Screening of Cervical Cancer: Barriers and Facilitators

To the Editor: Cervical cancer is highly preventable with the use cervical cancer screening tools, and can be easily treated if detected at early stages [1]. Worldwide, cervical cancer is the second most common cause of cancer associated mortality [2]. Though incidence of cervical cancer has reduced in last three decades in the developed nations, it still contributed to 200,000 deaths of women in the year 2010, of whom 46,000 were in the reproductive age group and from developing countries [2, 3]. The observed reduction in incidence is mainly because of widespread application of cervical cancer screening with the Papanicolaou (Pap) test [3]. Different national organizations have issued guidelines for screening and surveillance of cervical cancer [4, 5]. The new guidelines recommend initiation of screening with pap smear at age 21, and repeat it after every three years in women age 21 to 29. For women age 30 and older should be screened by combined pap smear and Human Papilloma Virus (HPV) testing, and should be rescreened every five years if both tests are negative [5]. However, these guidelines are based on multiple factors and thus cannot be easily recalled by healthcare providers as a result of which many women do not receive the benefits of screening [6]. However, under-utilization of the screening methods persists as a major challenge as almost 60% of cervical cancers have been diagnosed in those women who have not been screened in last three years [7]. In a Turkey-based study, only 14.6% of women utilized the service of pap-smear testing [8]. Study findings across the globe has revealed that multiple factors (viz. rural residence; no family physician; poor knowledge; low education status; acceptability by the healthcare providers; lesbians sub-groups of women; etc.) have predicted the underutilization of screening methods [9-11]. The utilization of pap smear has been found to be positively associated with education status of the women, persistent motivation to act and the caring nature of the clinician [12]. To counter the challenge of under-utilization of screening methods of cervical cancer, different strategies have been proposed and implemented with variable extent of success. Findings of a review concluded that HPV self-collected testing resulted in marked improvement in the participation of women in cervical cancer screening programs [13]. Employment of tele-medicine technique in screening of cervical cancer has been advocated to overcome geographic barriers for rural women [14]. Other measures like organization of pap test week clinics [15]; HPV vaccination [16]; health educationcounseling [17]; and economic incentives [18]; can be implemented based on the needs in local settings. To conclude, for ensuring proper utilization of screening services and better management of cervical cancer patients, there is an immense need for political commitment and specific public health interventions targeted towards educating the community about the risks of cervical cancer, benefits of screening method and implementation of newer strategies to overcome barriers. Furthermore, the message conveyed during awareness campaigns should be socio-culturally acceptable for increasing the utilization of cervical cancer screening among the women of lower socio-economic class.