Of the half million new cases of invasive cervical cancer (ICC) reported globally each year, over 80% occur in Low-and Middle-Income Countries (LMICs)1. Nigeria is one of these countries with a huge burden of ICC incidence and mortality.2 As reported in the Global Burden of Cancer 2013, cervical cancer is ranked the 2nd most common in incidence and mortality among all cancers in Nigeria.3', '\tCervical cancer screening (CCS) is an important health care service intervention known to significantly reduce the incidence and mortality from invasive cervical cancer, particularly in developed countries where organized CCS programs are available. 4-10 However, such organized CCS programs are currently lacking in Nigeria and in most other LMICs. Therefore, the opportunity for such screening intervention likely depends on several factors ranging from systems-level factors such as availability of screening and health systems support to overcome barriers to access services, provider-level factors such as offering screening recommendations, and patient-level factors related to health beliefs and ability to complete a screening intention. Indeed, the literature on cancer screening suggests that screening is a process of care consisting of several steps and interfaces between patients, providers, and health care organizations.11 In this context, screening rates are largely driven by strategies that promote interface across organizational boundaries, recruit patients and promote referrals, facilitate appointment scheduling, and promote continuous patient care and engagement.11 ', '\tCervical cancer screening services in Nigeria has been largely opportunistic, and dependent on either recommendation or referral from a provider or the individual woman’s decision to go for screening if aware of such services.12 In such opportunistic screening setting, we currently do not understand the sociodemographic characteristics associated with cervical cancer screening utilization and outcomes. Our overarching hypothesis was that patient-reported HIV was significantly associated with cervical cancer screening utilization in an opportunistic cervical cancer screening service in Nigeria. The scientific premise for this is evidence that ICC is entirely attributable to the persistent infection of a sexually transmissible virus, the high-risk human papillomavirus (HPV),13 and its persistence is facilitated by HIV-mediated cellular immune compromise leading to increased risk of cervical dysplasia and ICC.14-18 ', 'This retrospective analysis utilized the de-identified records of women who received cervical cancer screening services offered in an opportunistic screening program through the “Operation Stop†cervical cancer unit of the Jos University Teaching Hospital, Jos, Nigeria over a 10-year period (2006-2016). We adapted the constructs of the Health Belief Model (HBM)19 and the system-model of clinical preventive care20 to understand three interrelated but distinct aims in this dissertation: 1. Understand the association between patient-reported HIV and the likelihood of provider referral for a cervical cancer screening; 2. Understand the association between patient-reported HIV and the age at which women have their first cervical cancer screening; and 3. Understand the predictors of abnormal cervical cytology outcome at the time of first cervical screening, and also to understand the hazard of an abnormal cervical cytology outcome at subsequent follow up pap in women with a prior normal pap cytology.', 'The findings of this dissertation contribute to the knowledge and understanding of health care service factors that could guide implementation of cervical cancer screening and prevention in settings with opportunistic screening services. Specifically, this study provides evidence that women who report being infected with HIV are significantly more likely to receive a provider referral for cervical cancer screening compared to women who are HIV uninfected (aOR=2.35; 95% CI: 1.95, 2.82). This study provide for the first time in Nigeria, evidence that women initiate cervical cancer screening at relatively older age (median age: 37 years; IQR: 30-45 years) compared to the recommended age by screening guidelines in developed countries.21-23 We also found that women who were HIV infected had their first cervical cancer screening at a significantly younger age than HIV uninfected women (the mean age at first screening for HIV infected women was 35.0 ± 7.4 years, compared to 38.2 ± 10.2 years for HIV uninfected (p-value=0.001). We also found a positive correlation between the median age at first cervical cancer screening and the severity of underlying precancerous cervical abnormalities. In other words, women who screened at an older age were more likely to have underlying severe dysplasia than women who screened at a younger age. Patient-reported HIV was not significantly associated with mild (aOR=1.04; 95% CI: 0.80, 1.36) or severe (aOR=1.26; 95% CI: 0.83, 1.92) cervical dysplasia. We found that women with other sociodemographic characteristics, such as age at first cervical cancer screening ≥35 years were significantly more likely to have an underlying mild (aOR=2.56; 95% CI: 2.23, 2.95) or severe (aOR=3.57; 95% CI: 2.74, 4.64) cervical dysplasia. Similarly, women who were ≥35 years had a significant hazard of developing an abnormal cytology outcome at follow up (aHR=1.63; 95% CI: 1.11, 2.41). ', 'Finally, our analysis showed that women who completed 7-12 years (aOR=3.07; 95% CI: 2.69, 3.51) or more (aOR=1.43; 95% CI: 1.27, 1.62) of formal education were significantly more likely to have their first cervical cancer screening before age 35. Women with this educational attainment were also significantly less likely to have an underlying precancerous cervical lesion at first screening compared to women of less formal education (aOR=0.65; 95% CI: 0.48, 0.88, and aOR=0.75; 95% CI: 0.58, 0.98, respectively for 7-12 years and >12 years of completed education). ', 'These findings are important and a clarion call for policy makers and women’s care advocates such as the Society of Gynecology and Obstetrics of Nigeria (SOGON) to develop or adopt guidelines that will facilitate early initiation of cervical cancer screening in Nigeria. The effect of education in women seen in these analyses supports the importance of the society to view and invest in women education as a social and public health intervention in Nigeria. In our subsequent project we plan to obtain qualitative data on barriers and facilitators to CCS implementation in Nigeria, and with our current findings we might have sufficient evidence to inform the design of effective health services interventions to improve CCS and outcomes in Nigeria and similar settings in Africa.', 'References', '1.\tLatest world cancer statistics Global cancer burden rises to 14.1 million new cases in 2012: Marked increase in breast cancers must be addressed [press release]. World Health Organization2013.', '2.\tForouzanfar MH, Foreman KJ, Delossantos AM, et al. Breast and cervical cancer in 187 countries between 1980 and 2010: a systematic analysis. The Lancet. 2011;378(9801):1461-1484.', '3.\tGlobal Burden of Disease Cancer C, Fitzmaurice C, Dicker D, et al. The Global Burden of Cancer 2013. JAMA oncology. 2015;1(4):505-527.', '4.\tWHO. WHO guidelines for Screening and Treatment of Precancerous lesions for Cervical Cancer Prevention. WHO guidelines. 2013.', '5.\tWhite MC, Wong FL. Preventing premature deaths from breast and cervical cancer among underserved women in the United States: insights gained from a national cancer screening program. Cancer causes & control : CCC. 2015;26(5):805-809.', '6.\tMiller JW, Royalty J, Henley J, White A, Richardson LC. Breast and cervical cancers diagnosed and stage at diagnosis among women served through the National Breast and Cervical Cancer Early Detection Program. Cancer causes & control : CCC. 2015;26(5):741-747.', '7.\tLantz PM, Mullen J. The National Breast and Cervical Cancer Early Detection Program: 25 Years of public health service to low-income women. Cancer causes & control : CCC. 2015;26(5):653-656.', '8.\tEkwueme DU, Uzunangelov VJ, Hoerger TJ, et al. Impact of the National Breast and Cervical Cancer Early Detection Program on cervical cancer mortality among uninsured low-income women in the U.S., 1991-2007. Am J Prev Med. 2014;47(3):300-308.', '9.\tAllemani C, Weir HK, Carreira H, et al. Global surveillance of cancer survival 1995–2009: analysis of individual data for 25 676 887 patients from 279 population-based registries in 67 countries (CONCORD-2). The Lancet. 2015;385(9972):977-1010.', '10.\tMoshkovich O, Lebrun-Harris L, Makaroff L, et al. Challenges and Opportunities to Improve Cervical Cancer Screening Rates in US Health Centers through Patient-Centered Medical Home Transformation. Advances in preventive medicine. 2015;2015:182073.', '11.\tAnhang Price R, Zapka J, Edwards H, Taplin SH. Organizational factors and the cancer screening process. J Natl Cancer Inst Monogr. 2010;2010(40):38-57.', '12.\tBruni L B-RL, AlberoG, SerranoB, Mena M, GómezD, Muñoz J, Bosch FX, de Sanjosé S. ICO/IARC Information Centre on HPV and Cancer (HPV Information Centre). Human Papillomavirus and Related Diseases in Nigeria. ICO/IARC HPV Information Centre2017.', '13.\tPlummer M, de Martel C, Vignat J, Ferlay J, Bray F, Franceschi S. Global burden of cancers attributable to infections in 2012: a synthetic analysis. The Lancet Global Health. 2016;4(9):e609-e616.', '14.\tAgaba PA, Thacher TD, Ekwempu CC, Idoko JA. Cervical dysplasia in Nigerian women infected with HIV. Int J Gynaecol Obstet. 2009;107(2):99-102.', '15.\tChama CM NH, Gashau W. Cervical dysplasia in HIV infected women in Maiduguri, Nigeria. J Obstet Gynaecol. 2005;25(3):286-288.', '16.\tBiggar RJ, Chaturvedi AK, Goedert JJ, Engels EA, Study HACM. AIDS-related cancer and severity of immunosuppression in persons with AIDS. J Natl Cancer Inst. 2007;99(12):962-972.', '17.\tBateman AC, Katundu K, Mwanahamuntu MH, et al. The burden of cervical pre-cancer and cancer in HIV positive women in Zambia: a modeling study. BMC Cancer. 2015;15:541.', '18.\tBlitz S, Baxter J, Raboud J, et al. Evaluation of HIV and highly active antiretroviral therapy on the natural history of human papillomavirus infection and cervical cytopathologic findings in HIV-positive and high-risk HIV-negative women. J Infect Dis. 2013;208(3):454-462.', '19.\tEDWARD C. GREEN EM. Health Belief Model. In: William C. Cockerham RD, and Stella R. Quah, ed. The Wiley Blackwell Encyclopedia of Health, Illness, Behavior, and Society. Vol First Edition: John Wiley & Sons Ltd; 2014.', '20.\tWalsh JME, McPhee SJ. A Systems Model of Clinical Preventive Care: An Analysis of Factors Influencing Patient and Physician. Health Education & Behavior. 1992;19(2):157-175.', '21.\tUSPSTF. USPSTF Current Recommendation for Cervical Cancer Screening. 2012.', '22.\tMoyer VA. Screening for Cervical Cancer: U.S. Preventive Services Task Force Recommendation Statement. Annals of Internal Medicine. 2012;156:880-891.', '23.\tMaura G, Chaignot C, Weill A, Alla F, Heard I. Cervical cancer screening and subsequent procedures in women under the age of 25 years between 2007 and 2013 in France: a nationwide French healthcare database study. Eur J Cancer Prev. 2017.']

Last modified

• 10/08/2019

Creator

• Jonah Musa

DOI

• https://doi.org/10.21985/n2-cnvk-rq67

Subject

• Health Sciences Integrated PhD Program

Keyword

• Abnormal cervical cytology outcome
• Cervical Cancer Screening
• HIV status
• Nigeria
• Provider recommendation
• Opportunistic screening

Date created

• 2018-01-01

Resource type

• Dissertation

Rights statement

• In Copyright