Knowledge of and access to screening in women with carcinoma of the cervix ín Brazil

Summary In order to assess the levei of knowledge of screening for carcinoma of the cervix among women presenting with this condition, a survey of a consecutiva series of patients was undertaken. AH 266 patients presenting at this hospital during 1988 for the treatment of carcinoma of the cervix completed a structured questionnaire about cervical câncer screening. A percentage of 68.8% patients had never been screened. Those patients who had not previousiy had a cervical smear test were more likely to be in the older age groups (over 45 years) and to come from low income groups with poor educatlon and poor access to medicai facilities. Even among patients who had previousiy had contacts with the medicai profession, only a minority (approximately 40%) had undergone cervical screening at any time. Since carcinoma of the cervix is currentiy the commonest malignant neoplasm in women in Brazil, it is evident that an urgent campaign is necessary to educate both the public and the medicai profession in cervical screening, hopefully to reduce the very high rate of Invasive carcinoma of the cervix in this country.


Introduction
reason why so many patients in Brazil are presenting late with invasive carcinoma of the cervix and with littie knowdiedge of or exposure to cervical smear screening.
Since 1943, when the Papanicolaou test was introduced to detect the earliest stages of cervical câncer [1], cervical smear screening has been used in many countries to reduce mortality from invasive carcinoma of the cervix [2][3][4][5][6][7][8][9][10], Despite this, it appeared to us in this hospital that many women were presenting with carcinoma of the cervix who had not had any form of previous screening. Thus, in this institution between 1968 and 1986, 1,173 women were treated for carcinoma of the cervix. Of these cases 96% were invasive cancers. This was equivalent to 32% of all malignant disease seen in women in this hospital (excluding skin câncer). In Brazil, as a whole, carcinoma of the cen/ix is a very common neoplasm and, in ten States, it accounts for approximately half of all cancers in women, including câncer of the skin [4-Methods All 266 patients treated in the São Judas Tadeu Hospital Barretos, São Paulo, Brazil in the 12 months ending November 1986 who had histologically proven carcinoma of the cervix were included in the study. This hospital is a regional câncer therapy centre, and belongs to the Integrad System for the fight against câncer.
All patients were interviewed by one of us (E.C.M.), using a structured questionnaire. They were asked about their knowledge of cervical screening, the source of their information, whether they had previousiy undergone cervical smear testing, and how frequentiy. They were aiso asked about any contacts 14].
This study was undertaken in order to assess the Information abóut previous treatment was confined to that available in hospital notes, as the area in which Barretos is situated has relatively poor records both for diagnostic Services and medicai treatment [12], The significance of differences was measured by the technique. about it from friends or relatives, some from television or radio programmes, and some from information in books or magazines. Knowledge about cervical screning was closely related to the levei of education of the patient. This is detailed in Table 2. Thus, ignorance of cervical screening was commoner among iiliterate patients than those who had completed primary schooling (P < 0.001), and ignorance of screening was similarly commoner in those who had only undergone primary schooling than in those who had undergone secondary education (P < 0.001).
A similar relationship was seen between knowledge of cervical screening and family income, but this was much less dose than the relationship seen with the levei of education (see Table 3). Thus those women with family income in the lowest bracket were significantiy more likely than others to be ignorant of cervical screening methods.
Amongst other factors analysed, the ethnic •P < 0.01 background and occupation bore no relationship to previous screening, but patients who had multiple (more than three) pregnancies tended to be more ignorant about cervical screening.
Althought 133 patients were aware of the possibility of screening for cervical câncer, only 83 had actually undergone screening. Of those who knew about screening but chose not to undergo it, 28 (56%) feit that it was unimportant, 11 (22%) were embarrassed about having the test done, and the remainder (22%) gave a variety of other reasons for not having the test. The majority of patients who had had screening had only undergone screening on a single occasion rather than repeatediy. carcinoma of the cervix, yet were not offered cervical screening. The benefits of doctors and paramedical staff encouraging cervical screening on hospitalised patients is well known [22][23][24]. In New York State it is a legal requirement to offer cervical smear screening tests to all inpatients [21].
This study clearly demonstrates that in Brazil, where carcinoma of the cervix is a very serious health problem, there is an urgent need to publicise the importance of cervical smear screening tests. There is a need for widespread public education, but aiso an increase in the education of medicai and paramedical workers.
Carcinoma of the cervix extremely common in Central and South America, and in África, India China and Asia [13]. In Europe and North America is the fourth commonest câncer in women. In Brazil, in 1980, malignant neoplasms were responsible for 8.5% of deaths in women, carcinoma of cervix being responsible for 8% of them. For 1981 these figures were 8.9% and 12.86% and for 1983 they were 9.5% and 7.6% respectively [15].
We were surprised by the discovery in this study that half of all our patients with carcinoma of the cervix were completely ignorant of the fact that a screening test was available for this condition. A significant number of those who knew about the existence of cervical screening had never actually undergone screening, mainly because of ignorance abouth the test itself or what was involved.
It is disappointing, in view of the fact that the larger the proportion of women undergoing cervical screening the greater the reduction in clinically invasive carcinoma of the cervix [16], that more than two thirds of our patients with invasive carcinoma of the cervix had never undergone any sort of screening for carcinoma of the cervix.
Similarly poor resuits have been reported by authors in other countries [17][18][19]. However, it is possible to achieve much better resuits, as demonstrated in Sweden [20]. The medicai and paramedical Services are not aiways particularly good at ensuring that women who come into contact with them are reminded about the possibility of screening for carcinoma of the cervix. Thus Fruchter et al.
showed that approximately half of those 97 patients with invasive carcinoma that they studied had not had screening, despite the fact that they had been in frequent contact with medicai Services [21]. We found similar resuits, in that 152 of our 266 patients had undergone some form of contact with the medicai profession in the three years before the diagnosis of UNITERMOS: câncer do colo do útero, rastreamento