Knowledge of cervical cancer and utilization of pap smear among patients in a tertiary Centre in South West Nigeria

Dr Olusegun K Ajenifuja FWACS  Dr Adepiti C A

Gynaecological Oncology Unit Department of Obstetrics & Gynaecology, Obafemi Awolowo University
Teaching Hospitals complex, Ile-Ife. Osun state, Nigeria.

ABSTRACT
Objective: The objective of the study was to determine the knowledge of cervical cancer, patients' life style in relation to risk factors for cervical cancer and utilization of Pap smear as a screening method for cervical cancer.
Materials and Method: A structured questionnaire incorporating demographic, life style and knowledge of cervical cancer and its prevention was distributed to 500 consecutive women attending the gynaecological out- patient clinic of the Obafemi Awolowo University Teaching Hospital.
Results: 437 (87.4%) respondents completed the questionnaire. The mean age of respondents was 37.1 years (17-70). Knowledge of cervical cancer was low, as 62.7% of the respondents had never heard of cervical cancer. Also very few had actually done Pap smear.
Conclusion: Knowledge of cervical cancer is poor among Nigerian women and there is poor utilization of screening services
Key words: Cervical Cancer, Pap smear,  Prevention Risk factors

INTRODUCTION
Cervical cancer is an important reproductive health problem for women in the developing countries where it is the most common gynaecological cancer[1]. World wide, about 500,000 new cases are diagnosed every year with at least 288,000 deaths.[2]
About four out of every five new cases and most of the deaths from cervical cancer occur in the developing world [3]. The highest mortality rates have been reported in western and southern Africa, southern and Central America, Caribbean and south-central Asia [4].  Cervical cancer unlike other gynaecological cancers is a preventable disease because it has a preinvasive phase that can be detected and treated if women are screened for it.
Cervical cancer affects women in the premenopausal and postmenopausal years. It is a social problem due to the effects of the deaths of these women on their children and families.
The incidence and mortality from this form of malignancy has been largely reduced in the developed parts of the world because of organised screening for the premalignant lesions of the cervix as well as adequate treatment of these lesions [5].
While cervical cancer screening has become a success story of cancer prevention in the developed countries, this cannot be said of developing countries, which still bear the burden of this preventable malignancy.
Risk factors for cervical cancer includes early age at initiation of sexual intercourse multiple sexual partners or having partner who has multiple partners [6, 7]. Most women with cervical cancer are also highly parous women [8]. These factors are believed proxies for Human papillomavirus (HPV) infection, a sexually transmitted agent of the female genital tract [9]. Cervical cancer generally develops slowly taking over several decades from preinvasive to invasive lesion. This gives ample opportunity for the detection and treatment of the pre invasive lesion. The method of cervical cancer screening introduced several decades ago by Papanicolau and Traut has been the mainstay of cervical cancer screening in the developed countries and has contributed greatly to the reduction in the incidence of cervical cancer in these countries 10. Incidence of cervical cancer in many developed countries has fallen by more than 75% since the introduction of the Pap smear more than 40 years ago [1].
Incidence and mortality from cervical cancer continue to be high in developing countries so the survival of patients with cervical cancer is poorer when compared to the developed countries.
Unlike in the western countries, however, majority of women in developing countries present with advance stage disease which is often beyond the scope of surgery and the radiotherapy facilities in most developing countries are poorly developed thus most often death is inevitable. It is thus important to research into the reason(s) for the high incidence and mortality of this highly preventable cancer in this part of Nigeria.

OBJECTIVE: To determine the knowledge, life style and utilization of Pap smear as screening method  for the prevention of cervical cancer among women attending the gynaecological out patient clinics of Obafemi Awolowo University Teaching Hospitals Complex (OAUTHC).

MATERIALS AND METHODS
A structured questionnaire incorporating demographic, reproductive and sexual data as well as knowledge of cervical cancer and its prevention was designed for this cross  sectional survey. These were administered to 500 consecutive women attending the Gynaecological out Patients clinic of Obafemi Awolowo University Teaching Hospital in southwestern part of Nigeria over a period of three months. The hospital provides secondary and tertiary health care for 5 out of the 36 states in the country.
The questionnaires were administered by House officers posted to the department and were available for help while the participants completed the questionnaires.
Approval for this study was granted by the Ethics and Research Committee of the Teaching Hospital.
DATA ANALYSIS
All the data were analyzed using SPSS version 11 for Windows. Percentages and means were calculated.

RESULTS:
Of the 500 questionnaires administered, 437 (87.4%) completed the questionnaire. The mean age of respondents was 37.1 years (17-70). Most respondents were literate. 419 (96.0%) of the patients had had a form of formal education while 196 (45.0%) of the respondents were either housewives or employed in the informal sector (Table 1). Risk factors for cervical cancer were high in the respondents as 175 (40.0 %) of the respondents had their first sexual intercourse before the age of 20 years and 52 (12.0%) married before 20 years indicating that many of the women had their first sexual intercourse in the adolescent years. About 144 of the respondents (34.8%) had their first pregnancy before of 20 years and the mean pregnancy per respondent was 3.8(Table 2.) Contraceptive usage was also low.
175 (40.0%) of the respondents had never used any form of modern contraceptive. One hundred and thirty one (>30.0%) of the women had had more than one sexual partner while the number of women whose husbands had more than one wife was slightly less than this (28.4%). Knowledge of cervical cancer was low as 274(62.7%) of the women in this study has never heard of cervical cancer while only 58 (13.3%) knew of anyone that had had cervical cancer. The number that knew that cervical cancer could be prevented was 129 (29.5%). Awareness of Pap smear was low as only 85 (19.5%) had ever heard of Pap smear and only14 (3.2%) had done a Pap smear in the previous 5 years. However, 315 (72.1%) were ready to do Pap smear after it was explained to them. The importance of spousal consent was demonstrated in this study as 292 of the respondents (66.8%) said that they would require the consent of their partner before they could do Pap smear (Table 3)

DISCUSSION.
Global efforts to reduce the incidence and mortality from cervical cancer has been through the screening of women with Pap smear, which was introduced over four decades ago. This method of screening has largely been responsible for the reduction seen in developed countries[2,5]. In many developing countries, many women have never had a Pap smear as has been demonstrated by this study. 423(96.8%) of the women in this study had never done Pap smear in the  previous five years compared to the United States of America where more than 80% have had Pap smear in the previous three years[11]. This finding in this study is similar to the one done in South Africa where it was discovered that 80% of the women had never been screened[12].
Important risk factors for cervical cancer include having multiple sexual partners or having partners who in turn have multiple partners. This is because having multiple sexual partners increases the risk of acquiring Human Papillomavirus, the aetiological agent for cervical cancer. About 30% of the women in this study have had more than one sexual partner, and the number whose husband had more than one wife was only slightly less, hence most women in the study were at high risk for cervical cancer.
Pap smear is a cytological test designed to detect precancerous cells from the cervix.
Though Pap smear has been practiced in Nigeria for many years, the incidence and mortality from cervical cancer has not shown any significant reduction. Most women still present with advance stage disease with little chance of cure. The screening has been well concentrated in urban areas and largely focused on low risk women. This is similar to the experiences of many developing countries. For example, in Mexico, many young women in urban areas were repeatedly screened in a nation-wide screening program while older
women who are more at risk had no access to screening[13].
Knowledge about cervical cancer is still low in the developing countries as was demonstrated by this study. Most women in this study (62.7%) had never heard of cervical cancer. Lack of awareness about cervical cancer and its prevention is an important barrier to women seeking cervical screening[14]. This was demonstrated in this study as 85 (19.5%) of the women in this study had never heard of Pap smear as a screening method for cervical cancer. This result is similar to the one obtained by Ajayi et al[15]. Also in Kenya, a study done revealed that only 32% of women admitted in a hospital knew about Pap smear testing[16]. When, however Pap Smear was explained to the participants in this study, a large number, 315 (72.1%) were willing to undertake the test. Thus, creating awareness among women through public campaigns, Non Governmental Organizations as well as health institutions about national screening programs as have been done in many developed countries, would greatly assist in reducing the burden of this highly preventable cancer. The information should not only target the women, their male partners should also be made to know the importance of cervical cancer screening. From this study over 288 (66.4%) of the women would require the consent of their partners before doing Pap smear.
One of the risk factors for the development of cervical cancer is early age of initiation of sexual intercourse. This is because the most critical phase of initiation of squamous metaplasia is at puberty and during the first pregnancy. In fact, it has been shown that the lifetime risk of developing cervical cancer is increased 26-fold if the age of first sexual intercourse is within 1 year of menarche as opposed to 23 years of age or older[11].
Most women in this study were at high risk for developing cervical cancer. In this study 175 of the women (40.0%) had their first sexual intercourse before the age of 20 years and 144 (34.8%) had their first pregnancy before 20 years. 52 women (12%) married before the age of 20 years. Thus the risk of developing this disease among the respondents, taking into consideration the recognized risk factors, is very high. Screening will therefore be essential and probably life saving in this group of patients.

CONCLUSION:
Knowledge of cervical cancer is low, and utilization of screening services is poor among Nigerian women. A lot needs to be done in terms of public enlightenment about the risk factors and provision of screening services to the populace.

REFERENCE:

1. Sankaranarayanan R, Ferlay J: World wide burden of gynaecological cancer: The size of the problem. Best Practice &Research Clinical Obstetrics and Gynaecology 2006 Vol 20 (2) 207-22.
2. Tjalma WAA. Cervical cancer and prevention by vaccination: results from recent trials. Annals of oncology 17 2006 (suppl10): X217-X223.
3. Parkin DM, Bray F, Ferlay J, and Pisani P. Global cancer statistics, 2002. CA Cancer J Clin 2005; 55:74-108.
4. Paola Pisani, D. Maxwell Parkin, Freddie Bray, Jacques Ferlay. Estimates of the worldwide mortality from 25 cancers in 1990. Int J cancer 1999; 83: 18-29.
5. Cannistra SA, & Niloff JM. Cancer of the uterine cervix. N Engl J Med 1996; 334: 1030-1038.
6. Green J,  Berrington A de Gonzalez,  Sweetland S,  Beral V, Chilvers C, Crossley B, et al. Risk factors for adenocarcinoma and squamous cell carcinoma of the cervix in women aged 20-44 years: the UK National Case-Control study of cervical cancer. Br J Cancer 2003; 89: 2078-2086.
7. Chicharson S, Herrero R, Munoz N. Risk factors for cervical cancer in Thailand: a case-control study. J Natl Cancer Inst 1998; 90: 50-57.
8. Kjaer SK: Risk factors for cervical neoplasia in Denmark. APMIS Suppl 1998;   80: 1-41.
9. Bosch FX, Lorincz A,  Muñoz N, Meijer CJLM, and  Shah KV. The causal relation between human    papillomavirus and cervical cancer [comment] (review). J Clin Pathol 2002; 55: 244-265.
10. Laara E et al. Trends in mortality from cervical cancer in the Nordic countries: association with organised screening programmes. Lancet 1 1987 (8544) : 1247-1249
11. Campion MJ, Preinvasive Disease In: Berek JS and Hacker (Eds) Practical Gynecologic Oncology. Lippincott Williams & Wilkins. 2005. 256-336.
12. Fonn S, Bloch B, Mabina M, et al.Prevalence of precancerous lesions and cervical cancer in South Africa: a multicentre study. S Afr Med J 2002; 92(2): 148-56.
13. Lazcano-Ponce EC, Moss S, Alonso de Ruiz P, Jorge Salmerón Castro, Mauricio Hernández Avila.  Cervical screening in developing countries: why is it ineffective? The case of Mexico. Arch Med Res1999; 30: 240-250.
14. Lazcano-Ponce EC, Castro R, Allen B. Barriers to early detection of cervical-uterine cancer in Mexico. Journal of Women's Health 1999. 8 (3):399-408.
15. Ajayi IO, Adewole IE. Knowledge and Attitude of General Outpatient Attendants in Nigeria to Cervical Cancer.  Central African Journal on Medicine 44 (2)41-42.1998.
16. Gichangi P, Estambale B, Bwayo J. Knowledge and practise about cervical cancer and Pap smear among patients at Kenyatta National Hospital, Nairobi. Int J Gynecol Cancer 2003; 13: 827-833.