Correlation of cervical cancer mortality with fertility, access to health care and socioeconomic indicators / Correlação da mortalidade por câncer do colo do útero com fertilidade, acesso a cuidados de saúde e indicadores socioeconômicos

Abstract Objective The present study aimed to examine which development indicators are correlated with cervical cancer (CC) mortality rates in Brazil. Methods This was an ecological study that correlatedmortality rates and indicators, such as human development index (HDI), gross domestic product (GDP) per capita, illiteracy rate, fertility rate, screening coverage, proportion of private health insurance use, density of physicians, and density of radiotherapy centers. Themortality rateswere obtained fromthe Brazilian national registry, while the indicators were based on official reports from the Ministry of Health. Univariate and multivariate linear regression was used. Results Among the states of Brazil, the average age-specific CC mortality rate from 2008 to 2012 varied from 4.6 to 22.9 per 100,000 women/year. In the univariate analysis, HDI, proportion of private health insurance use, density of physicians, and density of radiotherapy centers were inversely correlated with the mortality rates. Fertility rate was positively correlated with the mortality rates. In the multivariate analysis, only fertility rate was significantly associated with the CC mortality rate (coefficient of correlation: 9.38; 95% confidence interval [CI]: 5.16-13.59). Conclusion A decrease in the fertility rate, as expected when the level of development of the regions increases, is related to a decrease in the mortality rate of CC. The results of the present study can help to better monitor the quality assessment of CC programs both among and within countries.

Resumo Objetivo O presente estudo teve como objetivo examinar quais indicadores de desenvolvimento estão correlacionados com as taxas de mortalidade por câncer do colo do útero no Brasil. Métodos Este foi um estudo ecológico que correlacionou as taxas de mortalidade com indicadores como índice de desenvolvimento humano (IDH), produto interno bruto (PIB) per capita, taxa de analfabetismo, taxa de fertilidade, cobertura do rastreamento, proporção do uso do seguro privado de saúde, densidade de médicos e densidade de centros de radioterapia. A fonte das taxas de mortalidade foi o registro nacional, enquanto que os indicadores foram baseados em relatórios oficiais do Ministério da Saúde. Foi utilizada regressão linear univariada e multivariada. Resultados Entre os estados, a taxa média de mortalidade específica por idade por câncer do colo do útero de 2008 a 2012 variou de 4.6 a 22.9 por 100.000 mulheres/ano. Na análise univariada, foram inversamente correlacionadas com as taxas de mortalidade: IDH, proporção do uso do seguro privado de saúde, densidade de médicos e densidade de centros de radioterapia. A taxa de fertilidade foi positivamente correlacionada com a mortalidade. Na análise multivariada, apenas a taxa de fertilidade foi significativamente associada à taxa de mortalidade por câncer do colo do útero (coeficiente de correlação: 9,38; índice de confiança [IC] 95%: 5,16-13,59). Conclusão A diminuição da taxa de fertilidade, como esperado quando o nível de desenvolvimento das regiões aumenta, está relacionada a uma diminuição da taxa de mortalidade por câncer do colo do útero. Os resultados do presente estudo podem ajudar amonitorarmelhor a avaliação da qualidade dos programas de câncer do colo do útero nos países tanto interna quanto externamente.

Response to article titled "US-funded measurements of cervical cancer death rates in India: scientific and ethical concerns" by Eric J Suba.

Dr Eric Suba has been distorting facts and persistently disseminating biased and misleading views and statements regarding our studies over the past several years. His article in the Indian Journal of Medical Ethics fails to mention the facts that seem unfavourable to his arguments, and the ethical concerns are unsubstantiated by the evidence. In this context, we present the following clarifications for the attention of your readers, notably with regard to: (i) the study design and inclusion of a control group; (ii) the informed consent of the women participating in the study; (iii) the conformity with international ethical standards and guidelines, and (iv) the provision of screening to women in the control arm of the studies. We also highlight the benefits that are flowing from this research and the risk that misinformation may further delay access for women to life-saving cervical cancer screening.

Determinantes sociales del abandono del diagnóstico y el tratamiento de mujeres con papanicolaou anormal en Buenos Aires, Argentina / Social determinants of the abandonment of the diagnosis and treatment of women with abnormal pap smears in Buenos Aires, Argentina

Objetivo. Determinar la magnitud y los motivos del abandono del proceso de diagnóstico y tratamiento de la smujeres con citología anormal, así como la relación entre las características socioeconómicas de las mujeres y dicho abandono...

Determinantes sociales del abandono del diagnóstico y el tratamiento de mujeres con Papanicolaou anormal en Buenos Aires, Argentina / Social determinants of dropout from diagnosis and treatment by women with abnormal Pap smears in Buenos Aires, Argentina

OBJETIVO:Determinar la magnitud y los motivos del abandono del proceso de diagnóstico y tratamiento de las mujeres con citología anormal, así como la relación entre las características socioeconómicas de las mujeres y dicho abandono. MÉTODOS: Estudio transversal-retrospectivo. Se realizó un análisis de fuentes secundarias y entrevistas domiciliarias a mujeres con Papanicolaou (Pap) anormal atendidas en el sistema público municipal entre 2009 y 2011. RESULTADOS: El abandono confirmado en la población de estudio fue de 18,3%. Las mujeres con mayor probabilidad de abandono fueron las que vivían en hogares con presencia de niños menores de 5 años de edad (razón de probabilidades [RP]: 2,4; intervalo de confianza de 95% [IC95%]: 1,2-4,8) y las que vivían en hogares con hacinamiento (RP: 2,9; IC95%: 1,2-7,3). Las mujeres que realizaron el Pap inicial en un centro de atención primaria poseían 4,6 veces más probabilidad de abandono que las atendidas en el hospital (IC95%: 1,7-12,3). Los principales motivos de abandono reportados fueron problemas con la organización de los servicios de salud y la carga de trabajo doméstico. CONCLUSIONES: Las condiciones de vida de las mujeres, y la organización y calidad de los servicios de salud, inciden en el abandono del proceso de diagnóstico y tratamiento de las lesiones precancerosas. Es fundamental desarrollar estrategias que actúen sobre los determinantes sociales del abandono como un modo de asegurar la efectividad de los programas de tamizaje del cáncer cervicouterino.

OBJECTIVE: Determine the extent and reasons why women with abnormal Pap smears drop out from diagnosis and treatment, and the relationship between women's socioeconomic characteristics and dropping out. METHODS: Cross-sectional retrospective study. Analysis of secondary sources and household interviews with women with abnormal Pap smears seen in the public municipal system from 2009 to 2011. RESULTS: Confirmed dropout in the study population was 18.3%. Women with the greatest probability of dropping out lived in homes where there were children under five (probability ratio [PR]: 2.4; 95% confidence interval [95%CI]: 1.2-4.8) and where there was overcrowding (PR: 2.9; 95%CI: 1.2-7.3). Women whose initial Pap smear was done in a primary care center had a 4.6 times greater probability of dropping out than those seen in a hospital (95%CI: 1.7-12.3). The main reasons reported for dropping out were problems with health services organization and domestic workload. CONCLUSIONS: Women's living conditions and the organization and quality of health services affect dropout from diagnosis and treatment of precancerous lesions. Strategies need to be developed that address social determinants of dropping out as a way to ensure effectiveness of cervical cancer screening programs.

Socio-economic factors & longevity in a cohort of Kerala State, India.

Background & objectives Even though Kerala State is well-known for its egalitarian policies in terms of healthcare, redistributive actions and social reforms, and its health indicators close to those of high-resource countries despite a poor per-capita income, it is not clear whether socio-economic disparities in terms of life expectancy are observed. This study was therefore carried out to study the impact of socio-economic level on life expectancy in individuals living in Kerala. Methods A cohort of 1,67,331 participants aged 34 years and above in Thiruvananthapuram district, having completed a lifestyle questionnaire at baseline in 1995, was followed up for mortality and cause of death until 2005. Survival estimates were based on the participants’ vital status and death rates were calculated separately for men and women and for several socio-economic factors, stratified by age. Results At 40 years, men and women were expected to live another 34 and 37 years, respectively. Life expectancy varied across the participants’ different socio-economic categories: those from high income households with good housing conditions, materially privileged households and small households, had a 2-3 years longer life expectancy as compared to the deprived persons. Also, those who went to college lived longer than the illiterates. The gaps between categories were wider in men than in women. Interpretation & conclusions Socio-economic disparity in longevity was observed: wealthy people from Kerala State presented a longer life expectancy.

Challenges faced by cervical cancer prevention programs in developing countries: a situational analysis of program organization in Argentina / Retos de los programas de prevención de cáncer cervicouterino en países en desarrollo: análisis de situación de la organización del programa en Argentina

OBJECTIVE: To carry out a situational analysis of cervical cancer prevention activities in Argentina, specifically regarding (a) the organizational framework of cervical cancer prevention activities; (b) Pap-smear coverage; (c) cytology laboratory organization; and (d) follow-up/treatment of women with abnormal lesions. METHODS: A situational analysis of provincial cervical cancer programs using data from an ad-hoc questionnaire sent to the leaders of cervical cancer prevention programs in Argentina's 24 provinces. In addition, the provinces' program guidelines, statistical reports, laws, and program regulations were reviewed and certain key leaders were personally interviewed. RESULTS: Data were obtained for 19 of Argentina's 24 provinces. Four of the 19 provinces had no formal program framework. Conventional cytology was the most commonly used screening test. Screening was mainly opportunistic. The recommended interval between normal tests was 3 years in most provinces. The eligible age for screening ranged from 10-70 years of age; however, annual or biannual screening was the usual practice after becoming sexually active. None of the provincial programs had data available regarding Pap-smear coverage. Most of the cytology laboratories did not have a quality control policy. The number of smears read varied greatly by laboratory (650-24 000 per year). A log of events related to screening and treatment did not exist in most provinces. CONCLUSIONS: Screening in Argentina is mainly opportunistic, characterized by an estimated low coverage, coexisting with over-screening of women with access to health services, and an absence of quality control procedures. Policies for cervical cancer screening in the provinces vary and, most often, deviate from the national recommendation of one Pap smear every 3 years for women 35-64 years of age. Ensuring compliance with national program guidelines is an essential step toward significantly reducing the burden of cervical cancer.

OBJETIVO: Realizar un análisis de la situación actual de las actividades de prevención del cáncer cervicouterino en Argentina, específicamente con respecto a los siguientes aspectos: a) el marco organizativo de las actividades de prevención del cáncer cervicouterino; b) la cobertura de la prueba de Papanicolaou; c) la organización de los laboratorios de citología; y d) el seguimiento y el tratamiento de las mujeres que presentan lesiones anómalas. MÉTODOS: Se llevó a cabo un análisis de la situación actual de los programas provinciales de prevención del cáncer cervicouterino a partir de los datos de un cuestionario ad hoc enviado a los directivos de los programas en las 24 provincias de Argentina. Además, en cada provincia se examinaron las directrices del programa provincial, los informes estadísticos, las leyes y los reglamentos de los programas, y se entrevistaron algunos directivos clave. RESULTADOS: Se obtuvieron datos de 19 de las 24 provincias argentinas. Cuatro de las 19 provincias no tienen instaurado ningún marco programático formal. La citología convencional es la prueba de tamizaje que más se utiliza y, en general, el tamizaje es oportunista. El intervalo recomendado entre las pruebas de resultado normal es de 3 años en la mayoría de las provincias y la edad a la que se indica efectuar el tamizaje en las distintas provincias se ubica entre los 10 y los 70 años; sin embargo, el tamizaje anual o bianual es la práctica habitual una vez que la mujer comienza a mantener relaciones sexuales. Ninguno de los programas provinciales pudo aportar datos acerca de la cobertura de la prueba de Papanicolaou. La mayoría de los laboratorios de citología no disponen de una política de control de calidad. Es muy variable el número de pruebas de citología cervical que llega a cada laboratorio (entre 650 y 24 000 por año). La mayoría de las provincias carece de un registro de acontecimientos relacionados con la detección y el tratamiento del cáncer cervicouterino. CONCLUSIONES: En Argentina, el tamizaje suele ser oportunista, tiene baja cobertura, se realiza con una frecuencia excesiva en las mujeres que tienen acceso a los servicios de salud y carece de procedimientos de control de calidad. Cada provincia aplica políticas diferentes en relación con el tamizaje del cáncer cervicouterino y, lo más habitual, es que no se atenga a la recomendación nacional de efectuar una prueba de Papanicolaou cada 3 años a las mujeres de entre 35 y 64 años de edad. A fin de reducir significativamente la carga del cáncer cervicouterino, es esencial garantizar el cumplimiento de las directrices del programa nacional de prevención.

Monitoring and evaluation of a model demonstration project for the control of cervical cancer in Nakhon Phanom province, Thailand.

Cancer of the uterine cervix is the second most common cancer in females in the world with about half a million new patients per year. Since the introduction by Papanicolaou of cervical smear screening, the incidence of cervical cancer has declined in many developed countries. The decrease in the incidence of and mortality from cervical cancer is mainly due to the organized mass screening using Pap smear programmes. Uterine cervical cancer is the leading cancer among women in Thailand with age-standardized incidence rates of 24.7 per 100,000 in 1999. Most cases present at advanced stages with poor prognoses of survival and cure. In the present study, cervical cancer screening programme with cervical cytology was organized for Nakhon Phanom province, Thailand. The specific objectives were: 1) to evaluate the reduction in incidence and mortality from cervical cancer in the province by means of an organised low-intensity cervical cytology programme. 2) to demonstrate the different aspects of programme implementation as a potential model for nationwide implementation. The screening activities were integrated in the existing health care system. Organized screening for women in the target population (aged 35-54 years) at 5-year intervals was free of charge. Sample taking was done by trained nurses (midwives) and primary health care personnel in the local health care centers. Sample quality was under continuous controlled by the cytology laboratories and pathologists. Confirmation and treatment were integrated into the normal health care routines. The screening results of the programme, including histologically confirmed diagnosis, were registered at the National Cancer Institute using PapReg and CanReg 4 programmes. A population-based cancer registry in Nakhon Phanom province was also set up in 1997. In the period 1999-2002, 32,632 women aged 35-54 years were screened. Women with low-grade lesions returned for routine follow-up smears. High-grade preinvasive disease was further evaluated by repeating Pap smear, conization or biopsy and subsequent treatment through surgical removal or ablation. This organized low-intensity cervical cytology programme showed a considerable increase in early carcinoma in situ and CIN II -III cases and should reduce incidence of and mortality from cervical cancer in Nakhon Phanom province in the future. Screening with the Papanicolaou smear plus adequate follow-up diagnosis and therapy can achieve major reductions in both incidence and mortality rates.

Incidence and mortality of cervical cancer in Latin America

Se presentan estimaciones de la incidencia y de la mortalidad por cáncer cervical para los 21 países latinoamericanos en el año 2000. Se utilizaron el paquete estadístico GLOBOCAN 2000 y las bases de datos de mortalidad de la Organización Mundial de la Salud. En el año 2000, al menos 76 000 casos incidentes de cáncer cervical y 30 000 muertes se estimaron para la Región en general, lo cual representa 16 y 13 por ciento del total del mundo, respectivamente. Por lo tanto, los países de América Latina se encuentran en un área geográfica con tasas de incidencia de las más altas en el mundo, junto con países del Sub-Sahara, en Africa, y del sureste de Asia. La variación de la incidencia entre los países es grande; existen tasas muy altas en Haití (93.9 por 100 000), Nicaragua (61.1 por 100 000) y Bolivia (58.1 por 100 000). Es poco probable que las diferencias en los riesgos entre las regiones sean explicadas como resultado de las actividades de tamizaje. Varios estudios descriptivos se han llevado a cabo para evaluar programas de tamizaje en América Latina, señalando problemas relacionados con la frecuencia y la difusión insuficiente del tamizaje. Otro problema relacionado incluye la inadecuada colección y lectura de muestras citológicas, así como el seguimiento incompleto de las mujeres después de la prueba. El principal cambio para los países de América Latina se encuentra en cómo organizar programas efectivos de tamizaje y, para esto, es necesaria una real y urgente integración entre los servicios de salud pública y los tomadores de decisiones en la Región.