DOI:http://dx.doi.org/10.7314/APJCP.2012.13.9.

4221
Current Status of Knowledge and Screening for Cervical Cancer with Levels of Economic Development

MINI-REVIEW

Current Status of Knowledge, Attitude and Practice (KAP)

and Screening for Cervical Cancer in Countries at Different
Levels of Development
Sreejata Raychaudhuri*, Sukanta Mandal
Abstract
Cancer of the uterine cervix is a worldwide menace taking innumerable womens’ lives. The literature is vast
and a large number of studies have been conducted in this field. Analyses have shown significant differences
exist in terms of screening and HPV testing facilities among high income and low to middle income countries. In
addition, acute lack of awareness and knowledge among the concerned population is particularly noted in rural
areas of the low income countries. A detailed review of Indian case studies revealed that early age of marriage
and childbirth, multiparity, poor personal hygiene and low socio-economic status among others are the principal
risk factors for this disease. This review concludes that a two pronged strategy involving strong government and
NGO action is necessary to minimize the occurrence of cervical cancer especially in low and medium income
countries.
Keywords: Cervical cancer - pap smear - HPV- risk factors – KAP - country income levels
Asian Pacific J Cancer Prev, 13 (9), 4221-4227

Introduction gynaecological malignancy in the USA. (Jemal et al., 2002).

The number of women with cervical adenocarcinoma
Cancer of the uterine cervix is a killer disease, which (AC) has been increasing over the past decades. The
affects the female population in India. Next to breast observed survival rate for patients with cervical AC
cancer, cervical cancer is the most dreadful type of human generally has been poorer compared with the survival
cancer (Mitra, 2009). It has been estimated that 100,000 rate for patients with cervical squamous cell histologies.
new cases of cancer of the cervix occur in India every The independent significance of AC histology in cervical
year and 70% or more of these are stage III or higher carcinoma however remains controversial and is a subject
at diagnosis (Nandakumar et al., 1995).The risk factors of debate in the literature. Recent studies of cervical AC,
known to increase the incidence of cervical cancer are have been conflicting, showing both a poor prognosis and
early marriage (child marriage) and sexual practice, minimal or no importance as a predictor of overall survival
delivery of the first baby before the age of 20, too many of patients diagnosed with cervical carcinoma (Smith et
or too frequent childbirths, multiple sexual partners, poor al., 2000; Lea et al., 2002).
practice of personal hygiene, low socio economic status, In addition, some authors have suggested that only the
Human Papilloma Virus, Herpes Simplex Virus type II, adenosquamous histology of cervical AC carries a poor
HIV positivity, use of oral contraceptive pill, smoking etc. prognosis whereas other authors discount the significance
The present review is a report on retrospective as of this particular histology.
well as recent publications on assessment of risk factors Ruffin et al. (2000) carried out an investigation on
and awareness of cervical cancer across the world. The the current rates of cancer screening (breast, cervical,
discussion has tried to highlight the significant difference colorectal, and prostatic cancer) and also to determine
in the context of knowledge, attitude and practice (KAP) which factors predict completion of a single screening
and screening between high income and low income test, of all tests for each cancer and of all procedures
countries. India is separately taken as a case study to for age and sex. Medical records of 200 eligible patients
magnify some of the lesser known but widely prevalent (100 men and 100 women) from each of 24 community
causes of cervical cancer. based primary care practices were abstracted for cancer
screening events. The study indicated that it is essential to
International scenario increase the percentage of patients who schedule a health
maintenance visit which could serve to increase cancer
High income countries screening and help to reach goals set for the year 2010.
Cervical carcinoma is the third most common A wealth of evidence has led to the conclusion that
Department of Community Medicine, North Bengal Medical College, Susrutanagar, Darjeeling, West Bengal, India *For
correspondence: [email protected]
Asian Pacific Journal of Cancer Prevention, Vol 13, 2012 4221
Sreejata Raychaudhuri and Sukanta Mandal
virtually all cases of cervical cancer are attributable to to 2.54 per 10(5) in 1989-1994. There has been a marked
persistent infection by a subset of human papilloma virus age shift with the main increase in incidence occurring in
(HPV), especially HPV type-16 (HPV-16) and HPV type- younger women aged 30-39. The mean incidence (ASR)
18 (HPV 18). These HPV types also cause a proportion of squamous cell carcinoma of the cervix has decreased
of other cancers, including vulval, vaginal, anal, penile, from 9.78 to 8.74 per 10(5) over the period 1971-76
and oropharyngeal cancers. Although cervical cancer and 1989-94. Again there has been an age shift moving
screening, primarily with the Papanicolaou (Pap) smear, from a single incidence peak in the 45 to 59 age band in
has reduced the incidence of this cancer in industrialized earlier years to incidence peaks in both 30-39 and 55-
countries, cervical cancer remains the second most 69 age bands in more recent years. Similar trends were
common cause of death from cancer in women worldwide, noted when data for England and Wales were analysed.
because the developing world has lacked the resources Birth cohort analysis show that both tumors are occurring
for widespread, high quality screening. In addition to progressively earlier (about 5 years earlier in each 5 year
advances in Pap smear technology, the identification of birth cohort). This study indicated that although the overall
HPV as the etiologic agent has produced 2 recent advances incidence of cervical carcinoma is declining, an increased
that may have a major impact on approaches to reduce incidence of cervical adeno carcinoma, particularly in the
the incidence of this disease. The first is the development younger age groups was imminent.
of a preventive vaccine, the current versions of which Mathew and George (2009) summarized and quantified
appear to prevent close to 100% of persistent genital the trends in incidence and mortality rates of cervical
infection and disease caused by HPV-16 and HPV 18. squamous cell carcinoma (SSC) and adenocarcinoma (AC)
Future second generation vaccines may be able to protect worldwide. The authors included all indexed publications,
against oncogenic infections by a broader array of HPV which provided information on time trends in incidence
types. The second is the incorporation of HPV testing or mortality rates of cervix, published during 1998-2009.
into screening programs. In women aged>30 years, HPV According to these authors cytology screening as well as
testing can identify high grade cervical intraepithelial changes in socioeconomic profile have led to declines in
neoplasia earlier than Pap smear with acceptable rates of cervical SCC incidence and mortality rates worldwide.
specificity. These results together with the high sensitivity Higher percentage decline in SSC is observed in countries
of HPV testing, suggest that such testing could permit where organized screening programmes were available.
increased intervals for screening. An inexpensive HPV The results suggested that Pap smear screening has played
test is in development (Lowy et al., 2008) a significant role in the reduction in SCC in the US,
Liu et al. (2001) generated data on the incidence Canada, New South Wales and in almost all European
of cervical cancer by histologic subtype and mortality countries (except Ireland) as well as in some of the Asian
for the Canadian provinces of Ontario, Saskatchewan, countries. Increasing incidence and mortality rates of
and British Columbia. Age adjusted incidence rate of cervical AC has been reported in many countries such as
squamous cell carcinoma of the cervix decreased from the US, Canada, UK, Iceland, Sweden, England, Spain,
11.1 per 100,000 women in 1970-72 to 5.3 in 1994-96, Finland, Slovakia, Slovenia, Netherlands particularly
while the rate for cervical adenocarcinoma increased from among young women. However the increase was mainly
1.1 per 100,000 women to 1.5 over the same period. Age in earlier periods till 1995 and stable or declining trends
adjusted mortality rate declined from 7.9 per 100,000 in cervical AC have been observed in later periods in
women in 1953-55 to 1.9 in 1195-97. The patterns in many of the above countries such as the US, UK, Canada,
Age specific mortality in 1953-72 were different from Sweden. The increasing risk of AC suggested that a major
those in 1973-97; younger women experienced larger role for an increasing prevalence of persistent oncogenic
reduction in mortality during the earlier period while HPV infection and its cofactors, whereas the down turn
older women benefited to a greater extent during the latter in period effects in several countries during the 1990s
period. Age-period-cohort modeling showed that cohort provided evidence that cytological screening is detecting
effects were responsible for the decreasing trends in the more preinvasive ACs than in previous decades and
incidence of squamous cell carcinoma of the cervix and suggested that cytology screening might be starting
increasing trends in adenocarcinoma, and both period to have a protective impact on AC. The decline in AC
and cohort effects account for the observed trends in the incidence might be due to improved specimen collection
mortality. The results suggested that Pap smear screening as well as due to increased awareness of AC precursors
played a significant role in the reduction in squamous cell among cytopathologists and clinicians, improvements in
cervical carcinoma. The causes for the increase in cervical laboratory training and quality assurance. In conclusion,
adenocarcinoma are unclear. cytology screening in combination with HPV screening
To determine trends in the incidence of invasive for high risk HPV types may maximize the possibilities
adenocarcinoma of the uterine cervix in East Anglia, of having early cervical lesions detected and treated.
Stockton et al. (1997) obtained data for both squamous Assessment of KAP of female students towards
cell carcinomas and adenocarcinomas from the East cervical cancer prevention was studied (Ghotbi et al.,
Anglia Cancer Registry for the period 1971-94. The 2012) words should be deleted in Japan. A national
authors also obtained similar data for England and Wales. immunization plan to vaccinate 13-16 year old female
European Age Standardized Rates (ASRs) were used for students was initiated in Japan in 2010 and may reach full
comparisons. The mean incidence (ASRs) of cervical coverage by the end of 2012. According to these authors
adeno carcinoma was 0.85 per 10(5) in 1971-1976, rising HPV vaccination alone does not offer full protection,
4222 Asian Pacific Journal of Cancer Prevention, Vol 13, 2012
 DOI:http://dx.doi.org/10.7314/APJCP.2012.13.9.4221
Current Status of Knowledge and Screening for Cervical Cancer with Levels of Economic Development
because only some HPV types are covered by the vaccines 23% reported use of other methods, barrier methods or no
and the long term efficacy of the vaccines has not been form of contraception. Barrier contraceptive use was not
determined yet. A survey was therefore conducted at an significantly different between cases and controls. Current
international university in Japan to study the KAP of and/or past exposure to hormonal contraceptives (HC) by
female college students towards cervical cancer. The use of pill or injection, alone or in combination with other
authors opine that there is need to increase awareness methods was significantly higher in the cases. The study
among Japanese female adolescents and to enhance the indicated that hormonal contraception did confirm some
cervical screening rates among older females who are risk of dysplasia and women using HC should therefore
already sexually active. be encouraged to do regular Pap smear screening.
In Korea, cervical cancer is the third leading cancer Screening facilities for cancer cervix are available in
among females and is fifth highest in mortality. The 100.0South Africa but the incidence and mortality from cervical 100.0
persistent oncogenic human papillomavirus (HPV) cancer remains
6.3 very high and many women present at the
10.1 6.
1
20.3
infections are the greatest risk of developing cervical facilities with late stage disease. A study was conducted by
intraepithelial neoplasia and invasive cancer. The overall Hoque et al. (2008) to determine the baseline information 30.0
75.0 25.0 75.0
prevalence of HPV was 10.4% in Korea and strong risk on knowledge and practices on risk factors for cervical
factors for HPV infection included a young age at sexual cancer and Pap smear 46.8 and to design an intervention to
56.3 56
5
debut. The National Cancer Screening Program, which improve Pap smear uptake. A cross sectional population
includes cervical cancer screening, has the following50.0based descriptive study was 54.2undertaken at a rural50.0
31.3 30.0
principles: the main screening tool is the Papanicolaou community of South Africa targeting women 30 years
test conducted by gynecologists, which targets. All women and over. The assessment was performed by means of a
aged 30 and over, and which is done every 2 years. HPV25.0questionnaire survey. Outcome measures were percentage25.0
DNA tests have not yet been permitted as a screening test of women with the38.0 knowledge on risk factors for cervical
31.3 31.3 3
31
for cervical cancer in Korea; however, these are conducted cancer and use of Pap smear test23.7and had under taken Pap
30.0

along with a Pap test for screening cervical cancer in the smear test. This study showed low uptake of Pap smear
clinic. The use of prophylactic HPV vaccine has been 0test and low level knowledge on prevention of cervical 0
accepted in Korea; The Korean Society of Gynecologic cancer and risk factors thus warranting urgent extensive

None
Remission
Persistence or recurrence
Newly diagnosed without treatment

Newly diagnosed with treatment

Oncology and Colposcopy’s recommendation for routine health education program for these rural communities.
vaccination is for females aged 15-17 years with a Cervical Cancer is the commonest cancer of women
catch-up vaccination recommended for females aged in Uganda. Over 80% of women diagnosed in Mulago
18-26 years who have not been previously vaccinated. national referral and teaching hospital, the biggest hospital
However, many people in Korea are not familiar with in Uganda, have advanced disease. Pap smear screening,
the HPV vaccine. Therefore, it is necessary to improve on opportunistic rather than systematic basis, is offered
awareness of the disease and HPV vaccination and to free in the gynaecological outpatients clinic and the
establish the effective strategies to obtain funding for postnatal/family planning clinics. A study was undertaken
HPV vaccination. In future, cervical cancer is expected to describe knowledge on cervical cancer, attitudes and
to disappear throughout the world, including the Asia practices towards cervical cancer screening among the
Pacific region, through a combination of vaccination medical workers of Mulago hospital. (Mutyba et al., 2006).
and qualified screening programs for cervical cancer The study indicated that attitude and practices towards Pap
(Kim, 2009). Tran et al (2011) made a comparative study smear screening were negative.
among rural and urban female health care practitioners in Terefe and Gaym (2008) carried out a study on KAP
Korea regarding KAP and screening for cervical cancer. of cancer cervix among reproductive health clients at
According to these authors misconceptions and ineffective three teaching hospitals in Addis Ababa, Ethiopia. Most
clinical practices need to be addressed among both study respondents had never heard of Pap smear screening. The
groups. The authors found no major differences between source of information for those who were aware of the
rural and urban respondents regarding their KAP. test, were health institutions. The younger population was
better informed than their older counterparts. According
Low and middle income countries to these authors there is a need to intensify the level of
A study was conducted to determine whether use health education in the city.
of hormonal contraceptives is associated with cervical HPV prevalence and Cervical Intraepithelial Neoplasia
dysplasia and cancer in a population of Jamaica (McFarlen- (CIN) in HIV infected women were studied in Yunnan
Anderson et al., 2008) where there is a widespread use of province, China by Zhang et al. (2012). The authors
hormonal contraception and the rates of cervical cancer employed cervical cytology, HPV detection by Hybrid
remain high at 27.5/100,000. This study included women Capture assay and diagnostic colposcopy with cervical
visiting the colposcopy and gynaecological clinics at a biopsy. Colposcopic histopathologically proven CIN2+
tertiary referral hospital. Two hundred and thirty six cases lesions were found to be present in 8.4% HIV infected
CIN I (72), II (59), III (54), cancer (51) and 102 controls women. Nearly half (43%) were co-infected with
consented and were interviewed on use of contraceptives carcinogenic HPV genotypes. According to these authors
using a structured questionnaire. Contraceptives used HIV/AIDS care and treatment programmes should
were: oral contraceptives-35%, injections depot medroxy integrate effective cervical cancer prevention.
progesterone acetate (Depo-provera)-10%, Intrauterine Currently, little is known regarding cervical cancer
devices-2%, combinations of these and tubal ligation-30%. incidence in Laos, although it is anticipated to be high
Asian Pacific Journal of Cancer Prevention, Vol 13, 2012 4223
Sreejata Raychaudhuri and Sukanta Mandal
like in neighboring countries. To be able to develop a methods to detect cervical cancer and could contribute to
screening program in the country, it is essential to explore the reduction of disease in these countries. While HPV
women’s perception of the disease. The purpose of this vaccination provides hope for the future, several barriers
study was therefore to describe knowledge, awareness, prohibit the introduction of prophylactic vaccines in these
and attitudes regarding cervical cancer among rural countries such as high costs and low public awareness
women of Laos. In a descriptive cross-sectional study, of cervical cancer. Efforts to implement screening based
women were interviewed using a structured questionnaire on the research experiences in the region offer the only
covering socio-demographic factors, knowledge of the currently viable means of rapidly reducing the heavy
disease and its risk factors, awareness, and attitudes burden of disease ( Sankarnarayanan et al., 2008)
toward cervical cancer and its prevention. Eight hundred
women were included in the study, and 58% claimed to The Indian Scenario
knew about cervical cancer. Approximately one third
(38%) considered themselves to be at risk, but less than Among the modern epidemics, cancer is the second
5% had ever had a Papanicolau test. Sixty-two percent largest non communicable disease and it has a sizable
believed it was possible to prevent cervical cancer and contribution to the total number of deaths. The World
that vaccination may be a suitable method, but only 14% Health Organization (WHO) documents that cancer rates
knew about risk factors. Another method for prevention are set to increase at an alarming rate globally and it is
was frequent vaginal douching, which was suggested by projected by the WHO that cancer burden would increase
70% of the women. Symptoms like bleeding and discharge to 20 million by 2020 with 70% in the developing world.
were correctly identified as possible indicators of cervical (http://www.who.int/mediacentre/factsheetsfs297/en/(s)).
cancer, but only 57 women (7%) knew that an early stage The incidence of cancer is increasing in developing
of the disease could be symptom-free. Lack of subjective countries as deaths from infectious diseases and childhood
symptoms was the main reason for women to refrain from mortality is decreasing. As a result, longevity increases.
gynecological examinations. This study indicates that rural However, this leads to higher incidence of cancer at older
women in Laos have limited knowledge about cervical ages. It is estimated that there are 2 million cancer patients
cancer and even less about screening and prevention. in India with 0.7 million new cases each year. However,
According to the authors ( Phongsavan, 2010) there is a many of these cases of cancer could be tackled to a large
need to educate the general community about the disease extent by simple cost effective methods that emphasize
and its prevention. on primordial, primary and tertiary levels of prevention.
Vu and Bui (2012) showed that the burden of cervical The promotion of preventive measures could be done by
cancer is increasing in Vietnam in the recent years, giving impetus to public awareness activities and early
infection with high risk HPV being the cause. The authors detection and screening programmes. Many investigations
studied prevalence of HPV and the distribution of specific done in developed countries show a strong association
types of HPV in five big cities in Vietnam. The most between early reporting for screening and treatment in
common HPV types in all five cities were HPV 16, 18 and the community.
58. Most of the positive cases were infected with high risk An investigation was undertaken by Puri et al (2010)
HPV both in Hanoi and Can Tho. to assess the knowledge, attitude and practices in the
Although one-third of the world cervical cancer community pertaining to various aspects of cancer so
burden is endured in India, Bangladesh, Nepal and Sri that higher authorities could use the data as baseline
Lanka, there are important gaps in our knowledge of the for further interventional studies. The knowledge about
distribution and determinants of the disease in addition cancer and other aspects related to cancer was low in slum
to inadequate investments in screening, diagnosis and dwellers as compared to urban population. A wide gap in
treatment in these countries. Prevalence of human the awareness was found between the slum dwellers and
papillomavirus (HPV) infection among the general the urban community. More than 80% of the respondents
populations varies from 7-14% and the age-specific were aware of the term cancer and also the symptoms
prevalence across age groups is constant with no clear of the disease. The results were in corroboration to the
peak in young women. This observation may be the result study done in urban slum dwellers in New Delhi (Seth et
of a low clearance rate of incident infections, frequent re- al., 2005), where also a large number of subjects could
infection/reactivation, limited or no data in target high-risk tell at least one sign of cancer. The study indicated that
age groups (teenagers), and sexual behavioural patterns in educational programmes should be developed to promote
the population. High-risk HPV types were found in 97% of adherence to recommended screening guidelines. For
cervical cancers, and HPV-16 and 18 were found in 80% of the program to be effective, the educational campaigns
cancers in India. Beyond research studies, demonstration need to be in vernacular and elaborated scientifically.
projects and provincial efforts in selected districts, there Raychaudhuri and Mondal (2012) made use of Powerpoint
are no serious initiatives to introduce population-based presentations prepared in the Bengali language on
screening by public health authorities in these countries. Cancer in general and Cervical Cancer in particular to
Cervical cancer is a relatively neglected disease in terms communicate with the urban and rural slum dwellers of
of advocacy, screening and prevention from professional Shaktigarh and Kawakhali in the districts of Jalpaiguri
or public health organizations. Cytology, HPV testing and Darjeeling, North Bengal, respectively. They were
and visual screening with acetic acid (VIA) or Lugol’s educated about symptoms of cervical cancer, personal
iodine (VILI) are known to be accurate and effective hygiene and prevention measures. Their opinion on PAP
4224 Asian Pacific Journal of Cancer Prevention, Vol 13, 2012
 DOI:http://dx.doi.org/10.7314/APJCP.2012.13.9.4221
Current Status of Knowledge and Screening for Cervical Cancer with Levels of Economic Development
Test and HPV vaccination were also sought. The study also area of West Bengal was carried out by Dasgupta et al.
highlighted the comparative status of knowledge between (2002).This was a community based, cross-sectional
slum dwellers of urban and rural North Bengal. type observational study conducted in East Govindopur
Dhamija et al. (1993) undertook a survey on knowledge, village, Singur Block in Hoogly district of West Bengal,
attitude and practice (KAP) study prior to initiation of undertaken during October 2000 to January 2001. 103
cytological screening. A total number of 1411women married women of reproductive age group were included
were interviewed by random sampling. Subjects for the in the study and respondents were interviewed directly to
analysis consisted of a group of women who had reported collect the data. The factor of early marriage was found to
previous gynaecological problems related to cervical be predominant in the said investigation since 59.3% of
cancer. The study brought out that younger women had the population consummated marriage before they attained
better awareness and knowledge about cervical cancer the age of 18.
and related information. Literacy status and exposure to Dasgupta et al. (2002) also reported poor genital hygiene
family planning were influential in creating awareness of the cases studied. Two third of the study population used
about cancer cervix. In the present investigation, it was one or more methods of contraception while only 7.7%
evident that younger women selected by random sampling, were using barrier methods of contraception. It has been
followed the practice of contraception after birth of two documented that there was a slightly reduced incidence
children which also gave them some information on of cancer cervix in women using barrier contraceptives
healthy, disease free life style. and higher incidence in those using oral contraceptive
A study in Kerala, India (Varghese et al., 1999) pills (Dasgupta et al., 2002). These authors concluded that
confirmed the importance of genital hygiene in the fight various risk factors of cancer cervix e.g., early marriage,
against infections that have a role in the development of increased parity and early marriage, low literacy, poor
cervical dysplasia and cancer. Many women could not genital hygiene and symptoms of reproductive tract
afford sanitary pads, while adequate facilities for washing infection were highly prevalent among subjects under
after coitus are often unavailable. Health education, study. In the present investigation, the younger women
satisfactory living standards and the empowerment of practiced barrier method of contraception, the older
women are prerequisites for reducing the incidence of women, on the other hand depended on oral pills.
cervical dysplasia. A recent study of the risk factors for cancer cervix in
An investigation was carried out with a view to a speciality hospital in Kolkata was carried out by Mitra
establish the prevalence of cancer cervix in a rural (2009). The study was done on 133 cancer cervix patients
Muslim community in the State of Jammu & Kashmir, in along with a control group of 88 women, to know the risk
India. For this, a community based screening for cancer factors for cancer cervix actually relevant in the particular
cervix was conducted on married women aged 20-65 study area. Each subject was interviewed by a pretested
years. Following provision of information to promote questionnaire and relevant records were examined. Some
awareness on Pap smear and its role in prevention of important risk factors were identified in the study-Early
cervical cancer, 270 women were screened for cancer age at sexual debut, higher number of child births, low
cervix by the conventional technique. Of the 270 subjects, spacing between consecutive deliveries and non use of
the majority were married before 19 years of age (81.1%) sanitary napkin during menstrual period. Percentage of
and 42.5% delivered their first child within a year or two. low age (up to 19 years) at first sexual intercourse is
Multiparity was seen to the tune of 51.3%.There was no significantly higher among the cases (94.7%) than that
evidence of cervical dysplasia or cancer cervix among the among the controls (71.4). It has been observed that most
screened population. According to these authors (Yasmeen of the cases (70.3%) had average spacing between two
et al., 2010) despite the presence of risk factors of high children of 2 years or less, but most of the controls (52.5%)
parity , early age of marriage, and early childbirth after were having average spacing of 3-4 years. Use of sanitary
marriage, absence of cervical dysplasia and malignancy napkin during menstrual period were observed among
emphasizes the fact that socio-cultural factors like absence only 3.8% of cases, whereas, 47.7% of the controls were
of promiscuity and male circumcision , play an important in the habit of using sanitary napkin. The cancer cervix
role in the low prevalence of cancer cervix. patients had a significantly higher age range than the
Joy et al. (2011) conducted a study among the female control subjects, indicating that age may be a risk factor.
educated youths from India, Nepal and Srilanka and The present authors Raychaudhuri and Mondal (2012),
concluded that the awareness of cervical cancer was 66% observed that repeated use of cloth, washed after every
in India, 58.8% in Nepal and 57.7% in Srilanka. However, use during menstruation was the usual practice. As a
the concerned subjects had lesser knowledge of risk result, poor genital hygiene could be a serious factor
factors. According to these authors, despite the advent of in the population studied. Use of barrier contraception
HPV vaccine there has been no major improvement in was found to be observed in the women of younger ages
awareness among the undergraduate female students of indicating a better method of family planning. However,
these countries. In a study carried out in Kolkata, 41% of some subjects from both urban as well as rural populations
college students included in the survey , were aware of a revealed symptoms of reproductive tract infection which
link between sexual activity and cervical cancer (Saha et could also be a serious risk factor of cervical cancer. The
al., 2010) . review of Indian reports highlights more minutely the
A community based study on the prevalence of risk categories and causes which exacerbate the incidence of
factors of cancer cervix in married women of a rural cervical cancer in a low income country.
Asian Pacific Journal of Cancer Prevention, Vol 13, 2012 4225
Sreejata Raychaudhuri and Sukanta Mandal
Conclusion J Genaecol Cancer, 11, 24-31.
Lowy DR, Solomon D, Hildeshein A, Schiller JT, Schiffman M
It is clear from the above discussion that there is a (2008). Human papiloma virus infection and the primary
serious dearth of screening facilities and HPV vaccination and secondary prevention of cervical cancer. Cancer, 113,
in low and middle income countries including India. This , 1980-93.
Mathew A, George PS (2009). Trends in incidence and mortality
is in stark contrast to careful design of such activities by
rates of squamous cell carcinoma and adeno carcinoma of
the government in high income countries. However this Cervix-world wide. Asian Pac J Cancer Prev, 10, 645-50.
is one part of the story since there is a serious lack of McFarlene-Anderson N, Bazuaye PE, Jackson MD, Smikle M,
knowledge and attitude among the concerned population Fletcher HM (2008). Cervical dysplasia and cancer and the
regarding the importance of early detection of cervical use of hormonal contraceptives in Jamaican women. BMC
cancer as well as its rate of mortality. The rural-urban Women’s Health, 8, 9-10.
divide also comes out prominently in the low and middle Mitra S (2009). Study of the risk factors for cancer cervix in a
income countries. India, which has got the second largest speciality hospital in Kolkata. J of Community Medicine,
population in the world, has been specially mentioned to 5, 1-5.
Mutyba T, Mmiro FA, Weiderpass E (2006). Knowledge,
highlight this absence of KAP towards cervical cancer
attitudes and practices on cervical cancer screening among
as well as presence of rural-urban divide. Hence a two the medical workers of Mulago hospital, Uganda. BMC
pronged approach is necessary to eradicate the menace Med Edu, 1, 6-13.
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government action on one hand and targeted campaign of mortality and survival in cancer of the cervix in Bangalore.
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Women’s perception of cervical cancer and its prevention in
Acknowledgements rural Laos. Int J Gynecol Cancer, 20, 821-6.
Puri S, Mangat C, Bhatia V, Kaur AP, Kohli DR (2010).
The authors are grateful to the Department of Knowledge of cancer and its risk factors in Chandigarh,
India. Internet J of Epidemiology, 8, 1-7.
Community Medicine for the facilities provided. Sreejata
Raychaudhuri S, Mandal S (2012). Socio-demographic and
Raychaudhuri sincerely acknowledges the award of Short behavioral risk factors for cervical cancer and knowledge,
Term Studentship (STS) 2010 Fellowship from Indian attitude and practice in rural and urban areas of North Bengal,
Council of Medical Research (ICMR). India. Asian Pac J Cancer Prev, 13, 1093-6.
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