The impact of a community intervention to improve cervical cancer screening uptake in the Amazon region of Brazil
Keywords:
Cervix uteri, Neoplasms, Diagnosis, Ambulatory care, Vaginal smearsAbstract
CONTEXT AND OBJECTIVE: In the northern region of Brazil, cervical cancer is the most important cause of cancer-related deaths among women. There is considerable likelihood, however, that offi cial incidence and mortality fi gures are greatly underestimated. The aim of this study was to estimate the repercussions from improvement in cervical cancer screening programs on the incidence of pre-invasive and invasive cervical lesions in a municipality in this region. DESIGN AND SETTING: This was a quasi-experimental study that assessed process dimensions relevant to the program objectives. The study comprised a sample of 2,226 women seen at primary healthcare units in Cruzeiro do Sul, a small city in the Brazilian Amazon region, from April 2003 to July 2004. METHODS: Women were recruited through local radio advertisements and by oral communication from the investigators. The women answered a structured questionnaire and underwent pelvic examination, which included Papanicolaou (Pap) smears and naked-eye inspection of the cervix after applying diluted acetic acid. Women with positive Pap smears or abnormal gynecological examination were referred for colposcopy and possible biopsy, diathermic large loop excision of the transformation zone or conization. RESULTS: The results obtained were compared with historical offi cial data retrieved from the Brazilian Ministry of Health’s database. Intervention resulted in a 40% increase in positive Pap smears and detection of cancer was nine times higher than had been observed in routine screening. CONCLUSIONS: Detection of pre-invasive and invasive cervical lesions in the intervention group was remarkably higher than among women seen during routine screening.
Downloads
References
Brasil. Ministério da Saúde. Instituto Nacional do Câncer. Estimativas de Incidência de Câncer no Brasil. Nordeste. Available from: http://www.inca.gov.br/estimativa/2006/index.asp?link=tabelaregioes.asp&ID=3. Accessed in 2006 (Dec 11).
Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Secretaria de Atenção à Saúde. Instituto Nacional do Câncer. Coordenação de Prevenção e Vigilância. Estimativas 2005: Incidência de câncer no Brasil. Rio de Janeiro: INCA; 2004. Available from: http://bvsms.saude.gov.br/bvs/publicacoes/estimativa_versaofinal.pdf. Accessed in 2006 (Nov 21).
Brasil. Ministério do Planejamento, Orçamento e Gestão. Insti- tuto Brasileiro de Geografia e Estatística. Cidades@. Available from: http://www.ibge.gov.br/cidadesat/default.php. Accessed in 2006 (Dec 11).
Solomon D, Davey D, Kurman R, et al. The 2001 Bethesda System: terminology for reporting results of cervical cytology. JAMA. 2002;287(16):2114-9.
Scully RE, Bonfiglio TA, Kurman RI, Silverberg SG, Wilkins EJ. Histological typing of female genital tract tumors – World Health Organization – International histological classification of tumors. 2nd ed. Berlin: Springer-Verlag; 1994.
Miller AB, Nazeer S, Fonn S, et al. Report on consensus conference on cervical cancer screening and management. Int J Cancer. 2000;86(3):440-7.
Denny L, Kuhn L, Pollack A, Wright TC Jr. Direct visual inspection for cervical cancer screening: an analysis of factors influencing test performance. Cancer. 2002;94(6):1699-707.
Denny L, Kuhn L, Pollack A, Wainwright H, Wright TC Jr. Evaluation of alternative methods of cervical cancer screening for resource-poor settings. Cancer. 2000;89(4):826-33.
Solomon D, Schiffman M, Tarone R; ALTS Study group. Comparison of three management strategies for patients with atypical squamous cells of undetermined significance: baseline results from a randomized trial. J Natl Cancer Inst. 2001;93(4):293-9.
Ponten J, Adami HO, Bergström R, et al. Strategies for global control of cervical cancer. Int J Cancer. 1995;60(1):1-26.
Cronje HS, Parham GP, Cooreman BF, de Beer A, Divall P, Bam RH. A comparison of four screening methods for cervi- cal neoplasia in a developing country. Am J Obstet Gynecol. 2003;188(2):395-400.
Sigurdsson K. The Icelandic and Nordic cervical screening programs: trends in incidence and mortality rates through 1995. Acta Obstet Gynecol Scand. 1999;78(6):478-85.
Sankaranarayanan R, Wesley R, Thara S, et al. Test characteristics of visual inspection with 4% acetic acid (VIA) and Lugol’s iodine (VILI) in cervical cancer screening in Kerala, India. Int J Cancer. 2003;106(3):404-8.
Sankaranarayanan R, Wesley R, Somanathan T, et al. Visual inspection of the uterine cervix after the application of acetic acid in the detection of cervical carcinoma and its precursors. Cancer. 1998;83(10):2150-6.
Visual inspection with acetic acid for cervical-cancer screening: test qualities in a primary-care setting. University of Zimbabwe/JH- PIEGO Cervical Cancer Project. Lancet. 1999;353(9156):869-73.
Sankaranarayanan R, Nene BM, Dinshaw K, et al. Early detection of cervical cancer with visual inspection methods: a summary of completed and on-going studies in India. Salud Publica Mex. 2003;45(Suppl 3):S399-407.
Nazeer S. Aided visual inspection of the cervix. “Acetic acid test” picture atlas. Geneva Foundation for Medical Education and Research. Available from: http://www.gfmer.ch/Books/Cervical_cancer_modules/Aided_visual_inspection_atlas.htm. Accessed in 2006 (Dec 05).
