ABSTRACT

The purpose of the study was to investigate the knowledge and practice of screening tests for breast and cervical cancers among women in Uyo. Four specific objectives and corresponding research questions and hypotheses were used in the study. A descriptive cross-sectional design was adopted for the study. A multistage sampling technique was used to select 420 women aged 18 to 50 years from a population of 5,860. The data collected were analyzed using the International Business Machines (IBM), Statistical Package for Social Sciences (SPSS) version 20. 0. Many of the women (66.7%) knew about Breast Self Examination (BSE), few of them (24.5% and 24%) knew Clinical Breast Examination (CBE) and Mammogram respectively and a little over half of them (54.3%) practiced them. A little number of the women (27.3%) knew cervical cancer screening and only 16.7% practiced them. There was a significant association between knowledge of eligible women to be screened and practice of breast cancer screening (x² 17.62; P = 0.00527). There was no significant association between knowledge and practice of breast cancer screening (x² = 4.93, 10.23, 6.83; P = 0.176995, 0.805028, 0.077625) and cervical cancer screening (x² = 5.26, 18.71, 6.75; P = 0.153719, 0.22717, 0.080308). There was a significant relationship between women’s age 18 – 28 years and the practice of breast cancer screening (r = 0.59; P = 0.00001) whereas there was no relationship between women’s age 29 -39 years and practice of breast cancer screening (r = – 0.001; 0.99135) and age 40 – 50 years (r = 0.038; P = 0.658129).  Findings also showed relationship between age 18 – 28 years and practice of cervical cancer screening (r = 0.197; P = 0.011983) whereas there was no significant relationship between other age groups and practice of cervical cancer screening with P > 0.05. Adequate health education through women friendly organizations and screening for all women  during regular physician office visit for other health issues are recommended.

 

CHAPTER ONE

INTRODUCTION

Background to the study

Cancer is the uncontrolled growth of abnormal cells anywhere in the body.  The abnormal cells are termed malignant or misnomer cells (Dugdale, 2010). Cancer is a group of more than 200 diseases characterized by unregulated growth of cells. It can in persons of all ages and all races and is a major health problem in many countries worldwide. It is known to be the most feared of all diseases, feared far more than heart diseases (Seeley, Stephen & Tate, 2010). These authors viewed cancer as synonymous with death, pain, disfigurement and dependency.

Hippocrates coined the word carcinoma, meaning a tumour that spreads and destroys the host.  However, ancient Egyptians and later Galen described cancer as being crablike in nature because cancerous tumours stick onto the body and prey on the flesh like crabs. They grasp the tissues they invade and cause pain that is throbbing, creeping, gnawing the flesh and resembling the pinching of a crab (Dugdale, 2010).

In the females, the most occurring cancers are those affecting the mammary glands ( breast cancer) and those affecting the neck of the uterus (cervical cancer) (Bassey, Ekpe & Abasiatai, 2007; American Cancer Society (ACS), 2009 & Odetola, 2011). Breast cancer is cancer that occurs in the breast tissue. It is a malignant proliferation of epithelial cells that line the ducts or lobules of the breast. It is formed when the processes that control normal cell growth breaks down, enabling a single abnormal cell to multiply at a rapid rate. These new cells tend to destroy an increasing portion of normal breast tissue overtime and may occur metastasize to other parts of the body (Smeltzer, Bare, Hinkle & Cheever, 2010). Breast cancer is the most frequently diagnosed cancer among women in 140 of 180 countries worldwide (Ferlay, Soerjomataram, Ervik, Rebelo, Parkin & Forman, 2013). In 2007, 1.7 million women were diagnosed with breast cancer and there were already 6.3 million women who were alive with the diagnosis of breast cancer in the previous five years (Ferlay, et. al, 2013). Since 2008 estimates, breast cancer incidence has increased by more than 20% while the mortality has increased by 14% making it to be the most common cause of cancer death among women,  with 522,000 deaths in 2012 worldwide (Ferlay, at. al, 2013; Fasoranti, 2013).

Worldwide trends show that developing countries are going through rapid societal and economic changes in an attempt to become industrialized. There is also a shift in the life style of people towards that of industrialized countries, leading to a rise in the burden of cancer especially those associated with reproductive, dietary and hormonal risk factors. Breast cancer incidence and mortality are increasing in most countries of Africa and Asia (International Agency for Research on Cancer (IARC), 2012).Ferlay, et. al (2013) reports that the incidence rate of breast cancer varies in different regions of the world,  it remains highest in more developed regions, while its mortality is relatively much higher in less developed  countries due to lack of early detection  and access to treatment facilities. For instance in Western Europe, breast cancer incidence has reached more than 90 new cases per 100,000 women annually compared with 30 per 100,000 women in East Africa.

Jedy-Agba, Curado, Ogunbiyi, Oga, Falowole, Osubor & Otu (2012) posited that the most common cancers in Nigeria among women are breast cancer 50.8% and cervical cancer 15.7%. The standardized incidence rate of breast cancer from both Abuja Cancer Registry (ABCR) and the Ibadan Cancer Registry (IBCR) in 2012 was 58.3 per 100,000. For IBCR only, it was 52.0 per 100,000 while ABCR had 64.6 per 100,000 (Jedy-Agba, et. al, 2012). According to Odeh, (2012) breast cancer is responsible for about sixteen percent (16%) of all cancer related deaths in Nigeria and is still the number one disease, and leading cancer scourge affecting humans with 25% of cases being reported early while 75% are reported late.

There is no single, specific cause of breast cancer, but a combination of genetic, hormonal and possibly environmental factors may increase the risk of its development. It is not a pathologic entity that develops overnight, it starts with a genetic alteration in a single cell and takes time to divide and double in size. Doubling time varies but breast tumours are often present for several years before they become palpable. For this reason every woman needs to have a clear understanding of her risk factors, warning signs of breast cancer for example, a lump, discharge from nipple and her normal breast size and shape so that any abnormality can be detected at a very early stage. Unfortunately, some women often underestimate their risk of developing breast cancer and are rarely engaged in breast screening programmes and as such seek initial treatment after years of ignoring symptoms.

Similarly, cervical cancer is a disorder of cell growth and behaviour. It is malignant and predominantly squamous cell cancer caused by the Human Papilloma virus (HPV). It usually begins in cells on the surface of the cervix and over time can invade more deeply into the cervix and nearby tissues (Kumar, et. al, 2007). HPV infection and a number of factors help to increase the risk of cervical cancer (Campbell, 2006).

Cervical cancer is the second most common and fifth deadliest cancer in women worldwide. It affects 16 per 100,000 women per year and kills about 9 per 100,000 per year (WHO, 2009). Approximately, 80% of cervical cancers occur in developing country (WHO, 2009). Data from the new cervical cancer crisis card launched globally put the annual total death count from the five top ranked countries at 137,817. Nigeria and 49 other countries were selected to provide a snapshot of the world and Nigeria ranked 10^th with cervical cancer mortality rate of 22.9 deaths per 100,000 with a total of 9,659 deaths recorded every year. The annual incidence of cervical cancer in Nigeria is confirmed at 14,000 with about 26 women losing their lives every day (Ogundipe, 2013). A five year review in University College Hospital, Ibadan Cancer Registry about the rate and incidence of ten different types of carcinomas found in women also revealed that the incidence of cervical cancer was the second highest to breast cancer (Odetola, 2011). Bassey, et. al, (2007) in a retrospective study of all female genital malignancies in University of Uyo teaching hospital between 2000 and 2005 found that cervical cancer was the commonest (49.2%).

Cancer of the cervix is a relatively common type of cancer of the reproductive organs in females and it is usually accompanied with severe discomfort and stress. Early in its development, the cells of the cervix change in a characteristic way. This change can be observed by examining a cell sample microscopically. The most common technique is to obtain a Papanicoloau smear, which is named after Dr. George Papanicoloau, a physician who developed the technique. Pap smears have a reliability of 90% for detecting cervical cancer (Seeley, et. al, 2010). Through this test and other screening tests, precancerous lesions can be detected and treated early to avert cancerous change. Hence screening is very vital to early detection and treatment of this cancer.

Screening refers to the examination of individuals or groups of usually asymptomatic people to detect those with high probability of having a given disease, typically by means of inexpensive diagnostic tests (IARC, 2012). Screening tests can often times detect cancer in its earliest stages, long before any actual symptoms can be noticed. There are specific cancer screening tests that are available for women. Each test is highly effective and recommended for all females particularly those for breast and cervical cancers. The World Health organization (WHO) in several reports indicated that cancers are largely preventable by effective screening programmes. Considerable reduction in breast and cervical cancers incidence and deaths have been achieved in developed nations with symptomatic cytological smear, screening and breast examination programmes organized by the national breast and cervical cancers early detection programmes (Elovainio & Miller, 2007).

Despite evidence that breast and cervical cancer screening reduces morbidity and mortality, Odetola (2011) reports that most women have not undergone regular screening examinations. The major factor which determines people’s participation in screening programmes either in high risk group or in the general population is the awareness which is a motivating factor (Odetola, 2011). This study therefore would assess the women’s knowledge and practices of the various screening tests for breast and cervical cancers.

Statement of Problem

Most people with chronic diseases including cancer in Nigeria prefer to consult traditional healers first, although these healers do not understand the scientific basis of cancer management (Sofulowe & Bennet, 2011). Patients therefore utilize existing facilities in conventional hospitals as a last resort. This practice causes delay in presentation of cancer cases at the hospitals with a large proportion of patients being diagnosed at advanced stages of the disease. Breast and cervical cancers are the most commonly diagnosed cancers in women with an increasing morbidity and mortality rate in most developing countries (IARC, 2012; Ferlay, et. al, 2013).  Whereas breast and cervical cancer screening have become a success story of cancer prevention in the developed countries (Ferlay, et, al, 2013), Odetola, (2011) reports that most women in her study have not undergone regular screening examinations.

In Nigeria, Bassey, et. al, (2007) and Odetola, (2011) in their studies in University of Uyo Teaching Hospital (UUTH), Uyo and University College Hospital (UCH), Ibadan respectively indicated that breast and cervical cancers are the commonest cancers found in women. During a free integrated health outreach by the Vision of Hope International (a non Governmental Agency) at Eket, Akwa Ibom State in 2013, seventeen (17) out of 88 women screened through visual inspection with Lugol’s iodine tested positive  while cancerous lesions were discovered in 6 out of the positive women. It was discovered that about 90.1% (80) of the women were ignorant about cervical cancer. Those who were diagnosed were not aware of the condition and the few who were aware did not know about the screening tests and where to get screened (Nwoko, 2013).

The researcher has also observed nine (9) women die between 2012 and 2013 in the State due to breast and cervical cancers. Two of them were seen receiving spiritual care/treatment in a church where they remained till death. May be these and other unknown cases could have been prevented through screening, early detection and appropriate treatment. However, in effort to avail women of screening facilities, the State branch of the Medical Women Association (MWA) offers weekly screening services at their clinic at Uyo for breast and cervical cancers in women.  Nwoko, (2013) reports that the Vision of Hope after the outreach programme donated cryotherapy equipment to Akwa Ibom State Government and set up a cervical cancer unit in University of Uyo Teaching Hospital. Furthermore, the State government purchased mammography machines and supplied them to the General Hospitals to mark the 2014 world cancer day in Uyo. These efforts were to encourage screening and early detection of breast cancer among women in the State.

With the availability of screening centers in Uyo, one would want to know if the women in Uyo have knowledge of breast and cervical cancers screening? Do they participate in the various screening tests for breast and cervical cancers? This study therefore seeks to provide answers to the above questions.

 Purpose of the study

The purpose of the study is to investigate the knowledge and practice of screening tests for breast and cervical cancers among women aged 18 to 50 years in Uyo.

The specific objectives include to:

1. determine the knowledge of breast / cervical cancer screening among women in Uyo.
2. determine the practice of breast / cervical cancer screening among women in Uyo.
3. ascertain if there is a relationship between women’s age, level of education and the practice  of breast cancer screening in Uyo.
4. ascertain if there is a relationship between women’s age, level of education and the practice of cervical cancer screening in Uyo.

Research Questions

1. What is the women’s knowledge on breast /cervical cancer screening in Uyo?
2. What is the women’s practice of breast / cervical cancer screening in Uyo?
3. Is there any relationship between women’s age / level of education and the practice of breast cancer screening?
4. Is there any relationship between women’s age / level of education and the practice of cervical cancer screening?

Research Hypotheses

1. There is no significant association between knowledge of women and practice of breast cancer screening.
2. There is no significant association between women’s knowledge and their practice of cervical cancer screening.
3. There is no significant relationship between women’s age, level of education and the practice of breast cancer screening.
4. There is no significant relationship between women’s age, level of education and the practice of cervical cancer screening.

 

 

 

Significance of the study

The result of this study will provide information on the knowledge of screening tests for breast and cervical cancers among women in Uyo. It will also indicate whether the women in Uyo participate in the screening programmes for breast and cervical cancers or not. The study will help to fill the gap in knowledge and practice of breast and cervical cancers among women in Uyo, Akwa Ibom State. Findings if utilized will help equip and guide nurses, health planners and other stakeholders in the health sector with the right information to direct health education programmes and campaigns to increase awareness among women on the various screening tests for breast and cervical cancers. If the results of the study were put to use, it will help to improve the number of women who present themselves for screening, thus reducing the delays in presentation, diagnosis and treatment of cancer cases. This will generally help to reduce the incidence and mortality rates of breast and cervical cancers among women in the State.

 

The findings will also add to the existing literature on knowledge and practice of breast and cervical screening tests, evaluate the success of cancer screening programmes in the state. Finally, the study will serve as a reference material to other researchers on related topics.

 

Scope of the study

The study was delimited to knowledge and practice of screening tests for breast and cervical cancers among women. It focused on knowledge of various screening tests, knowledge of signs to look for during screening, knowledge of screening centres and the frequency of screening.

The study was conducted in Uyo municipality and covered all women within the age range of 18 and 50 years who were present in the area during the period of the study.

 

Operational definitions of terms

Knowledge of breast and cervical cancer screening tests – Being able to identify the appropriate screening tests for breast and cervical cancer.

• Knowledge of when the tests should be done.
• Knowledge of likely findings to report for breast cancer for example lump, discharge from the nipple, pain.
• Knowledge of likely findings to report for cervical cancer example bleeding during sex, swelling, pain.

Practice of breast and cervical cancer screening – having had her breasts and cervix examined or screened for signs of breast and cervical cancers within the past three years and more than once.

Screening tests – the screening tests of concern in this study include:

Breast self-examination – Examination of the breast by an individual for lumps, changes in size or shape of the breast or any other changes in the breasts or underarm.

Clinical breast examination – Examination of breast by medical Doctor or Nurse for signs of cancer.

Mammogram – The use of an X-ray machine by a radiographer to check the women’s breasts for abnormal cells or cancer cells or signs.

Inspection of the cervix – Having ones cervix inspected by a doctor or nurse with the aid of a speculum. Example, visual inspection of the cervix with application of acetic acid (VIA) or lugol’s iodine (VILI). This is examination of the cervix for abnormal changes or cancerous cells after applying either acetic acid or lugol’s iodine.

Pap smear- is a test in which a speculum is inserted in to the vagina, a brush used to collect cells from the cervix and the cells thereafter checked for signs of cancer microscopically.

Human Papillomavirus  DNA test- is a test in which cell sample from the cervix are checked for the presence of human papillomavirus.

Women – adult females within the age of 18 and 50 years who will be found in Uyo municipality during the study.