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HPV – Cervical Cancer in Women Essay

Human papillomavirus (HPV) is considered to be a common viral infection of the reproductive tract. Most of the women, engaged into sexual relations, have the risk of being infected with this virus at some moment of time or even repeatedly infected. “Worldwide, cervical cancer is the fourth most frequent cancer in women with an estimated 530 000 new cases in 2012 representing 7.5% of all female cancer deaths. Of the estimated more than 270 000 deaths from cervical cancer every year, more than 85% of these occur in less developed regions.” (American Cancer Society, 2014). Usually the peak of potential time for acquiring of this infection is shortly after becoming sexually active. HPV is sexually transmitted, and it is important to note that it happens only in case of penetrative sex, skin-to-skin contact is already enough for transmission. There are a lot of different types of HPV and luckily most of them are not problematic for humans. “HPV infections usually clear up without any intervention within a few months after acquisition, and about 90% clear within 2 years.HPV – Cervical Cancer in Women Essay. A small proportion of infections with certain types of HPV can persist and progress to cancer.” (Human papillomavirus (HPV) and cervical cancer, 2018). The most common type of HPV-related disease is cervical cancer, as most of the cases of cervical cancer are considered attributable to HPV infection. It was already mentioned that there are types of HPV, which are not responsible for cancer, usually these are types 6 and 11 and they can cause genital warts and respiratory papillomatosis – when tumors grow in all air passages, starting from the nose and into the lungs. HPV – Cervical Cancer in Women Essay.

The most dangerous aspect about HPV infections is that most of them do not cause any symptoms, thus they resolve spontaneously. In cases of persistent infection, mostly by types 16 and 18, it could lead to precancerous lesions. If an individual is not treated, then these lesions are luckily to progress to cervical cancer. The process usually lasts during a relatively long period of many years. The first symptoms of cervical cancer start to appear only as soon as the cancer reaches the advances stage. These symptoms include:

irregular, intermenstrual bleeding after sexual intercourse
leg, back and pelvic pain
weight loss, fatigue, lack of appetite
single swollen leg
vaginal discomfort

The more advanced stages bring more serious symptoms. Most of the HPV infections tend to clear up on their own, even most of the pre-cancerous lesions could resolve spontaneously, but still there is a risk for all females, that HPV infection could pass to the chronic stage and pre-cancerous lesions could progress into cervical cancer. For the women with normally functioning immune systems it might take up to 20 years for cervical cancer to develop. In case the immune system is weakened, then it might take only 10 years, as well as in cases with untreated HIV infections.HPV – Cervical Cancer in Women Essay. The major risk factors for HPV persistence and consequent development of cervical cancer include early sexual intercourse, tobacco use, multiple sexual partners, immune system suppression.

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In order to manage the problem in developed countries were a lot of programs developed, which provide the opportunities for women to get screened with the aim to identify pre-cancerous lesions with following treatment of them. HPV – Cervical Cancer in Women Essay. Such approach of screening and early treatment helps to prevent at least 80% of cervical cancers there. In developing countries the lack of access to screening leads to further development of symptoms, as they were not identified at early stages. The mortality rates from cervical cancer are rather high globally, which means that it is important to conduct effective screening and introduce treatment programs in all countries of the world.

Cervical cancer screening is the process of testing for pre-cancer and cancer among women, who actually experience no concrete symptoms and feel themselves healthy. This screening helps to detect pre-cancerous lesions and then there are high chances for treating them and avoiding of cancer. Screening could also help to detect cancer at early stages and again timely treatment could lead to rather positive results. “Because pre-cancerous lesions take many years to develop, screening is recommended for every woman from aged 30 to 49 at least once in a lifetime and ideally more frequently. Screening is only effective on cervical cancer mortality, if a high proportion of women participate.” (Human papillomavirus (HPV) and cervical cancer, 2018).

Nowadays there are three types of screening tests available: conventional Pap test along with liquid-based cytology, visual inspection with the help of Acetic Acid and HPV testing for high –risk HPV types. Prevention is certainly the best option for avoiding of cervical cancer development. HPV – Cervical Cancer in Women Essay.HPV vaccination could currently be done with 2 vaccines, which could protect from HPV 16 and 18, which are responsible for 70% of cervical cancer cases. HPV – Cervical Cancer in Women Essay. The vaccines could also have cross-protection functions against other types of HPV, which could also lead to cervical cancer. It is important to remember that HPV vaccination is not a replacement for cancer screening.

According to World Health Organization (WHO) cervical cancer could be prevented and controlled only with the help of comprehensive approach. “The recommended set of actions includes interventions across the life course. It should be multidisciplinary, including components from community education, social mobilization, vaccination, screening, treatment and palliative care.” (Human papillomavirus (HPV) and cervical cancer, 2018). Also there is a list of recommended preventive interventions, including:

education about healthy sexual practices, including motivation for delayed start of sexual activity
warning about tobacco use especially starting this during adolescence
promotion of condoms as the protection means for those young individuals, who are already engaged into sexual activities.
Sexually active women should be screened for abnormal cervical cells and pre-cancerous lesions, starting from 30 years of age.

Overall, human papillomavirus is rather dangerous as it does not have serious symptoms and some types of it could lead to cervical cancer. This is the reason why there is a need to organize a whole range of preventive measures. HPV – Cervical Cancer in Women Essay.

References:

American Cancer Society. (2014). Cancer Facts & Figures 2014. Atlanta: American Cancer Society

Centers for Disease Control and Prevention. (2012). Human papillomavirus-associated cancers—United States, 2004-2008. Morbidity and Mortality Weekly Report

Chaturvedi A.K., Engels E.A., Pfeiffer R.M., et al. (2011). Human papillomavirus and rising oropharyngeal cancer incidence in the United States. Journal of Clinical Oncology

Human papillomavirus (HPV) and cervical cancer. (2018). WHO

Urban D, Corry J, Rischin D. (2014). What is the best treatment for patients with human papillomavirus-positive and -negative oropharyngeal cancer? Cancer; 120(10)

What are the Barriers of Human Papillomavirus (HPV) Vaccination and Cervical Cancer Screening amongst Minority Women age 12-26? HPV – Cervical Cancer in Women Essay.

Abstract

Background: Minority women systematically experience socio-economic disadvantages, which put them in the face of greater obstacles in attaining optimal health. Approximately 44 million women in the United States, nearly one third of all women in America, self-identify as women of a minority racial or ethnic group. Yet, minority women fare worse than non-Hispanic white women across a broad range of measures, with some of the largest disparities being that of HPV-related cervical cancer mortality. Objective: The objective is to emphasize the barriers of care in relation to cervical cancer screening and HPV vaccination, as well as examine patterns in barriers like demographic, cultural, and health belief factors amongst minority women.Methods: The data collection review and process was based on article review factors that were associated with HPV vaccine acceptability, initiation, and series completion among adolescent and young adult women of different racial, ethnic, and socioeconomic groups in the United States. Results: Selected characteristics of the included studies contended that an estimated 12,000 women are diagnosed with cervical cancer annually in the United States, and 4500,000 women worldwide develop cervical cancer each year. Higher rates of cervical cancer are found in US regions with large minority and impoverished populations. Conclusion: It is imperative for clinicians to progress minority women screening and early detection. Further intervention models need to reflect multifactorial determinants of screening utilization. HPV – Cervical Cancer in Women Essay.

Introduction

Background

While there have been strides in HPV and cervical cancer prevention efforts, many minority women across the board still experience significant barriers to care. For example, women from rural and poor communities tend to have health illiteracy in regard to their own self-care, which also includes their mistrust for the healthcare system. Additionally, many minority women simply lack financial access to care. Socio-economic disadvantages (i.e. race, class, gender, education, occupation, etc.) are the underlying issues. Though many health efforts are made by health professionals, and health ramifications like informative technologies and preventative care strategies have been achieved, there is a continual socio-economic and racial imbalance with both the diagnosis and treatment of cervical cancer, especially the strains directly influenced by HPV.

Specific Aims

Our specific aims are to first identify Health care barriers and challenges to cervical cancer screening and HPV vaccination within the population of minority women. We also want to uncover minority women, health care provider & health care system risk factors for cervical cancer screening & HPV vaccination, as well as, health care challenges and opportunities in improving cervical cancer screening rates amongst minority women. Lastly, we want to pinpoint the nurses’ roles in preventing cervical cancer in underserved racial and or ethnic populations.

Methods

Search Strategy

In June 2017,we searched four electronic bibliographic databases (Google scholar, Medline, Pubmed and Cinahl) using the search terms ‘HPV’ ‘cervical cancer’ ‘pap smear’ ‘minority women’ ‘ethnic women’ and ‘health disparities’. All of the studies identified during the database search were assessed for relevance to the review based on the information provided in the title, abstract, and description of key words and terms. A full report was retrieved for all studies that met the inclusion criteria.

Inclusion Criteria

The data collection review and process was based on article review factors that were associated with HPV vaccine acceptability, initiation, and series completion among adolescent and young adult women of different racial, ethnic, and socioeconomic groups in the United States.

We reviewed relevant peer-reviewed and evidence-based qualitative literature in order to identify current vaccination trends, rates and factors associated with HPV and cervical cancer. Study findings a related to race (black, Latina, Asian), and socio-economic disadvantages were summarized. HPV – Cervical Cancer in Women Essay.

Eligibility Criteria

Understanding current vaccination trends and the barriers to series initiation and completion, the Centers for Disease Control and Prevention (CDC) recommends that 11 to 12 year old adolescents receive two doses of the HPV vaccine in order to protect against themselves against cancers that are caused by HPV. The HPV vaccine series can be given to girls beginning at age 9 years old, but many parents believe this age is too immature for a sexually transmitted disease vaccination. Additionally, it is recommended by the CDC that girls and women age 13 through 26 years of age who have not yet been vaccinated or completed the vaccine series to be given the HPV vaccination immediately to provide HPV-cancer related protection.

In understanding HPV vaccination parameters, it is essential that we too recognize gaps in knowledge and all the misconceptions surrounding HPV vaccination and cervical cancer. When the vaccine is given prior to HPV exposure, it is highly effective in preventing infection from two high-risk genotypes (HPV-16/HPV-18) of HPV, which causes approximately 70 percent of cervical cancers, and two low-risk (HPV-6/HPV-11) genotypes that are responsible for over 90 percent of all genital warts.

As we assessed the appropriateness of our criteria interests, we focused on Black/African-American, Latina and non-white adolescent women age 12-26, minority teen women reported having sexual intercourse, adolescent women who have completed puberty, and low income and health care illiterate young women, who are too uninsured or have limited access.

Quality Assessment

The methodological quality is significant to our study. It was organized and detailed oriented. HPV – Cervical Cancer in Women Essay. It presented evidence that there is a need for increasing HPV vaccination among young minority women. The failure to achieve equitable vaccination has exacerbated health disparities in HPV and cervical cancer incidence and mortality. Research suggests that low- income and minority women are disadvantaged due to the difference in cervical cancer screening, practices and beliefs, as well as healthcare access barriers and systemic risk factors.

We used the ‘Research and Quality Scoring Method’ by Sackett and Haynes, the Jadad scale, and the items published by Cho and Bero to rate the quality of each study (Table 1). The range of total quality scores was from 0 to 9. Studies that ranged from 0 to 5 were considered low quality, whereas studies that ranged from 6-9 were considered high quality. Two raters independently coded variables using Microsoft Excel. Discrepancies were identified and resolved amongst our team members.

Statistical Analysis

Race/ethnicity and low socio-economic status are known predictors of late-stage diagnosis of cervical cancer and are important predictors of cancer mortality.

In the United States, approximately 12,000 women develop cervical cancer and 44000 die of the disease each year, with higher incidence and mortality rates reported in low-income minority populations.

HPV vaccination has been shown to reduce the prevalence of high-risk HPV infection among teen women and thus, has the potential to decrease the risks of cervical cancer among vaccinated young women.

According to preceding surveillance and qualitative studies, it is indicated that a decline in the annual rate of high-grade cervical cancer, from 834 per 100,000 in 2008 to 688 per 100,000 in 2014, among women aged 21 to 24 years, which reflects the impact of HPV vaccination. However, declines were not significant in areas with high proportions of minority women (i.e blacks, Latinas) and/or people living in low-income areas.

Results

Included Studies

The search yielded nearly 500 potential article titles for review, yet less than 70 were relevant to our interests. And of that 70, about 20 were dated within the last 10 years. Accordingly, less than 20 seemed more characteristic of our research interests and provided adequate information to our research question. HPV – Cervical Cancer in Women Essay.

Description of Studies

Selected characteristics of the included studies contended that an estimated 12,000 women are diagnosed with cervical cancer annually in the United States, and 4500,000 women worldwide develop cervical cancer each year. In the United States, cervical cancer incidence is nearly twice as high in counties with poverty levels > 20% compared with those with poverty levels <10%, and cervical cancer incidence and mortality are 25% and 95% higher, respectively, among black women and 53% and 41% higher for Latina women compared with that of white women. Rates of cervical cancer are inversely proportional to screening and treatment access, and poor and minority women face more barriers to health care access. Therefore, higher rates of cervical cancer are found in US regions with large minority and impoverished populations.

Quality Assessment

It is crucial to understand current vaccination trends and barriers to the HPV vaccination series initiation, in order to influence effective strategies to improve HPV vaccine completion and to reduce disparities in cervical cancer.

All studies assessed literature review aims to identify barriers and facilitators of equitable uptake of HPV vaccination and cervical cancer prevention among low-income and ethnic minority young women. Outcome measures revealed that approximately 44 million women in the United States, nearly one third of all women in America, self-identify as women of a minority racial or ethnic group. Consequently, it is imperative that we not only improve HPV vaccination rates overall, but also focus on high-risk populations to prevent an increase in HPV and cervical cancer disparities.

Assessment methods and deductions varied between studies. For example, according to Race, Ethnicity, and Income Factors Impacting Human Papillomavirus Vaccination rates, current trends in the United States indicate HPV rates stagnated between 2011 and 2012 amongst adolescent women. HPV – Cervical Cancer in Women Essay.They believe that provider recommendation is a key factor in HPV vaccination, and minorities are less likely to report receiving recommendations for HPV vaccination.

Fittingly, Challenges and Opportunities to Improve Cervical Cancer Screening Rates in US Health Centers through Patient-Centered Medical Home Transformation states that HPV vaccination improvement and cervical cancer screening processes amongst young minority women can be divided into four sections based upon health center and patient characteristics, patient-level, provider-level and system-level barriers, patient-targeted solutions, provider-targeted solutions and system-level changes, and lastly, the patterns across health center characteristics.

Addressing the Barriers to Cervical Cancer Prevention Among Hispanic Women identifies the reasons why Hispanic women fare an increased risk to HPV related cervical cancer, which is multifactorial. This includes resource limitations within the healthcare system, as well as language, cultural, and knowledge difficulties.

Similarly, Individual, Provider, and System Risk Factors for Breast and Cervical Cancer Screening Among Underserved Black, Latina, and Arab Women, distinguishes between race, culture and pap test between three different minority women. Black women have more health literacy risks associated with reduced odds of a Papanicolaou (Pap) test. For Latina women, the lack of doctor recommendations were significantly associated with decreased odds a Pap test. And, for Arab women, the lack of doctor recommendations was considerably associated with the decreased odds of a Pap test.

In Barriers to cervical cancer screening among ethnic minority women: a qualitative study, the analysis reveals that fifteen women had delayed screening and/or had never been screened for cervical cancer. These ethnic minority women felt that there was a lack of awareness about cervical cancer in their community, and some did not recognize or understand the terms cervical screening or pap smear test. However, negative healthcare experiences were identified by all women, and are the biggest barrier to preventative and screening efforts.

Correspondingly, Differences in cervical cancer screening knowledge, practices, and beliefs: An examination of survey responses, interviews respondents aged 21 to 35 and of minority ethnicities. Within the interview participants were asked “What is the purpose of a Pap smear or Pap test?” 49% stated that a Pap test checks for cancer, although not all participants knew it tested specifically for cervical cancer. 20% stated that it checked for abnormal or precancerous cells. 41% knew that a Pap test checked the cervix. 29% were vague in their answers, which suggest that they did not fully understand the purpose. HPV – Cervical Cancer in Women Essay. 9% indicated that a Pap test checked for STIs. Some participants thought a Pap test evaluated other body parts including the ovaries, uterus, breasts, and used nonspecific terms like “down there.” About 26% answered correctly, while 36% did in fact answer incorrectly. The correct and the incorrect answers were then analyzed by race. Those who answered incorrectly had more than four times the odds of being non-Hispanic black women.

Cervical Cancer Prevention: New Tools and Old Barriers, shares many ethnic minority (African-American and Hispanic) women’s cervical cancer prevention experiences in the face of high cervical cancer burden. The outcome of the study is to enlighten future research and outreach efforts in order to positively reduce the burden of cervical cancer in underserved populations.

Disparities in HPV and Cervical Cancer Screening Between Highly Educated White and Minority Young Women, acknowledged that education effects health awareness, which in turn makes cervical cancer screening unequal across the racial/ethnic lines of young women. The study results indicate that women of color have greater time lapses since their last cervical cancer screening. However, research also accentuates that race and awareness are not fully capable of explaining the variation of preventative screening practices among highly educated women.

Lastly, The Nurse’s Role in the Prevention of Cervical Cancer Among Underserved and Minority Populations, identified disparities in the incidence of cervical cancer and barriers that may be contributed to underserved populations. The study calls for nurses to play many roles in the prevention of cervical cancer, with a prominent one being a patient educator. There is a need to educate nurses about the risks and impact of HPV and cervical cancer, which includes education and increasing awareness. HPV – Cervical Cancer in Women Essay.

Discussion

Implications for More Research

The studies analyzed found that cervical cancer screening practices between vaccinated and unvaccinated participants is an area for future research using stronger study designs in order to make stronger, causal arguments about the relationship of HPV vaccination to cervical cancer screening. Overall findings from the studies could enlighten future interventions with stronger study designs aimed at tailoring messages for patients, standardizing education for providers, or both.

Implications for Practice

The prevention of health disparities and disease is, in part, contingent upon preventative medical practices and techniques. Extra efforts need to be made to educate all young women, and particularly young women of color, about HPV and cervical cancer. This may be accomplished by stressing the efficacy of screening and addressing concerns and misunderstandings of HPV vaccination and cervical cancer screening. HPV – Cervical Cancer in Women Essay.

Limitations

The women in the sample studies may not be illustrative of the general population. There is a possibility of selection bias, whether it is with greater participation of pro-health attitudes or that of illiterate and disproportionate health knowledge. The measures for receipt and understanding of HPV vaccination and Pap screening of the studies are self-reported, and thus are subject to recall bias and reporting errors.

Conclusion

Health professionals have the competence and capacity to prevent, detect, and treat HPV and cervical cancer. Thus, chasm between the quality and quantity of medical care being delivered should no longer be a healthcare question. A paradigm shift is needed; with a multi-faceted approach including improved health care access, population-targeted outreach, language-appropriate services, and culturally competent care.

We call health professionals to work together to identify possible solutions and opportunities, as well as socio-economic patterns in healthcare barriers, which includes demographic, cultural, and health belief and behavior factors. Furthermore, intervention models need to reflect multifactorial determinants of screening utilization.

References

Alligood-Percoco, N. and J. P. Kesterson (2016). “Addressing the Barriers to Cervical Cancer Prevention Among Hispanic Women.” J Racial Ethn Health Disparities 3(3): 489-495.

Bennefield, Z. C. (2015). “Disparities in HPV and Cervical Cancer Screening Between Highly Educated White and Minority Young Women.” American Journal of Health Education 46(2): 90-98.

Jeudin, P., E. Liveright, M. G. Del Carmen and R. B. Perkins (2014). “Race, ethnicity, and income factors impacting human papillomavirus vaccination rates.” Clin Ther 36(1): 24-37.

Kasting, M. L., S. Wilson, T. W. Zollinger, B. E. Dixon, N. W. Stupiansky and G. D. Zimet (2017). “Differences in cervical cancer screening knowledge, practices, and beliefs: An examination of survey responses.” Prev Med Rep 5: 169-174.

Marlow, L. A., J. Waller and J. Wardle (2015). “Barriers to cervical cancer screening among ethnic minority women: a qualitative study.” J Fam Plann Reprod Health Care 41(4): 248-254. HPV – Cervical Cancer in Women Essay.

Moshkovich, O., L. Lebrun-Harris, L. Makaroff, P. Chidambaran, M. Chung, A. Sripipatana and S. C. Lin (2015). “Challenges and Opportunities to Improve Cervical Cancer Screening Rates in US Health Centers through Patient-Centered Medical Home Transformation.” Adv Prev Med 2015: 182073.

Rogers, N. M. and A. G. Cantu (2009). “The nurse’s role in the prevention of cervical cancer among underserved and minority populations.” J Community Health 34(2): 135-143.

Roman, L., C. Meghea, S. Ford, L. Penner, H. Hamade, T. Estes and K. P. Williams (2014). “Individual, provider, and system risk factors for breast and cervical cancer screening among underserved Black, Latina, and Arab women.” J Womens Health (Larchmt) 23(1): 57-64.

Scarinci, I. C., F. A. Garcia, E. Kobetz, E. E. Partridge, H. M. Brandt, M. C. Bell, M. Dignan, G. X. Ma, J. L. Daye and P. E. Castle (2010). “Cervical cancer prevention: new tools and old barriers.” Cancer 116(11): 2531-2542

Cervical cancer is the second most common cause of cancer death in developing countries. The cause of cervical cancer is the human papilloma virus (HPV).HPV – Cervical Cancer in Women Essay. Cervical cancer has other risk factors, like: having multiple male sexual partners, starting to have sexual intercourse at an early age, having other sexually transmitted disease, having weak immune system and smoking.

Cervical cancer can be prevented by avoiding risk factors and undergoing regular screening tests. The most common methods used in cervical screening are Pap testing and HPV testing.

World Health Organization estimated that about 510,000 new cases of cervical cancer were diagnosed yearly. HPV testing is used as a primary screening method in some developed countries. Fewer amounts of tests required and better cost efficiency can be achieved by doing HPV testing first and Pap testing as a second test. Some studies suggested that HPV testing might be the effective cervical screening method and other studies did not suggest that. The study “HPV Screening for Cervical Cancer in Rural India” indicated that HPV testing was the most objective and reproducible of all other cervical screening tests. It seems to be a good study with well designed methodology and reliable results and conclusions, but it was criticized by R Marshall and Chengquan. They showed clearly that the study marred by test group biases and ethical concerns. More well designed studies are needed to clarify this issue and to show which method is proper to that country or to this geographical area. HPV – Cervical Cancer in Women Essay.

Introduction:

Cervical cancer is the cancer of the lowest part of the uterus, which is known as cervix. Cervical cancer is very slow growing, but in some cases it can grow and spread quickly (Dolinsky & Hill-Kayser, 2009).

There are many types of cervical cancer. The most common type is called squamous cell carcinoma (figure 1), which found in about 80% of cervical cancer cases, whereas adenocarcinoma is the second most common type of cervical cancer (Dolinsky & Hill-Kayser, 2009). Cervical cancer is more common in developing countries than it is in developed countries. It is the second most common cause of cancer death in developing countries. It can affect young women who are 20 years old or some time younger than that (Dolinsky & Hill-Kayser, 2009).

The cause of cervical cancer is the human papilloma virus (HPV) (figure 2) which was discovered by Harald zur Hausen who won the Nobel Prize in 2008 for this discovery (Nobel Prize organization, 2009). This virus is a sexually transmitted virus. It can cause genital warts which may or may not change to a cervical cancer (Dolinsky & Hill-Kayser, 2009).

The subtypes of HPV which have been confirmed to cause cervical cancer are 16, 18, 31 and 33 (Murray et al., 1998; Dolinsky & Hill-Kayser, 2009). Other researches suggested that subtypes 35 and 45 also can cause cervical cancer (NHS cancer screening programmes, 2009). HPV – Cervical Cancer in Women Essay. A woman has HPV infection does not mean that she is going to have a cervical cancer (Dolinsky & Hill-Kayser, 2009).

Other risk factors for cervical cancer are: having multiple male sexual partners, starting to have sexual intercourse at an early age, having other sexually transmitted disease (herpes, syphilis, gonorrhea or Chlamydia), having weak immune system (HIV, organ transplantation or Hodgkin’s disease) and smoking (Dolinsky & Hill-Kayser, 2009).

The early stages of this disease usually do not have any symptoms, but as tumor increase in size, some non-specific symptoms for cervical cancer will occur, like: abnormal bleeding, abnormal vaginal discharge, pelvic or back pain, pain during urination and bloody stool or urine (Dolinsky & Hill-Kayser, 2009).

Cervical cancer can be diagnosed by Pap testing, HPV testing, liquid-base cytology and by taking a biopsy during Colposcopy. The biopsy is the only way to be sure if the patient has a cervical censer. Radiologic testing may also help in the diagnosing of this disease (Dolinsky & Hill-Kayser, 2009).

Cervical cancer can be treated by Surgery, radiotherapy and chemotherapy (Dolinsky & Hill-Kayser, 2009). It can be prevented by avoiding risk factors which have been discussed previously and undergoing regular screening tests (Dolinsky & Hill-Kayser, 2009).

In Islam religion for example, smoking and any sexual relationship not done between wives and husbands (reducing sexually transmitted diseases) are strictly forbidden, this can reduce the chance of having cervical cancer within Muslim societies (Adam, 2009). In addition, male circumcision which is a part of Islam religion has found to be a good factor in cervical cancer prevention as researches have found that the wives of circumcised men have less risk of getting this disease than the wives of uncircumcised (Mission Islam, 2009).

Moreover, many countries have started to do cervical cancer screening to diagnose this disease in its early stages. Pap testing (cytological testing), HPV testing and liquid-base cytology can be used in this screening programs which will be discussed later (Kufe et al., 2003; Jamison et al., 2006).

Now a day, the vaccine Gardasil is used to prevent cervical cancer in women who are not exposed to HPV (Dolinsky & Hill-Kayser, 2009).

This study is aimed to discus the importance of HPV screening in the control of cervical cancer and clarifies the most appropriate method for cervical cancer screening.

The Global Burden of Cervical Cancer and the Available Methods for Controlling the Disease:

Cervical cancer is the second most common cancer among females worldwide with about 493,000 new cases and 274,000 deaths in 2002. Cases occur in developing countries are estimated to be about 83% (Bosch et al., 2009). HPV – Cervical Cancer in Women Essay.Thomas Rohan and others stated that opportunities for cervical cancer prevention have been created by our understanding of the cause, particularly the role of HPV infection (Rohan et al., 2003). In addition, World Health Organization estimated that about 510,000 new cases of cervical cancer were diagnosed yearly. In Africa, about 68,000 new cases are reported every year, whereas 77,000 new cases are reported in Latin America and 245,000 in Asia (Pagliusi, 2009).

In United Kingdom, about 25.51 millions females who are 15 years old are at risk of having a cervical cancer during their life. This kind of cancer is ranked as the 11th most common cancer in females in UK and the 2nd most common cancer in females between 15 and 44 years old. In addition, about 8.9% of females in the population of UK are estimated to have HPV infection at a given time. Currently in UK, it is estimated that about 3181 females are reported with a cervical cancer yearly and about 1529 deaths (Bosch et al., 2009).

Many researches suggested that the decline in incidence and mortality of cervical cancer which have been observed in the last 50 years in developed countries can be related to the introduction of screening programs (Kufe et al., 2003).

The most common methods used in cervical screening are Pap (cytological) testing and HPV testing (Kufe et al., 2003). The most widely used method in the world is the Pap testing. This method is simple, cheap and some times is used as a secondary screening method. It basically involves exfoliating epithelial cells collection from the squamocolumnar junction of cervix or transformation zone (Walker et al., 1990; Kufe et al., 2003).

In addition, HPV testing is used as a primary screening method in some developed countries. It is used mostly to distinguish between a high risk women group and others (Kufe et al., 2003).

The study of Joakim Dillner and others suggested that HPV testing as a screening method is safe and effective when it is done every six years (Dillner et al., 2008) and it should be done for women who are 30 years old or older because they are typically past the peak age of self-limited infection (Castle, 2008). HPV – Cervical Cancer in Women Essay.

HPV DNA testing might be a more clinically effective method than cervical smear, but its specificity is low because it could lead to unnecessary repeated screening and follow up (Nelson (I), 2009).

Fewer amounts of tests required and better cost efficiency can be achieved by doing HPV testing first and Pap testing as a second test (Medscape Medical News, 2009; Nelson (I), 2009).

Existing Randomized Controlled Trails Investigating the Use of HPV Testing in the Control of Cervical Cancer:

Many randomized controlled trails have been done to investigate the use of HPV testing in the control of cervical cancer. Some studies suggested that HPV testing might be the effective cervical cancer screening method (Grce and Davies, 2008; Rebar, 2008; Nelson (II), 2009). On the other hand, other studies suggested that HPV testing does not improve cervical cancer screening (Brown, 2009; NHS cancer screening programs, 2009).

In Italy, the second recruitment phase of the study titled: New Technologies for Cervical Cancer Screening (NTCC), women to conventional cytology (24,661 women) with referral to colposcopy if cytology indicated a typical squamous cells of undetermined significance or more sever abnormality or to HPV DNA testing alone by Hybrid Capture 2 (24,535 women) with referral to colposcopy if the test was positive at a concentration of HPV DNA 1 pg/mL or greater were randomly assigned. It has been concluded that HPV testing with a cutoff of 2 pg/mL achieves a substantial gain in sensitivity compared to cytology with only a small reduction in Positive Predictive Value among a group of women aged 35 to 60 years. In contrast, for women aged 25 to 34 years, it is suggested that there is a frequent regression of CIN2+ that is detected by direct referral of younger HPV testing-positive women to colposcopy as a result of the large relative sensitivity of HPV testing compared with conventional cytology (Ronco et al., 2008).

In addition, the results from a 6-year prospective study in Rural China demonstrated that a single oncogenic HPV DNA testing is more effective than cytology in predicting future CIN2+ status (Shi et al., 2009). HPV – Cervical Cancer in Women Essay.

The study “Human Papillomavirus DNA versus Papanicolaou Screening Tests for Cervical Cancer” which was done in Canada, conducted a randomized trial comparing the two methods, found that HPV testing has greater sensitivity than Pap testing for the detection of cervical intra-epithelial neoplasia (Mayrand et al., 2007).

The Population Based Screening Study Amsterdam (POBASCAM) which is a population based randomized controlled trial for implementation of hrHPV testing by GP5+/6+ PCR-enzyme immunoassay (EIA) with a classical cytology as a control group was done between January 1999 and September 2002. It was done among 44,102 women aged between 29 and 61 who participated in the regular Dutch screening program. This study (POBASCAM) indicated that large scale hrHPV testing is accepted by both participating women and general practitioners, is practically feasible and yield highly reproducible results (Bulkmans et al., 2004).

In 1997, a 10-year study “Randomized Controlled Trial of Human Papillomavirus Testing in Primary Cervical Cancer Screening” (SWEDESCREEN) was started. This study aimed to investigate whether HPV-based cervical cancer screening which is known to increase sensitivity for detection of high grade cervical intraepithelial neoplasia (CIN) is represent overdiagnosis or a protective effect. It included 12,527 women aged between 32 and 38 years and were randomized (1:1) to HPV testing and cytology testing (intervention arm) or cytology only (control arm). Its conclusion indicated that HPV testing with a cytology testing is more sensitive than cytology testing alone (U.S. National Institute of Health, 2009).

In another study, titled “Randomized Controlled Trial of Human Papillomavirus Testing Versus Pap Cytology in the Screening for Cervical Cancer Precursors”, the Canadian Cervical Cancer Screening Trial (CCCaST), randomized women aged between 30 and 69 years were categorized in to Pap testing group and HPV testing group. The findings at recruitment phase of this study indicated that HPV testing is more sensitivity and less specificity than Pap cytology testing (Mayrand et al., 2006). HPV – Cervical Cancer in Women Essay.

An Overview on the Methodology, Results and Conclusions of the Study: “HPV Screening for Cervical Cancer in Rural India”:

Rengaswamy and others began their study “HPV Screening for Cervical Cancer in Rural India” in 1999 and finished after 8 years. In this study, 52 clusters of villages with a total of 131,746 healthy women aged between 30 and 59 years were randomly assigned to 4 groups of 13 clusters each. These groups assigned to go through screening by:

HPV testing group (34,126 women) (27,192 were screened and 2812 (10.3%) had positive results).
Cytology testing group (32,058 women) (25,549 were screened and 1787 (7.0%) had positive results).
Visual Inspection of the Cervix with Acetic Acid (VIA) group (34,074 women) (26,765 were screened and 3733 (13.9%) had positive results).
Standard care group (control) (31,488 women) (not offered screening but were advised on how to seek screening) (only 1946 (6.2%) requested screening and that means (93.8%) stayed without screening.

Women who had positive results went through colposcopy and biopsies were taken and those with cervical precancerous lesions or cancer received appropriate treatment (Sankaranarayanan et al., 2009).

The results of this study showed that:

In HPV testing group: cervical cancer was diagnosed in 127 women and 34 deaths occurred.
In Cytology testing group: cervical cancer was diagnosed in 152 women and 54 deaths occurred.
In VIA group: cervical cancer was diagnosed in 157 women and 56 deaths occurred.
In Control group: cervical cancer was diagnosed in 118 women and 64 deaths occurred.

In addition, this study indicated that of the 131,806 women, 60 died or migrated before the study began. The study groups were equally distributed in terms of household type, religion, occupation, marital status and number of pregnancies. The well balanced study will help to remove any biases to any group of the study. The results of this study showed also:

Invasive cervical cancer developed in 8 (0.033%) of 24,380 HPV negative results women.
Invasive cervical cancer developed in 22 (0.093%) of 23,762 cytology negative results women. HPV – Cervical Cancer in Women Essay.
Invasive cervical cancer developed in 25 (0.109%) of 23,032 VIA negative results women (Sankaranarayanan et al., 2009).

The protocol of this study was reviewed and approved by the scientific and ethical review committees of the International Agency for Research on Cancer (IARC), the Tata Memorial Center (TMC) and the Nargis Dutt Memorial Cancer Hospital (NDMCH). It was supported by the Bill and Melinda Gates Foundation through the Alliance for Cervical Cancer Prevention (Sankaranarayanan et al., 2009).

This study concluded that a single round of HPV testing was associated with a significant decline in the rate of advanced cervical cancers and associated deaths compared with the unscreened control group, whereas there was no significant reduction in the rate of death in either the cytology testing or the VIA group compared with the control group. Previous conclusions indicated that HPV testing was the most objective and reproducible of all other cervical screening tests (Sankaranarayanan et al., 2009).

This study seems to be a good one with well designed methodology and reliable results and conclusions, but it is clear that about 93.8% of the control group did not do any cervical screening during the 8 years which may raised an ethical issue might affecting the approval of this study if it was done in different country.

Further more, the courses and training period given to different staffs who participated in this study may be not enough to give them good experience in order to have less chance of error during the diagnosis.

An Overview on the Criticizing Article Titled: “Test Group Biases and Ethical Concerns Mar New England Journal of Medicine Articles Promoting HPV Screening for Cervical Cancer in Rural India”:

A few months after the publication of previous study, R Marshall and Chengquan had criticized it.HPV – Cervical Cancer in Women Essay. They suggested that unexpected biases might have occurred in some of the test groups of the study. The study stated that “the positive predictive value for detecting CIN 2-3 was 19.3% in the cytology testing group, higher than 11.3% in the HPV testing group and the study results indicated that essentially the same number of cervical cancers was detected after positive screening test results in the cytology group (88 women) and in the HPV group (87 women)” (Austin & Zhao, 2009).

Also, they observed that in the report of 2005, this study indicated that the detection rates of HPV testing did not show any improvement over cytology, but its conclusion of 2009 indicated different findings (Austin & Zhao, 2009). I think this is not a problem as findings and conclusions of scientific studies usually change over time.

In addition, of 54 cervical cancers related deaths in the cytology group, 27 deaths were in the “assigned but not screened” group and another 18 deaths were in patients who had abnormal cytology results. In HPV group, 19% fewer cervical cancer deaths (22 women) were in the “assigned but not screened” group and 33% fewer deaths (12 women) occurred in women with abnormal HPV testing results. These data supported the hypothesis that biases were introduced in the study groups. (Austin & Zhao, 2009). I think it is possibly true, because these data can show that the follow up and treatments were not equally effective in the two groups. So, even when cytological detection is successful, women can still die from cervical cancer due to inappropriate management.

In addition, these data also can show that the effectiveness of cytology as a cervical screening method is depended on its acceptance by women.

R Marshall and Chengquan have raised questions about the partnership between AACP’s coordinating organization and the HPV test manufacturer (Austin & Zhao, 2009). I think this partnership if it is real, it can affect the final results and conclusion in way that show the advantages of HPV testing in order to increase the income of the manufacture. HPV – Cervical Cancer in Women Essay.

Also they stated that it is not fare to allow a large number of control group to go without any screening during the study (Austin & Zhao, 2009). I think it is true that it is not fare to leave women in the control group without any screening and this can lead to ethical concerns.

In addition, cytology screeners were trained for only three months, which was very short period. They concluded that cytology screening is better than HPV screening according to the results of the previous study (Austin & Zhao, 2009).

In my opinion, the criticizing letter might be in the correct direction. From a brief reading and viewing of the study, the reader might believe that its finding indicated that HPV testing as a cervical cancer screening method is better than other tests, but deep reading will show him the limitation errors of this study which were firstly published by R Marshal and Chengquan. They showed clearly that the study marred by test group biases and ethical concerns. The study might try to cover and exclude some facts which can show that cytology testing was better than HPV testing.

Use or Not to Use HPV Testing as a Primary Screening Test for Cervical Neoplasia:

It has been argued that HPV testing is the best method for cervical cancer primary screening. I think that HPV testing is a good method to be used in cervical cancer primary screening in developing countries as well as in developed countries to reduce the incidence and mortality rates of cervical cancer. Studies which concluded that HPV testing is better than cytology testing are more than those which showed the opposite.

The high cost of HPV testing can be overcome by the support of WHO and privet sector companies in these developing countries. Also, the high cost of HPV testing can be overcome by the selective use of HPV testing, e.g. in the over 30s.

Many studies suggested that Human Papillomavirus is found in most of cervical cancer cases if not all. So, the use of HPV DNA testing in a well designed screening program may help in diagnosis early stages of cervical cancer, giving better chance for treatment compared with Pap testing which may give false negative results.

In conclusion, it is clear that different results and findings were gathered from different studies which try to find the proper method for cervical cancer screening. HPV – Cervical Cancer in Women Essay. These differences may be occurred because the studies done in different countries. And is it known that each country has its own geography, rate of mortality, rate of incidence and other factors which may affect the burden of cervical cancer disease.

So, more well designed studies are needed to clarify this issue and to show which method is proper to that country or to this geographical area in order to save women’s lives.

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