Beautiful rice terraces in the morning at Tegallalang village, Ubud, Bali, Indonesia.

Just one in five Indonesian women are aware of cervical cancer screening, according to a study, funded by the UK Medical Research Council and presented at the ESMO Asia 2017 Congress being held in Singapore, November 17 – 19, 2017. [1] The study results also showed that in nearly 5,400 women only 5% knew about mammography for early detection of breast cancer.

In developing countries, the incidence and death rates of cervical cancer, which is in virtually all cases of cervical cancer are caused by specific types of human papillomavirus (HPV), still high, due in large part to limited access to cervical cancer screening.

Worldwide, cervical cancer is the third most common cancer among women and the second most frequent cause of cancer-related death, accounting for nearly 300,000 deaths annually. In developing nations, it is often the most common cause of cancer-related death among women and a leading cause of death overall. [2]

There are more than 100 types of HPV, of which more than 40 can be sexually transmitted. Among these, about 15 are considered to be cancer-causing, or high-risk, types. Two of these high-risk types, HPV-16 and HPV-18, cause about 70% of cervical cancers worldwide. HPV infection is very common, but it usually goes away on its own. Persistent HPV infections, however, can cause cellular abnormalities that sometimes develop into cervical cancer if not treated.

?Early detection of cervical and breast cancers leads to better treatment, with improved survival and quality of life,? said lead author Sumadi Lukman Anwar, MD, oncologist in training, Gadjah Mada University and Dr. Sardjito General Hospital, Yogyakarta, Indonesia.

Late Stage
?In Indonesia, many patients are diagnosed with breast and cervical cancers at a very late stage when there are limited options for curative treatment. To improve early detection we need to know levels of awareness and participation in screening programs, and what factors influence these levels.?

Since 2015, all women in Indonesia aged 40 and above are eligible for cervical and breast cancer screening in primary healthcare funded by the Indonesian Ministry of Health (PERMENKES No.15/2015). Cervical smears are performed yearly for two years, then every five years if no abnormalities are found (otherwise they continue yearly). Clinical breast examinations are performed yearly and women are referred for sonography or mammography if there are any lumps or other signs of breast cancer. Women do not receive a letter inviting them to attend screening; in most cases they use their own initiative and ask for an appointment in primary healthcare.

The researchers assessed levels of awareness and participation in screening programmes for cervical and breast cancers. They also investigated factors that might influence these levels. The study used data from the Indonesian Family Life Survey (IFLS) which includes more than 30,000 individuals. [3] The first survey in 1993 was representative of 83% of the Indonesian population living in 13 of the 27 provinces in the country.

Collaboration
The current study is a collaborative work led by PILAR Research and Education and Gadjah Mada University and involves researchers from University College London, King?s College London and University of Manchester.

The analysis included 5,397 women aged 40 and older with no history of cancer who took part in the fifth IFLS survey, conducted in 2014 and 2015. Participants completed questionnaires about awareness and participation in cervical screening, mammography and breast self-examination. Information was also collected on factors that might be linked with cancer screening awareness and participation such as marital status, education, household expenditure, lifestyle, and distance to health facilities.

The researchers calculated the levels of awareness and participation in screening, and whether they varied by any of the population characteristics.

Only 1,058 (20%) of women were aware of cervical smears. Of those who were aware, only 297 women had ever had a cervical smear performed. Just 251 (5%) of women were aware of mammography and of those, only five women had received a mammogram in the previous year. Some 12% of women had done breast self-examination in the past year.

Education
Higher education and household expenditure were associated with greater awareness of cervical smears and mammography, and greater participation in cervical smears and breast self-examination. Awareness and participation in screening was greater in those with health insurance, a shorter distance to health services, and who took part in community activities.

?We found very low levels of awareness of screening programs for cervical and breast cancers in Indonesian women, and participation was even lower with indications of a social gradient. Health practitioners need to be aware of subgroups of women at risk who may benefit from improved information and communication concerning the availability of cancer screening. If further research supports the role of social participation, a campaign may be needed that is socially and culturally adapted for women in Indonesia and communicated using existing community networks and media they frequently use. Most people own mobile phones so the potential use of social media could also be explored,? Anwar said.

Common cancer
?Cervical cancer is the [one of the most] common cancer in women worldwide and 8% of the cases occur in the developing world. This is at least partly due to the low incidence of screening procedures being performed in the developing world,? Wen-son Hsieh,MD, Medical Oncologist, ICON-SOC and Farrer Park Hospital, Singapore, noted.

?The results of this study reinforce the concept that cancer screening programs can improve cancer screening rates in two ways: provide education resulting in improved awareness of the benefits of cancer screening and provide access to resources and facilities to allow cancer screening to occur.?

Awareness
?The rates of awareness and uptake of screening for cervical and breast cancer found in this Indonesian study were extremely low compared to Western Europe where we would expect a 70% uptake. A better understanding is needed as to why these rates are so low,? commented Jonathan Ledermann, Professor of Medical Oncology, UCL Cancer Institute, London, United Kingdom.

?The clear message is that education about screening is not well disseminated among the population and uptake is even lower. So there?s a lot of work to be done, and a lot of investment that needs to be made in education and facilities for screening if Indonesia is going to climb up the ladder of screening for those two cancers,? Lederman concluded.


Last Editorial Review: November 17, 2017

Featured Image: Indonesia.??Beautiful rice terraces in the morning at Tegallalang village, Ubud, Bali, Courtesy: ? Fotolia. Used with permission.

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