Barriers to uptake of cervical cancer screening services in low-and-middle-income countries: a systematic review

OBJECTIVES

Low-and-middle-income countries (LMICs) bear a disproportionate burden of cervical cancer mortality. We aimed to identify what is currently known about barriers to cervical cancer screening among women in LMICs and propose remedial actions.

DESIGN

This was a systematic review using Medical Subject Headings (MeSH) terms in Google Scholar, PubMed, Scopus, and Web of Science databases. We also contacted medical associations and universities for grey literature and checked reference lists of eligible articles for relevant literature published in English between 2010 and 2020. We summarized the findings using a descriptive narrative based on themes identified as levels of the social ecological model.

SETTING

We included studies conducted in LMICs published in English between 2010 and 2020.

PARTICIPANTS

We included studies that reported on barriers to cervical cancer screening among women 15 years and older, eligible for cervical cancer screening.

RESULTS

Seventy-nine articles met the inclusion criteria. We identified individual, cultural/traditional and religious, societal, health system, and structural barriers to screening. Lack of knowledge and awareness of cervical cancer in general and of screening were the most frequent individual level barriers. Cultural/traditional and religious barriers included prohibition of screening and unsupportive partners and families, while social barriers were largely driven by community misconceptions. Health system barriers included policy and programmatic factors, and structural barriers were related to geography, education and cost. Underlying reasons for these barriers included limited information about cervical cancer and screening as a preventive strategy, poorly resourced health systems that lacked policies or implemented them poorly, generalised limited access to health services, and gender norms that deprioritize the health needs of women.

CONCLUSION

A wide range of barriers to screening were identified across most LMICs. Urgent implementation of clear policies supported by health system capacity for implementation, community wide advocacy and information dissemination, strengthening of policies that support women's health and gender equality, and targeted further research are needed to effectively address the inequitable burden of cervical cancer in LMICs.

The National Cancer Data Base report on endometrial carcinoma in African-American women

BACKGROUND

Although the incidence of uterine carcinoma is lower among African-American women compared with white women, the mortality rates are higher for African-American patients. This report is part of an ongoing series on gynecologic malignancies in African-American women.

METHODS

Hospital registry reports collected by the National Cancer Data Base were used to describe some of the differences in case presentation and management characteristics of endometrial carcinoma in these two groups. The cases represented 52,307 Non-Hispanic white and 3226 African-American women diagnosed with primary carcinoma of the endometrium between 1988-1994.

RESULTS

More African-American patients were diagnosed with less favorable histologies than white patients, at more advanced stages of disease, and with less tumor differentiation. Income had no effect on stage or grade. African-American patients were treated less often for their tumor at every stage of diagnosis compared with white women. Income generally had no effect on whether treatment was provided, but limited income was associated with a lack of treatment in African-American patients with American Joint Committee on Cancer Stage IV tumors. African-American women were less frequently treated surgically and, among surgically treated patients at advanced stages of disease, they received adjuvant radiotherapy less often and chemotherapy more often than white patients. Five-year survival was poorer for African-American women, even for patients with the more favorable Stage I adenocarcinoma who were treated surgically.

CONCLUSIONS

All patients, regardless of race, should be treated appropriately as dictated by medical and prognostic factors and not by race. Although no screening methods currently exist for endometrial carcinoma, the development of procedures for identifying patients at risk for the prognostic factors that lead to a poor outcome should be a primary focus.

The National Cancer Data Base report on malignant epithelial ovarian carcinoma in African-American women

BACKGROUND

Epithelial ovarian carcinoma is the fifth most common cause of cancer death among African-American women. Although the incidence rate of ovarian carcinoma for whites is higher than that for African Americans, the relative survival rate for African Americans is poorer.

METHODS

Data were cases submitted to the National Cancer Data Base for invasive epithelial tumors of the ovary diagnosed between 1985-1988 and 1990-1993. African-American women with epithelial ovarian carcinoma were compared with non-Hispanic white women with the same disease. The groups of white women with which African-American women were compared were classified as "White-same facility" and "White-other facility." "White-same facility" were white patients from hospitals that contributed a substantial proportion of African-American patients. "White-other facility" were white patients from hospitals that contributed few or no African-American patients. No patient had a history of prior cancer.

RESULTS

African-American women with advanced invasive epithelial ovarian carcinoma were less often treated with combined surgery and chemotherapy and more often treated with chemotherapy only. African-American women were twice as likely as white women not to receive appropriate treatment. African-American women had poorer survival rates than white women from the same or different hospitals, regardless of income. Among staged cases, African-American women were more often diagnosed with Stage IV disease than either group of white women.

CONCLUSIONS

The current study findings show that African-American women with advanced epithelial ovarian carcinoma received less aggressive treatment than white women and had a poorer prognosis.

Prognostic significance of human papillomavirus DNA in vulvar carcinoma

OBJECTIVE

To determine the histopathologic, epidemiologic, and prognostic significance of human papillomavirus (HPV) DNA in primary invasive vulvar cancer.

METHODS

From December 1981 through October 1992, primary tumor tissue from 55 newly diagnosed vulvar cancers was evaluated for the presence of HPV DNA. The DNA was extracted from tumor tissue and subjected to the polymerase chain reaction (PCR) using highly conserved consensus L1 primers that detect 25 different HPV genotypes and primers specific for HPV type 6/E6, type 16/E7, and type 18/E6 gene sequences. All PCR products were hybridized to type-specific radiolabeled probes. The association between the presence of HPV DNA and histologic, epidemiologic, and clinical characteristics was analyzed.

RESULTS

Thirty-three (60%) tumors contained HPV DNA. Patients younger than 70 years of age or who smoked were more likely to have HPV-positive vulvar cancers. Twenty-one (95%) of 22 tumors classified as basaloid, warty, or verrucous contained HPV DNA, whereas 12 (39%) of 31 typical squamous tumors contained HPV (P < .001). Two adenocarcinomas were negative for HPV. Tumors with or without HPV DNA did not differ with respect to International Federation of Obstetricians and Gynecologists stage (size and nodal status), tumor grade, or therapy. Using life-table analysis, the absence of HPV DNA and the presence of regional nodal metastasis were predictive of recurrence and death from vulvar cancer. When controlling for lesion size, age, tumor grade, and nodal metastasis using the Cox proportional hazards model, only HPV status remained an independent prognostic factor.

CONCLUSION

Human papillomavirus DNA is more common in vulvar cancers of young women who smoke than in older nonsmokers. Patients with HPV-negative tumors are at an increased risk of recurrence and death from vulvar cancer.

Can you screen for ovarian cancer?

Screening for ovarian cancer has become an area of great interest because of the high mortality rate associated with advanced ovarian cancer. This article discusses the requirements for a test to be considered a screening modality, outlines the current methodology used in ovarian cancer screening, addresses the shortcomings as well as problems related to cost effectiveness with the current screening modalities, and identifies special circumstances in which ovarian cancer screening may be beneficial.

Metastasis from a stage IB cervical adenocarcinoma in a transposed ovary: a case report and review of the literature

Adenocarcinoma originating in the endocervix may remain occult for many years. This may result in an extension to the uterine isthmus and corpus, with subsequent dissemination along the pathways of spread of uterine carcinoma, including metastasis to the ovaries. The patient described in this report had a bulky stage Ib cervical adenocarcinoma with metastasis in a transposed ovary. The metastasis was noted 6 months following postoperative external pelvic irradiation. The sequence of events strongly suggests that microscopic ovarian disease was present at the time of the original surgery. Other cases have been reported; however, the exact incidence is difficult to determine. The current literature on this subject is reviewed and recommendations are made for evaluation and treatment.

Ureteral strictures and fistulae following radical hysterectomy

Three hundred patients have undergone radical hysterectomy and pelvic node dissection at The University of Alabama in Birmingham (UAB). Uretero-vaginal fistulae occurred in four (1.3%). None of these were associated with recurrent carcinoma. Two occurred because of intraoperative trauma and two were unexplained. Ureteral strictures occurred in 13 (4.3%). Three were early (within 3 months) and were due to benign causes. Ten were late (after 3 months) and were due to recurrent cancer. Thirty-two patients received whole pelvis radiation therapy for positive pelvic nodes or positive margins. None of these developed uretero-vaginal fistulae. Two developed ureteral obstruction and recurrent cancer was the etiology. Four patients received postoperative vaginal ovoids for positive vaginal margins. None developed a fistulae, but two developed ureteral obstruction secondary to recurrent cancer. Two patients received both whole pelvis and vaginal ovoid irradiation. No fistulae occurred, but one developed ureteral obstruction from recurrent cancer. Recurrent cancer causing ureteral obstruction was a serious finding as only 2 of 10 patients have been salvaged.