Cervical cancer is a major public health problem, as it is the second most common cancer in women world-wide after breast cancer. Cervical cancer is a common type of malignancy accounting for about 6% of all cancers found in women. It is a disease in which cancerous cells develop in the uterine cervix (this is the connecting passage between the uterus and vagina). The human papillomaviruses are the principal cause of most cervical cancers. The peak incidence of cervical cancer occurs between the ages of 40 to 55.
It is rare before the age of 35; however the incidence of cervical cancer in younger women rose dramatically during the two decades after 1960. Regular Pap smear tests may detect abnormal changes in the cervical tissues, before cancer develops. Symptoms of cervical cancer may include vaginal bleeding after intercourse or bleeding between periods. However, in the early stages of the disease there are often no obvious signs or symptoms, so regular smear tests are important. CERVICAL CANCER- A PUBLIC HEALTH APPROACH Cervical cancer is the sixth most common cancer in women in the UK.
(Department of Health, 1999). Around 3200 women are diagnosed with cervical cancer in the UK each year, with 95% of cases being in women over 35. However, deaths from cervical cancer have fallen by more than 40% over the last 20 years, and the incidence of cervical cancer is much lower than it is for breast cancer, for example (nearly 41,000 new cases a year). This reduction is mainly because of the NHS screening programme, for all women between the ages of 20 and 64 in the UK. Cervical cancer is a major health problem in the world today. In some developing countries it is the commonest female cancer.
It is estimated that around 370, 00 cases of cervical cancer are diagnosed in the world each year. (www. cervicalcancer. uk. com/index. html (6/05/06) date accessed) PUBLIC HEALTH Public health carries out its mission through organized, interdisciplinary efforts that address the physical, mental and environmental health concerns of communities and populations at risk for disease and injury (Roberts & Reich (2002). Public Health is everything to do with diagnosing, analyzing, reporting, monitoring, treating, educating, researching, managing and enforcing the overall health of the general public.
A sub-category of Public Health is Environmental Public Health. This specifically addresses the relationship between humans and the environment. It is focused on things like food safety, pest management, air quality etc. Six public health priorities are identified: health inequalities, (Department of health 2000) Smoking, Obesity, Sexual health, mental health, well being, and Sensible drinking. CAUSES OF CERVICAL CANCER The exact cause of cervical cancer is not known, but certain things appear to increase the risk.
Around 95% of all cases of cervical cancer are linked with the specific types of the Human Papilloma Virus. This is a common viral infection that is passed on during sexual intercourse. Most women who have had sex will get Human Papilloma Virus at some point in their life, but the immune system often gets rid of the virus without you realising you had it. The women having a lot of sexual partners can increase the risk of getting Human Papilloma Virus. Other factors that can increase the risk include smoking heavily, getting pregnant at an early age, or having three or more pregnancies.
(Department of Health Statistical Bulletin, Cervical Screening Programme, England: 2001-2002. ) There is an excess risk of cervical cancer associated with long-term use (12 years or more) of oral contraceptives. The association is somewhat stronger for adenocarcinomas than for squamous cell carcinomas (Schiffman, (1996). Women who smoke are more likely to be affected than non-smokers, and, as with most cancers, its thought that diet can affect the risk. Tobacco smoking has been a well-known risk factor for cervical cancer (Winkelstein, (1990). A weak immune system increases the risk.
Causes of immune deficiency include autoimmune diseases, such as rheumatoid arthritis, and human immunodeficiency virus infection. If abnormal cells (dyskaryosis) have previously been found on the cervix, women are at a higher risk. (BUPA’s Health Information Team August 2003) INCIDENCE OF CERVICAL IN UK In the United Kingdom approximately 3,000 women are diagnosed as having cervical cancer each year, just two per cent of new cancer cases (Cancer Research UK, 2005). The incidence of and mortality from cancer of the cervix is falling, due largely, it is thought, to the cervical cancer screening programme (ONS, 2005).
UK incidence rates are slightly below the European Union average while the mortality rates are slightly above (Cancer Stats, Cervical Cancer – UK, January 2003, Cancer Research UK, London). In 1997 there were 2,740 cases of cervical cancer in England and Wales with 1,222 women dying of this disease. This represents a death rate of around 4 per 100,000. This compares with a death rate in 1979 of 7 per 100,000, which is an improvement of over 40%. In 2001, there were 2,418 new registrations of invasive cervical cancer in England (Health Statistics Quarterly, summer 2003, National Statistics).
Cervical cancer incidence fell by 42 per cent between 1988 and 1997 (England and Wales). This fall is directly related to the cervical screening programme (National Statistics, Health Quarterly Statistics 07, and autumn 2000). There was a 25 per cent decrease in the incidence rate of cervical cancer for women under the age of 70 from 1990 to 1992. This has been attributed to a rapid increase in coverage of the cervical screening programme which occurred from 1989 onwards (Cancer Incidence and Mortality in England and Wales: trends and risk factors. Swerdlow, Silva and Doll OUP 2001). In 1995, there were 10.
4 newly diagnosed cases of cervical cancer per 100,000 women4. By 1999, this had fallen to 9. 3 per 100,000 women (National Statistics MB1 No 30 Registrations of cancer diagnosed in 1999) Cervical screening now saves approximately 4,500 lives per year in England (Julian Peto et al, The Lancet 2004 (Vol. 364: 249-56) Cervical screening prevents up to 3,900 cases of cervical cancer per year in the UK (Sasieni, British Journal of Cancer 1996 Apr; 73(8):1001-5 In England, 21,617 women were found to have the most severe type of CIN (CIN 3) (National Statistics MB1 No 30 Registrations of cancer diagnosed in 1999).
An estimated 471,000 new cases of cervical cancer are diagnosed each year in the world with 80 per cent of these occurring in the less developed world (National Statistics MB1 No 30 Registrations of cancer diagnosed in 1999) Death rates from cervical cancer fell below 1,000 in England for the first time in 2002 when 927 deaths were registered (Health Statistics Quarterly, summer 2003, National Statistics). Mortality rates generally increase with age with the highest number of deaths occurring in the 75-79 age groups.
Less than 5 per cent of cervical cancer deaths occur in women under 35 (National Statistics, Health Quarterly Statistics 07, and autumn 2000). Mortality rates in 2000 were 60 per cent lower (3. 3 per 100,000 women) than they were 30 years earlier (8. 3 per 100,000 in 1971) (Cancer Research UK December 2005). Cervical cancer is the eleventh most common cause of cancer deaths in women in UK, accounting for around 2 per cent of all female cancers (National Statistics, Health Quarterly Statistics 07, and autumn 2000).
The latest relative survival figures for England show that 61% of women diagnosed with cervical cancer between 1996 and 1999 were alive five years later (Health Statistics Quarterly, Summer 2003, National Statistics). PREVENTION OF CERVICAL CANCER – The NHS cervical screening programme aims to reduce the number of women who develop invasive cervical cancer (incidence) and the number of women who die from it (mortality). All women aged 25-49 are invited for screening every three years, and women aged 50-64 are invited every five years.
Regular cervical screening tests are the best way to identify abnormal changes in cells of the cervix early on. There is a strong link between certain types of Human Papilloma Virus (HPV), and the development of cervical abnormalities, which may develop into cancer. Human Papilloma Virus is spread through unprotected sex, so the best way to stop getting it, is to use a condom. Before sleeping with a new partner, it’s also a good idea for both to get tested for any sexually transmitted infections at a sexual health clinic.
All tests are free and confidential – they can find nearest clinic in the phone book under genito urinary clinics. (Department of Health Statistical Bulletin, Cervical Screening Programme, England: 2001-2002. ) In the light of evidence published in 2003 the NHS Cervical Screening Programme now offers screening at different intervals depending on age. This means that women are provided with a more targeted and effective screening programme. The new intervals are: |Age group (years) |Frequency of screening | |25 |First invitation | |25 – 49 |3 yearly | |50 – 64 |5 yearly | |65+.
|Only screen those who have not been screened since age 50 or have had recent abnormal tests | (National Statistics, Cancer registrations in England, 2000). Every Primary Care Trust (PCT) has a nominated person responsible for its cervical screening programme and implementing the national guidelines. Regional directors of public health are responsible for the quality assurance network in their region. The national office of the NHS Cancer Screening Programmes, based in Sheffield, is responsible for improving the overall performance of the programme.
Set up in 1994, its priorities are to: – develop systems and guidelines which will assure a high quality of cervical screening throughout the country – identify important policy issues and help resolve them, and improve communications within the programme and to women Cervical screening – including the cost of treating cervical abnormalities – has been estimated to cost around ? 157 million a year in England. Primary Care Trusts commission cervical screening from the overall allocation they receive from the Department of Health.
Whilst cervical screening cannot be 100% effective, cervical screening programmes have been shown to reduce the incidence of cancer in a population of women. For example: Percentage of Cancer Preventable (Protection offered by a single negative smear) | |20-39 years |40-54 years |55-69 years | |3-yearly screening |41% |69% |73% | |5-yearly screening |30% |63% |73% | |(Sasieni, Adams, and Cuzick, BJC 2003) | The effectiveness of the programme can also be judged by coverage. This is the percentage of women in the target age group (25 to 64) who have been screened in the last five years.
If overall coverage of 80% can be achieved, the evidence suggests that a reduction in death rates of around 95% is possible in the long term. In 2001/2 the coverage of eligible women was 81. 6 per cent (Department of Health Statistical Bulletin, Cervical Screening Programme, and England: 2001-2002). From 2001/2, women who have only had an inadequate smear are no longer counted as screened in the coverage calculations. Coverage is now calculated at 3. 5 and five years rather than at 3 and 5 years. – A vaccine designed to protect against cervical cancer has effects that last at least 4?
years. The findings are evidence that the new vaccine, made by GlaxoSmithKline, will protect against human papilloma virus— the cause of cervical cancer — over long periods (Health News, The times, April 06, 2006). – The evidence for an effect of diet on risk of cervical cancer indicates that a high intake of foods containing beta carotene and vitamin C and, to a lesser extent, vitamin A may reduce the risk of cervical cancer (Herrero et al. 1991 and Verreault et al 1989). A healthy diet is recommended, including fruit, vegetables, fibre-rich and starchy foods.
The World Health Organization is expecting at least one of these vaccines to be licensed for use in 2006 (World Health Organization. 2005). ROLE OF PUBLIC HEALTH NURSE IN PREVENTION Nurses play a dynamic and imperative role in improving health and delivering health services to the community. They are responsible to ensure that everybody should be getting all services they do need. Basically public health nurse, integrate community involvement and has the knowledge about the entire population with personal, clinical understandings of the health and illness experiences of individuals and families within the population.
The public health nurse explores issues associated with the introduction of HPV testing for the detection and management of cervical abnormalities and the impact of growing public awareness of the sexually transmitted nature of cervical cancer. The implications for public understanding of cervical cancer, psychosocial issues associated with screening, and the potential impact on screening uptake are discussed by the public health nurse to prevent cervical cancer.
The role of biobehavioral factors in the persistence and progression of human papilloma virus infection as well as possible interventions are provided to minimize the risk of persistence (Waller, et al 2005). The Public Health nurses work to prevent cervical cancer by encouraging women to go for cervical screening programs. They make aware to all women from the age of 25 to 64, to adopt the life style by which they can do primary prevention of cervical cancer. For example, quitting tobacco smoking, healthy diet, vaccination for human papilloma virus, safe sexual relation etc.
The efficacy of condoms to protect against human pappiloma virus is also play role for the primary prevention of cervical cancer. (Baer, H. , et al (2000) The full and effective participation of local people, voluntary and community organisations and the private sector are crucial to the success of this screening programme for the prevention of cervical cancer. This means the role of public health nurse in the prevention of cervical cancer is not ignorable which is likely to have an impact on local health.
Public health nurse is responsible in making the women in the target age group aware about the reasons of cervical cancer and encouraging them to cope with policies. She is the one who is directly responsible to implement the policies up to some extent. She is the one who can observe the need of change in some of the policies and ways of making them adaptable to the system. The efficacy of condoms to protect against human pappiloma virus is also play role for the primary prevention of cervical cancer.
In contrast, understanding of the risk factors associated with cervical cancer is very helpful to prevent it. This is the public health nurse, who can provide the up to date knowledge to the women in target age group (25 to 64) about the causes and ways of prevention of cervical cancer. Possible future developments Computer assisted detection of cervical abnormalities is a possibility for the future. The need for a programme of human papilloma virus vaccination can only intensify, and every country should be planning actively to implement and budget for early vaccination (Johnson AM, et al.(2001)
Human papilloma virus testing to be introduced as a standard screening procedure in the future, even if only for women recording mild/borderline smear results, the nature of this virus would presumably form an important additional component of informed consent. However, given that the principal transmission mechanism of HPV is sexual, women receiving human papilloma virus testing as an adjunct to screening would, in effect, also be being tested for a sexually transmitted disease.
Knowledge that this would be occurring might be expected to impact upon the acceptability of the procedure (Sevin, 1999). The new International Finance Facility for Immunisation will be used to accelerate their delivery in the poorer parts of the world, where the benefits will be greatest (www. iffim. com/05_090905_02_eng. html (accessed 17 Oct 2005). CONCLUSION Cervical cancer is a major health problem in the United Kingdom and the whole World today as well. The National Health Service’s cervical screening program is very effective to prevent cervical in women.
The national programme, with a combination of various other methods for quality improvement, appeared to be effective in improving the organization of cervical screening in general practice. Computerization and, to a lesser extent, delegation of many clinical tasks to the practice assistant and more intensive support of practices, positively influenced the effectiveness of the national programme. References Department of Health Statistical Bulletin, Cervical Screening Programme, England: 2001-2002. In 2002, 927 deaths from cervical cancer were registered.
International Finance Facility for Immunisation. New International Finance Facility for Immunisation Could Save 10 Million Lives. Press release 9 Sep 2005. www. iffim. com/05_090905_02_eng. html (accessed 17 Oct 2005). BUPA’s Health Information Team (August 2003) Cervical cancer. NHS cervical screening programme (http://www. cancerscreening. nhs. uk) Roberts MJ, Reich MR. Ethical analysis in public health. Lancet 2002; 359: 1055–59. Health News, The times, April 06, 2006. National Statistics, Cancer registrations in England, 2000.
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(1999) Social implications of sexually transmitted cancer. Journal of Women’s’ Health and Gender-based Medicine, 8, 759–766 Winkelstein, W. (1990) Smoking and cervical cancer: current status — a review. Am J Epidemiol 1990; 131:945-57. Schiffman, M. H. (1996) cervical cancer. In: Schottenfeld D, and Fraumeni JF Jr, editors. Cancer epidemiology and prevention. New York: Oxford University Press; 1996. p. 1090-116. Herrero R, et al. (1991) A case-control study of nutrient status and invasive cervical Cancer. I. Dietary indicators. Am J Epidemiol Verreault R,et al (1989). A case-control study of diet and invasive cervical cancer.
Int J Cancer 1989; 43:1050-4. World Health Organization. (2005) WHO consultation on human papillomavirus Vaccines. Wkly Epidemiol Rec 2005; 80: 299-301. Johnson AM, et al. (2001) Sexual behaviour in Britain: partnerships, practices, and HIV risk behaviours. Lancet 2001; 358: 1835-42. Waller, J. , et al (2005) Making sense of information about HPV in cervical screening: a qualitative study. British Journal of Cancer. Baer, H. , et al (2000) Knowledge of human papillomavirus infection among young Adult men and women: implications for health education research. Journal of Community Health.