INCIDENCE PREVALENCE SCREENING AND PATTERN OF CERVICAL CANCER AMONG WOMEN ATTENDING UNIVERSITY OF NIGERIA TEACHING HOSPITAL ENUGU

Abstract

This study examined the incidence, prevalence, screening and patterns of cervical cancer among women attending University of Nigeria Teaching Hospital from 2000-2005. To achieve the purpose of the study, seven objectives with corresponding research questions were posed and three hypotheses were postulated. The descriptive research design utilizing the expost-facto type was used for the study. The instrument for data collection was a researcher designed Cervical Cancer Inventory Proforma (CCIP). Five experts in the Department of Health and Physical Education and Department of Science Education validated the proforma. The population for the study consisted of all the records of cervical cancer cases in University of Nigeria Teaching Hospital, Enugu from 2000-2005 which were   82 cases. No sampling was done as the population was not too large to handle. Data collected from the cancer registry of the health facility were used for analysis. Frequencies and percentages were used to answer the research questions while the chi-square statistic was used to test all the null hypotheses at 0.5 level of significance. The result of the study showed that the highest percentage of cervical cancer was recorded in 2004 (30.5%) while the lowest percentage was recorded in 2001 and 2002 (8.5%) respectively. The highest incidence of cervical cancer occurred among age group 61-100  years and above (35.4%), while the lowest occurred among age group 21 -30 years (1.2%). Incidence of cervical cancer was recorded more among married women (75.6%), than widowed/separated women (17.1%) and lowest incidence was found among single women (7.3%). Rural dwellers recorded a higher incidence of cervical cancer (56.1%) than urban dweller (43.9%). Highest prevalence rate (25 cases per 1000 women) was recorded in 2004 while the lowest occurred in 2000 (12 cases per 1000 women). Majority of the women (75.6%) had never gone for cervical cancer screening. There was no statistically significant difference in the incidence of cervical cancer according to age. There was statistically significant difference in the incidence of cervical cancer according to marital status and location. There was no statistically significant difference between the incidence of cervical cancer and uptake of cervical screening. In conclusion, cervical cancer was recorded highest in 2004, and lowest in 2001 and 2002.The highest number of cervical cancer occurred among age group 61- 100 years, among married and rural women. The highest prevalence rate of cervical cancer occurred in 2004, the number of women who had never undertaken cervical screening were higher (62) than those who had undertaken cervical screening (20).From the findings of the study, it is recommended that the government should provide screening facilities in the hospitals, provide drugs for the treatment of sexually transmitted infections and also mount regular monitoring exercises for cervical cancer through effective registration of cases. It is also recommended that cervical cancer screening should be made mandatory for all women and should also be integrated into existing medical services.

CHAPTER  ONE

Introduction

Background to the Study

            Globally, women are being afflicted by different organ cancers. Such organs in women are the breasts, uterus, ovaries among others. Cancer is a disease characterized by the abnormal growth of cells of the tissue of the organs affected. These abnormal growths affect such organs like, the breasts, cervix and uterus. The abnormal growth that affects the cervix is called cervical cancer. Cervical cancer has a negative impact on the lives of women worldwide, particularly those in developing countries. According to Ferlay (2002) cervical cancer threatens the lives of women, creates long-term problems for families and challenges health care system. He further stated that globally, 493,000 new cases of cervical cancer occur each year among women and 274,000 women die of the disease annually.   He also stated that 83 per cent of new cases are in developing countries where screening programmes are not well established or effective. In most of these countries, cervical cancer is the leading cause of cancer deaths among women. In Nigeria, the national incidence of cervical cancer is 250/100,000(Adesokan, 2009).

According to Obinna and Ogundipe (2010), the World Health Organization (WHO) estimates that Nigeria has a population of 40.43 million women aged 15 years and older who are at risk of developing cervical cancer. WHO indicates that every year 14,550 women are diagnosed with cervical cancer and 9,659 die from the disease.

Adesokan (2009) defined cervical cancer as the malignant growth or immortalization of the cervix. According to her, it is the commonest form of female genital cancer in developing countries and the second commonest type of cancer in women. Within the context of this study, cervical cancer means a disease in which cells of the cervix become abnormal and start to grow uncontrollably, forming tumours. Usually, the disease affects the cervix which is part of the internal reproductive organs. Park (2009) stated that cervical cancer is a disease characterized by an abnormal growth of cells, ability to invade adjacent tissues and even distant organs and the eventual death of the affected patient if the tumour has progressed beyond that stage when it can be successfully removed. He further stated that cancer of the cervix follow a progressive course, from epithelial dysplasia to carcinoma in situ then to invasive carcinoma. Carcinoma in situ persists for a long time, more than 8 years on an average.

The cervix is the lower part of the uterus (womb). It connects the body of the uterus to the vagina (birth canal). It is made up of two types of cells, the squamous and the columnar cells. Approximately, 90 per cent of cervical cancer are made up of squamous cell carcinoma. This type of cancer originates in the thin, flat, squamous cells on the surface of the ectocervix, the part of the cervix that is next to the vagina. Another 10 per cent are of the adenocarcinoma type (Ezigbo, 2010). This originates in the mucus-producing cells of the inner cevix or endocervix near the body of the uterus. Occasionally, cervical cancer may have characteristics of both types and is called adenosquamous carcinoma or mixed carcinoma, (Benneth & Brown, 1999). The statistics for incidence of cervical cancer has been estimated for different countries as follows: Canada, 1,553; Mexico, 5,016; Brazil, 8,798; Britain,            2,880; Germany, 3,989; Italy, 2774. (U.S. Census Bureau, International Data Base, 2004). Usually, the cause of cervical cancer is not actually known but risk factors are attributed to infection by Human Papillomavirus and other factors.

Infection with the common Human Papillomavirus (HPV) is a cause of approximately 90 per cent of all cervical cancers. here are more than 80 types of HPV, about 30 of these can be transmitted sexually, including those that can cause genital warts. About half of the “high-risk” HPVs are associated with cervical cancer, they produce a protein that can cause cervical epithelial cells to grow uncontrollably. The virus makes a second protein that interferes with tumour suppressor that are produced by the human immune system. The HPV – 16 strain is thought to be a cause of about 50 per cent of cervical cancers (America Cancer Society 2011). Other risk factors to cervical cancer are as follows: lack of regular Pap test,

Smoking,sexual history,use of birth control pills,and exposure to Diethystibestrol.

Lack of regular Pap test (Papanicolaou test): Cervical cancer is more common among women who do not have regular test. The Pap test helps the doctor to identify abnormal cells which may eventually become cancerous, at this stage prompt treatment can be instituted. In women who are infected with HPV, smoking cigarette increases the risk of cervical cancer because nicotine suppresses the body immune system (American Cancer Society,2001). Nicotine concentrates on the cervical mucus with resultant reduction in the immunity of the Langerhan’s cells. Infection with Human immunodeficiency virus or taking drugs that suppress the immune system also increase the risk of cervical cancer.

Women who have had many sexual partners have a higher risk of developing cervical cancer, (American cancer society, 2001). Also, a woman who had sexual intercourse with a man who has had many sexual partners may be at higher risk of developing cervical cancer. In both cases, the risk of developing cervical cancer is higher because these women have a higher risk of contracting HPV infection.

Using birth control pills for a long period may slightly increase the risk of cervical cancer among women with HPV infection. However, the risk decreases quickly when women stop using the birth control pills. Exposure to Diethylstilbestrol (DES) may increase the risk of a rare form of cervical cancer in daughters exposed to this drug before birth DES used to be given to pregnant women to prevent abortion in the early 60s. Other risk factors include; early coitus, family history of cervical cancer, use of talcum powder, frequent douching and prolonged use of cortico-steroids for unrelenting asthmatic attacks, (America Cancer Society 2011). Cervical cancer at the early stage may present no symptom to the sufferer, making it impossible for the individual to identify the onset of the disease condition.

Adesokan,( 2009) asserted that with progression in the disease the following symptoms are noticed; anaemia, single swollen leg, frequent and persistent vaginal discharge which may be watery, pale, brownish or bloody, abnormal mid-menstrual bleeding, heavy menstruation, bleeding during sexual intercourse and painful sexual intercourse. In advanced cancer of the cervix, there is foul smelling discharge due to sloughing of the epithelial tissue, fatigue, anorexia, lower back pain, pelvic pain, heavy vaginal bleeding due to invasion of the cancerous cells, bone fracture due to demineralization by the cancerous cells, weight loss, dysuria, rectal bleeding, and presence of vaginal or cervical mass. Ideally, in a woman above 35years of age, if any of the aforementioned symptoms persists, it is suggestive of cervical cancer diagnosis of cervical cancer in a developing country like Nigeria is usually done late when the disease has affected other organs and tissues.

Dawtota and Olaseinde, (2004) opined that diagnosis of cervical cancer can be achieved by: colposcopy, x-rays, computerized tomography (CT) scans and magnetic resonance imaging(MRI).

Colposcopy, is the use of a special microscope (Colposcope) to examine the cervix for abnormal cells. X-rays, computerized tomography (CT) scans and magnetic resonance imaging (MRI) helps to determine whether the cancer has spread beyond the cervix. Other measures used in the diagnosis of cervical cancer include; biopsy, loop electro-surgical excision procedure (LEEP), endocervical curettage and conization. Biopsy as a method of diagnosis involves having tissue removed in the doctors office with local anaesthesia, loop electro-surgical excision procedure (LEEP), the doctor uses an electric wire loop to slice off a thin, round piece of the cervical tissue. Endocervical curettage is another method of diagnosis, the doctor uses a curette (a small, spoon-shaped instrument) to scrape a small sample of tissue from cervix. Conization, the doctor removes a cone-shaped sample of tissue. A conization, or cone biopsy, lets the pathologist see if abnormal cells are in the tissue beneath the surface of the cervix. After diagnosis of cervical cancer, staging is done to determine the extent of spread of the disease to nearby organs and tissues.

The International Federation of Gynaecologists and Obstetrician (FIGO) system is usually used to determine the stage of cervical cancer. The stage is based on where cancer is found, staging is a careful attempt to find out whether the tumour has invaded nearby tissues, whether the cancer has spread and, if so, to what parts of the body. This staging ranges from stage 0-IV. Cervical cancer spreads most often to nearby tissues in the pelvis, lymph nodes, or the lungs. When cervical cancer spread from its original place to another part of the body, it is called metastatic cervical cancer.  (Holland, Jimme & Sheldon, 2000). Successful treatment of cervical cancer depends on the stage of the disease in the individual.

According to Ezigbo, (2010) women with cervical cancer have many treatment options. The options are:surgery, radiation therapy, chemotherapy and combination of methods.

The choice of treatment depends mainly on the size of the tumour and whether the cancer has spread. Surgery is an option for women with stage I or II cervical cancer.  In this case the surgeon removes tissues that may contain cancer cells. The types of surgery include: radica trachelectomy,total hysterectomy, radical hysterectomy.

Radical trachelectomy is removal of the cervix, part of vagina and lymphnodes in the pelvis. Total hysterectomy is the removal of the cervix and uterus while radical hysterectomy is the: removal of the cervix, some tissue around the cervix, the uterus and part of the vagina, removal of the fallopian tubes and ovaries. Radiation therapy is the use of high-energy rays to kill the cancer cells. It could be the external radiation therapy or internal radiation therapy. Chemotherapy uses drug to kill the cancer cells especially when the disease has spread beyond the cervix. Chemotherapy kills fast-growing cancer cells, but can also harm normal cells. Depending on the doctor’s findings and the stage of the cervical cancer, chemotherapy and radiation are combined. This is usually carried out in stages IIB, III, IV and recurrent cervical cancer. (Mamadani, Garner, Harpham & Campbell 2003).

Park (2009) defined incidence as the number of new cases of a particular disease condition occurring in a defined population during a specified period of time. He further stated that incidence measures the rate at which new cases are occurring in a population and that it is not influenced by the duration of the disease. Similarly, Onwasigwe (2010) stated that incidence measures the probability that healthy people will develop disease or health – related event during a specified period of time. It indicates the rate at which new cases of the disease occur in a defined, previously disease free population. She further asserted that incidence can be determined by following a group of people and finding the rate at which new cases of a disease appear. Before this can be done, the individuals are grouped according to their health status, the diseased and the non-diseased. This information may be obtained after conducting a suitable screening test or from the available health records. It is necessary to determine the date of onset of the disease if possible, or the earliest sign of recognition of the problem. For malignancies like cervical cancer, the date of definite diagnosis is taken as the date of onset of the disease. Incidence is of two types; incidence risk and incidence rate.

Evans (1997) identified two measures of incidence: incidence risk and incidence rate. The incidence risk is also known as the cumulative incidence. It provides an estimate of the probability that an individual will develop a disease during a specified period of time. Incidence rate is also known as the force of morbidity or incidence density. It measures the number of cases of a particular disease within a specified period. The incidence rate is likely to be a more accurate measure of disease incidence than the incidence risk because it takes into account the fact that in most studies, not everyone is followed-up for all of the time. For this study, incidence will be considered as the number of new cases of cervical cancer in a specified population in a given period of time. Of the two types of incidence, rate will be used to measure incidence of cervical cancer. Rate is the number of cases of a disease multiplied by 1000 and divided by the population at risk. Chronic diseases like cervical cancer usually have high prevalence because of its long duration.

Prevalence is concerned with new cases of a disease and the duration of the disease that may either end in recovery or death. Onwasigwe (2010), defined prevalence of a disease as the number of people in a population that have a disease at a given period (old and new cases). Furthermore, Onwasigwe (2010) stated that there are two types of prevalence rates, the point prevalence and the period prevalence. Point prevalence measures the probability of people having a disease at one particular point in time such as a day, several days or even few weeks. Period prevalence measures the number of people that have a disease within a given period of time such as annual prevalence. Period prevalence will be a more appropriate measure for this study as it aims to investigate the prevalence of cervical cancer from 2000-2005 in UNTH, Enugu. In this study, incidence will be regarded as new cases of cervical cancer from 2000 to 2005 while prevalence is the number of cases of cervical cancer for this period of five years and the duration of the disease.

Incidence and prevalence can be determined using rate. Rate is the number of times something happens or number of examples of something or event within a certain period. In relation to disease condition, it means the number of time a particular disease occurs in a given population.

Incidence is measured against the number of people at risk because the individuals exposed to the disease are the ones likely to develop such disease which makes up the new cases while prevalence is concerned with the whole population. This is because both new and old cases of the disease are considered and it is assumed that the population is stable, and incidence and duration of diseases are unchanging. The difference between prevalence and incidence is that the knowledge of time of onset of disease is not required in prevalence study. However, it is necessary to determine the date of onset for studies of incidence.    Screening is an important aspect in identification of cervical changes. If done early, it helps for prompt treatment before it becomes invasive carcinoma.

Screening, according to McHenry (2009) is to examine (someone or something) to discover if there is anything wrong with them. This is usually done to identify existing problems in a situation or in somebody. The term “screening” refers to the regular use of certain examination or tests in people who do not have any symptoms of cancer (Ezem 2007). For certain types of cancer, screening makes it possible to identify cancer at an early stage, when treatment is most likely to work. McHenry (2009) defined health screening as a programme designed to evaluate the health status and potential of an individual. It is usually done to detect a disease in individuals without signs or symptoms of that disease being screened. Examples of screening for cancer include; Pap smear to detect potentially precancerous lesions and prevent cervical cancer, mammography to detect breast cancer, colonoscopy to detect colorectal cancer.

Screening programme for cervical cancer have been instituted in developed countries for decades and have been shown to be effective in reducing the overall mortality from this disease. Efforts are being made to make such programmes available and accessible in developing countries like Nigeria. Such programme however can only be made to work provided the necessary infrastructure and funds are available (Solomon, Darvy & Kurman, 2001). Screening techniques for cervical cancer include: conventional exfoliative cervicovaginal cytology, that is the cervical (Pap) smear, fluid sampling techniques with automated thin layer preparation (liquid based cytology), automated cervical screening techniques, neuromedical systems, HPV testing, polar probe, laser induced florescence, visual inspection of cervix after applying Lugol’s iodine (VILI) or acetic acid (VIA), speculoscopy and cervicography. (Cheryl, Clair & Kevin, 2000). For this study, screening will be taken to be the medical examination undertaken to detect the probability of one developing cervical cancer. Cervical cancer may vary in pattern of occurrence. These patterns may be: demographic, temporal or spatial pattern.

Schwartz (1993) described pattern as a design or guide which appears among people. According to Hornby (2001), pattern is a regular way in which something happens or is done. Roht (1982) stated that pattern refers to the occurrence of health –related events by time, places and personal characteristics. According to him, time characteristics include annual occurrence, seasonal occurrences and daily or even hourly occurrence during epidemic, while place characteristics include, geographical variation such as urban-rural differences, and location of worksites or schools. Personal characteristics according to him include demographic factors such as age, race, gender, marital status and socio-economic status, as well as behaviours and environmental exposures.

Pridemore, Andrew and Spivak (2003) classified pattern into three forms: demographic, temporal and spatial pattern. Morris (1981) and Stillion (1983) refer to demographic pattern as one that is concerned with the variables like age, gender, level of education, family type, socio-economic and marital status. Socio-economic status comprises of occupation, family income, educational level and living condition. In this study, demographic pattern will be referred to as occurrence of cervical cancer according to age, marital status, and level of education. Other variations like gender will be excluded because cervical cancer affects women only.

Temporal pattern is described by Pridemore et.al, (2003) as the pattern that has to do with time or days of week or seasons in which a thing or event occurs. For now there is not available information as to the season that favours the occurrence of cervical cancer. Therefore, this study will not focus on temporal pattern of season in relation to occurrence of cervical cancer but on the temporal pattern of annual occurrence of cervical cancer as the study is between 2002-2006.

Spatial pattern according to Pridemore, et.al., (2003) is based on geographical location in a particular country. It could be urban or rural areas. Geographical pattern according to them, can be based on country type which reflects level of urbanicity and metropolitan area. In this study, spatial pattern would refer to occurrence of cervical cancer according to location which could be urban or rural area.

Woman is a female human. Longman (2003) described woman as an adult female person regardless of the age. Womanhood is the period in a female’s life after she has transitioned through childhood and adolescence, generally age 18. Women are endowed with female sex organs (vagina, cervix, uterus, fallopian tubes and ovaries) that are involved in reproductive system whereas the secondary sex characteristics (menstruation, breast development, hormonal involvement) are involved in nurturing children or attracting a mate (Benneth and Brown 1999). This study will focus on the incidence, prevalence screening and pattern of cervical cancer among women attending UNTH, Enugu.

Cervical cancer just like other organ cancers has been a global health problem but more especially in the developing nations like Nigeria. Cervical cancer according to studies is a preventable disease and therefore can be avoided (Chukwuali, Onuigbo & Mgbor, 2003).

There are some demographic and socio-economic factors that may be associated with the incidence, prevalence, screening and patterns of cervical cancer. Such factors include age, level of education, occupation, income and geographical location. Age is a factor that can be implicated in cervical cancer. Early age at first sexual intercourse exposes young girls to sexually transmitted infections of which Human Papilloma Virus are included. In addition, incidence of cervical cancer increases with age, starting to rise in women between the age of 30 and 35years and reaching peak at about 50 to 60 years (Adap & Hedley, 1997).

Sexual behaviour is associated with the occurrence of cervical cancer. According to Adap and Hedley (1997), there is high incidence of cervical cancer in women with active sexual life and multiple sexual partners like the sex hawkers. These practices determine the woman’s risk of acquiring a sexually transmitted infection. They further stated that certain population subgroups such as nuns and groups with strict practices of abstinence and monogamy have long been noted to have very low rates of cervical cancer.

This study will be anchored on two theories. These are the health belief model (HBM) and protection motivation theory (PMT). The health belief model is a psychological model propounded by Rosenstock (1974). This theory attempts to explain and predict health behaviours. The HBM is based on the core assumptions that a person will take a health-related action if that person feels that a negative health condition can be avoided, has a positive expectation that by taking a recommended action he/she will avoid a negative health condition and believes that he/she can successfully take a recommended health action. The protection motivation theory by Rogers (1983) describes adaptive and maladaptive coping with a health threat as a result of two appraisal processes. A process of threat appraisal and a process of coping appraisal, in which the behavioural options to diminish the threat are evaluated.

The extent to which the incidence of cervical cancer is high do not appear to have received adequate research attention. In recent times, statistics available have shown that in Nigeria, cervical cancer accounts for 15 per cent of female cancers as compared to just about 3.6 per cent in the developed countries. Shockingly, less than 0.1 per cent of Nigerian women have ever had cervical screening in their lifetime and less than 1 percent is aware of the existence of this killer disease (Obinna & Ogundipe, 2010). It is therefore, justifiable to investigate the incidence, prevalence, screening and pattern of cervical cancer among women. This may help find out if the problem is on the increase or decrease. If it is on the increase, this will necessitate initiating programme to reduce its incidence and prevalence. Following from this therefore, one is then prompted to ask, what is the incidence, prevalence and pattern of cervical cancer attending UNTH, Enugu. The above represents the need for this study.

Statement of the Problem      

Cervical cancer is a global health problem, especially in the developing countries, including Nigeria. It is a disease characterized by uncontrollable growth of the cells of the cervix and symptoms do not present early thereby making the sufferer ignorant of the presence of such condition. Women who adopt healthy sexual behaviours by avoiding multiple sexual partners thereby not contracting sexually transmitted infection are not likely to suffer cervical cancer. Likewise those women who do not smoke nor take immune suppressant drugs may not suffer this disease because their immunity is not suppressed which may predispose them to cervical cancer. WHO (2009) asserts that cervical screening programme prevents 80 per cent of cervical cancer. The report also stated that a vaccine against HPVs has been invented and is advocated for the prevention of HPVs infection and will also be incorporated into the national immunization programme. The report further stated that adequate health education and enlightenment also help immensely in the prevention of cervical cancer because they create awareness on the predisposing factors of cervical cancer and how to avoid them.

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