ABSTRACT

Cervical cancer is an important women’s reproductive health problem. It is a preventable disease of significant public health concern especially in developing countries. It is the third most common cancer worldwide and the second most common cancer and leading cause of death from cancer among women in developing countries. A cross-sectional, descriptive study was performed in the Gynaecology clinic, Owerri General Hospital, from January to March 30, 2013. To determine the prevalence of premalignant lesions in cervical smears, to assess the knowledge, and risk factors of cervical cancer and to determine the uptake of screening among women of child bearing age group among women attending Gynaecology clinic in General Hospital Owerri. Data were analyzed with Epi-info V 3.5.3 Analysis at 95% confidence interval, 5% significance level. Univariate analysis applied include frequencies, means. proportions, while bivariate analysis include the calculation of prevalence odds ratios, analysis for association between cervical abnormalities and selected exposure factors, Fisher’s exact test for statistical significance. A total of 108 pap smear samples were collected and questionnaires administered to each of the participants, Of the participant 14 (13.9%) 95% CI (0.8-21.9) had pap smear with abnormal findings. The abnormal cytological results were low grade squamous intraepithelial lesion (LSIL) seen in 12 (11.11%) with 2 (1.9%) human papilloma virus (HPV) effects. Out of which 17(16%) had inflammation, Majority 72 (66%) of respondents reported having heard about cervical cancer, out of which 77 (71%) of respondents had heard about cervical cancer screening, 74 (68%) knew Pap smear test as the only screening method while 67(62%) of women did not have knowledge on the risk factors for cervical cancer. Uptake was low only (5) 4.6% have had cervical cancer screening prior to the study. This study showed prevalence of abnormal positivity of 14(13.9%) 95% CI (0.8-21.9) which is consistent with previous reports of the prevalence of abnormal cervical smear in women in Sub-Saharan Africa. The age pattern was notable, with the highest prevalence among women ≥ 49 years. Intense public health campaign be conducted on a recurring basis; providing cervical cancer education with emphasis on its aetiology, risk factors and methods of prevention. Policies should be put in place that encourage or as appropriate mandate that all women coming for antenatal services are provided with the options of a Pap smear test.

CHAPTER ONE

INTRODUCTION

1.1 Background of the study

Cervical cancer is an important reproductive health problem. It is a preventable disease of significant public health concern especially in developing countries. It is the third most common cancer worldwide and the second most common cancer and leading cause of death from cancer among women in developing countries.¹ In 2018, there were an estimated 529,000 new cases and 274,000 deaths due to cervical cancer. It is estimated that over one million women worldwide currently have cervical cancer, most of whom have not been diagnosed, neither do they have access to treatment that could cure them or prolong their life.² High-risk regions are Eastern and Western Africa: Agestandardized rate (ASR) greater than 30 per 100,000), Southern Africa (26.8 per 100,000), South-Central Asia (24.6 per 100,000), South America and Middle Africa (ASRs 23.9 and 23.0 per 100,000, respectively). Rates are lowest in Western, Northern America and Australia/New Zealand (ASRs less than 6 per 100,000).⁴ More than 85 % of cervical cancer deaths occur in developing countries, where it accounts for 13% of all female cancers.

Cervical cancer used to be the leading cause of cancer death for women in the United States. However, in the past 40 years, the number of cases of cervical cancer and the number of deaths from cervical cancer have decreased significantly.² This decline is largely due to the result of regular screening using Pap tests, which can detect cervical precancer before it turns into carcinoma in situ.³ In 2018, 11/100,000 women in the United States were diagnosed with cervical cancer while 3/100,000 women died from cervical cancer.⁴ While the incidence of cervical cancer in less developed countries is 453/100,000 women and 242/100,000 women died from it. In sub-Saharan Africa, lack of effective screening and treatment policy, strategies and programs largely explains the high cervical cancer prevalence and mortality in most countries. With no access to quality prevention and detection services, most women seek consultation only when the disease is already at an advanced stage, with age-standardized rates of 35.7 per 100,000 women in Bamako, Mali, and 41.7 per 100,000 women in Kyadondo, Uganda.

Nigeria is the most populous country in Sub-Saharan Africa, with approximately 167 million inhabitants (2021 population estimate), a life expectancy at birth of 50.6 years in men and 52.6 years in women, child mortality of 159 and 152 per 1000 in males and females, respectively, and per capita total expenditure on health of US $8 per year, with women population of 36.59 million aged 15 years and older who are at risk of developing cervical cancer.

A current estimate indicates that every year, 9,922 women are diagnosed with cervical cancer and 8,030 died from the disease. In Nigeria cervical cancer is the second most common cancer among the female population and the second most frequent cancer among women between 15-44 years.^5,6 The annual age-standardized incidence of cervical cancer in Ibadan in 1998–2019 was 19.9 per 1000,000 women.⁷

In spite of a vaccine that holds some promise for cervical cancer prevention, screening is still essential. A vaccination programm will not eliminate the need for screening because the current vaccines only protect against HPV types that are responsible for about 70% of cervical cancer cases.⁸ Hopefully, with a combination of a vaccine, good screening and education, young women will stand a better chance of avoiding cervical cancer.⁸ Human papillomavirus (HPV) is a primary cause of cervical cancer which is the second most common cancer in women worldwide. Human papillomaviruses are common throughout the world. As many as 50% of people with HPV genital infections are asymptomatic but persistent infection can cause cervical cancer in women and transmission of the virus to

others.⁹

Internationally, the worldwide prevalence of HPV in cervical carcinoma is 95-99.7%.¹⁰ virtually all cervical cancer cases (99%) are linked to genital infection with HPV which is the most common viral infection of the reproductive tract. HPV can also cause other types of cancer such as anogenital cancer, head and neck cancers, and genital warts in

both men and women. HPV infections are transmitted through sexual contact.¹¹

Cervical HPV infection is a common sexually transmitted infection affecting an estimated 50-80% of sexually active women at least once in their life time.¹² High risk HPV types 16 and 18 are together responsible for over 65% of cervical cancer cases.^13,10,12 Yet only recently has information on the prevalence of cervical infection become available. 7,14,15,16,17

Other risk factors such as early age of sexual activity onset, multiply sexual partners, low socio-economic status, smoking, nutritional factors and long use of contraceptives have all been implicated as potential risk factors for cervical cancer,⁷ cervical cancer is characterized by the abnormal growth of cells in the cervix, the region of the uterus that joins the vagina. It usually arises from a ring of mucosa called the cervical transformation zone which is a ring of active squamous metaphase where the stratified squamous epithelium of ectocervix progressively undermines and replaces the columnar epithelium of endocervix.¹⁸ Each year, there are about 400,000 new cases of cervical cancer, 80% of which occur in developing countries, Worldwide, every two minutes a woman dies of

cervical cancer.19,20,21

There are major steps in cervical cancer development which are the infection of metaplastic epithelium at the cervical transformation zone, viral persistence, progression of persistently infected epithelium to cervical precancer and invasion through the basement membrane of the epithelium. Cervical cancer may not cause any symptoms at first, but later could be manifested by unusual vagina bleeding or discharged bowel and

bladder problems, and pains.²²

It usually takes several years for normal cells in the cervix to turn into cancer cells. Cervical cancers could be prevented by doing a Papanicoloau (Pap) test which is used in detecting abnormal cells-examining cells from the cervix under a microscope and by getting regular Pap tests done, changing cells could be found and treated before turning into cancer. Women who do not have regular cervical cancer screenings substantially increase their risk of developing cancer, because potentially precancerous lesions are not detected and they do not receive appropriate follow up.²³

1.2 Statement of the Problem

Cervical cancer is the second most common cancer among women worldwide.²⁴ It is a major public health problem of low income countries including Nigeria, having only 5% of global resource for cancer control.^25,26,27 Annually 300,000 deaths occur from this cancer in low income Countries, where advanced disease is common and facilities for care are limited.²⁸ Most women in poorer countries do not have access to effective screening programm. In Nigeria, it is the commonest genital tract cancer and is the commonest cancer of women.^24,29 In our own environment we noticed an increase in the incidence and prevalence of the disease and also that our patients present late with a variety of complications.³⁰ We have observed that there is paucity of reports on the enormity of this problem in Nigeria, especially in Northern Nigeria.^31,32,33 The differences in the prevalence of cancer in different regions of the world can be explained through heredity, medical practices, lifestyle changes and environmental exposures like different diets, tobacco and pesticides. Since there are cheap and effective methods of treatment for pre invasive cervical lesions, cervical cancer screening is known to reduce the incidence of, and mortality from, invasive cancer of the cervix to an extent directly related to the proportion of the the population screened. To ensure that most women benefit from cervical screening services, most developed countries have put in place effective screening programmes. This is not the case in most developing countries where opportunistic screening remains the practices. However, there appears to be lack of interest in opportunistic screening among Nigerians. In order to increase the number of women screened, a plea has been made for an increased opportunistic screening by Nigerian gynaecologists and a suggestion made that cervical cancer screening be included in pre employment examination. In pursuance of a better coverage in cervical cancer screening the Medical Women Association of Nigeria in Enugu, South Eastern Nigeria establishes a highly subsidised screening centre in the late 1980s This study is essentially a cross-sectional study that is time bound with only limited number of participants, with a papanicolaou smear taken only once at recruitment. Follow up with multiple papanicolaou smears over a period of time would have been ideal. Further research will be needed and above issues be put into consideration. Result from this study will provide information on screening of women.

1.3 Aim and objectives of the study

To determine the prevalence of abnormal cervical smears and knowledge of cervical cancer screening among women attending Gynaecology Clinic of General Hospital

Owerri, Nigeria. The following are the specific objectives of the study:

1. To determine the number of women of reproductive age diagnosed of cervical cancer.

2. To determine the age of women with cervical cancer.

3. To determine the parity of women with cervical cancer.

4. To determine the number of women screened with pap smear test.

1.4 Research Questions

1. What is the number of women of reproductive age diagnosed of cervical cancer?

2. What is the age of women with cervical cancer?

3. What is the parity of women with cervical cancer?

4. What is the number of women screened with pap smear test?

1.5 Significance of the study

The result of this study will provide information on the prevalence of cervical cancer among women of child bearing age. It will also indicate whether the women in Uyo participate in the screening programmes for cervical cancers or not. The study will help to fill the gap in knowledge and practice of cervical cancers among women.

Findings if utilized will help equip and guide professional nurses, midwives, health planners and other stakeholders in the health sector with the right information to direct health education programmes and campaigns to increase awareness among women on the various screening tests for cervical cancers. If the results of the study were put to use, it will help to improve the number of women who present themselves for screening, thus reducing the delays in presentation, diagnosis and treatment of cancer cases. This will generally help to reduce the incidence and mortality rates of cervical cancers among women in the State.

The findings will also add to the existing literature on the prevalence of cervical cancer among women of child bearing age, evaluate the success of cancer screening programmes in the state. Finally, the study will serve as a reference material to other researchers on related topics.

1.6 Scope of the study

The study was delimited to the prevalence of cervical cancer among women of child bearing age. The study was carried out among women attending Gynaecology Clinic of General Hospital Owerri, Nigeria, within the age range of 18 and 45 years who were present in the area during the period of the study.

1.7 Operational definition of terms

Cervical cancer: Cervical cancer is a malignant tumour of the cervix, the lowermost part of the uterus.

Childbearing woman: A childbearing woman with respect to this study is a woman within the age of 18 – 45 that is still capable of conceiving and giving birth.

Prevalence: Prevalence is the proportion of a particular population found to be affected by a medical condition at a specific time.