to prevent these diseases. We conducted a systematic review to identify the key barriers to CCa and BCa screening in women in LMICs. Methods: We performed a systematic literature search using Ovid MEDLINE, EMBASE, PsycINFO, SCOPUS, CINHAL Plus, and Google scholar to retrieve all English language studies from inception to 2015. This review was done in accordance with the PRISMA-P guidelines. Results: 53 eligible studies, 31 CCa screening studies and 22 BCa screening studies, provided information on 81,210 participants. We found fewer studies in low-income and lower - middle - income countries than in upper - middle - income countries. Lack of knowledge about CCa and BCa, and understanding of the role of screening were the key barriers to CCa and BCa screening in LMICs. Factors that are opportunities for knowledge acquisition, such as level of education, urban living, employment outside the home, facilitated CCa and BCa screening uptake in women in LMICs. Conclusions: Improvements to CCa and BCa screening uptake in LMICs must be accompanied by educational interventions which aim to improve knowledge and understanding of CCa and BCa and screening to asymptomatic women. It is imperative for governments and health policy makers in LMICs to implement screening programmes, including educational interventions, to ensure the prevention and early detection of women with CCa and BCa. These programmes and policies will be an integral part of a comprehensive population-based CCa and BCa control framework in LMICs.     

Forgone Health and Economic Benefits Associated with Socioeconomic Differences in Organized Cervical Cancer Screening

Objective: To describe cervical cancer screening participation among women in Taiwan under its population-based screening policy and to estimate the economic burden of disease attributable to avoidable disparities in cervical cancer (CC) screening. Methods: We identified a nationally-representative sample of females aged 30 years or above who were eligible for Pap smear testing in Taiwan from 1 January to 31 December 2013. An administrative database with detailed claims of health care utilization under the universal coverage health care system was used. Socioeconomic position of the female subjects was defined using the occupation classification, and two groups were specifically identified: general (O1) and low-income (O5) groups. Differences in screening rate, CC prevalence, and CC-attributable deaths were assessed between the two groups. Economic consequences as a result of screening inequalities were estimated using actual total health care spending (health care expenditure), monetary value per life-year and years of life lost for ill health and screening disparities (health as consumption good), and productivity losses alongside costs of social benefits (health as capital good). Result: A total of 301,057 enrolled females aged 30 years and older eligible for screening were identified. Overall, 3-year and 1-year screening rates among all subjects were 0.601 and 0.372, respectively. Impact of observed differences in screening translated to US$59,568 of health care spending in one year, 90.4% of which was specific to hospital admissions. When we viewed health as a consumption good and capital good, the impact of screening disparity on health losses through CC would be equivalent to US$78,095 and US$190,868, respectively. Conclusion: Forgone health and economic benefits associated with inequalities in CC screening uptake can be considerable in productive women.     

Self-Collection Tools for Routine Cervical Cancer Screening: A Review

Sub-optimal participation is a major problem with cervical cancer screening in developing countries whichhave no organized national screening program. There are various notable factors such as ‘embarrassment’,‘discomfort’ and ‘no time’ cited by women as they are often also the bread winners for the family. Implementationof self-sampling methods may increase their participation. The aim of this article was to provide a survey ofvarious types of self-sampling tools which are commonly used in collection of cervical cells. We reviewed currentlyavailable self-sampling devices and collated the advantages and disadvantages of each in terms of its acceptanceand its accuracy in giving desired results. In general, regardless of which device is used, self-sampling for cervicalscrapings is highly acceptable to women in most of the studies cited.     

Breast Cancer Awareness at the Community Level among Women in Delhi,India

Background: To assess women’s awareness from diverse sections of society in Delhi regarding various aspectsof breast cancer (BC) – perceptions, signs and symptoms, risk factors, prevention, screening and treatment.Materials and Methods: Community-level survey was undertaken in association with the Indian Cancer Society(ICS), Delhi during May 2013-March 2014. Women attending BC awareness workshops by ICS were givenself-administered questionnaires before the workshop in the local language to assess BC literacy. Informationprovided by 2017 women was converted into awareness scores (aware=1) for analysis using SPSS. Awarenessscores were dichotomized with median score=19 as cut off, create more aware and less aware categories. Bivariateand multivariate analysis provided P-values, odds ratios (ORs) and 95% confidence intervals (CIs). Results:Broadly, 53.4% women were aware about various aspects of BC. Notably, 49.1% women believed that BC wasincurable and 73.9% women believed pain to be an initial BC symptom. Only 34.9% women performed breast selfexamination(BSE) and 6.9% women had undergone clinical breast-examination/mammography. 40.5% womenhad higher awareness (awareness score > median score of 19), which was associated with education [graduates(OR=2.31; 95%CI=1.78, 3.16), post-graduates (OR=7.06; 95%CI=4.14, 12.05) compared to ≤ high school] andsocio-economic status (SES) [low-middle (OR=4.20; 95%CI=2.72, 6.49), middle (OR=6.00; 95%CI=3.82, 9.42)and upper (OR=6.97; 95%CI=4.10, 11.84) compared to low SES]. Conclusions: BC awareness of women in Delhiwas suboptimal and was associated with low SES and education. Awareness must be drastically increased viacommunity outreach and use of media as a first step in the fight against BC.