Resumen

Objetivos:

Estimar la asociación entre tener conocimientos acerca del cáncer de cuello uterino (CaCu) y re alizarse una prueba de Papanicolaou (PAP) en mujeres peruanas mayores de 30 años.

Materiales y métodos:

Se realizó un análisis secundario de la Encuesta Demográfica y de Salud Familiar de los años 2015 al 2017. El nivel conocimiento fue evaluado utilizando las preguntas: ¿considera usted que el cáncer se puede prevenir?, ¿alguna vez ha oído hablar del CaCu?, ¿alguna vez ha oído hablar del virus del papiloma humano (VPH)? y ¿considera que el VPH puede causar CaCu? La variable dependiente fue la realización de un PAP en los dos últimos años. Para estimar la asociación se utilizaron modelos lineales generalizados de la familia Poisson crudos y ajustados. La medida de asociación fue la razón de prevalencia ajustada (RPa) con sus respectivos intervalos de confianza al 95% (IC 95%).

Resultados:

Se analizaron datos de 21 563 mujeres. La prevalencia de haberse realizado un PAP en los últimos dos años fue 52,4%. Se encontró que, quienes respondieron que se puede prevenir el cáncer (RPa = 1,09; IC 95%: 1,01-1,17), que habían oído hablar del CaCu (RPa = 1,27; IC 95%: 1,14-1,40) o del VPH (RPa = 1,20; IC 95%:1,13-1,28) o que respondieron que el VPH podía causar CaCu (RPa = 1,21; IC 95%: 1,11 1,33) tuvieron una mayor prevalencia de haberse realizado un PAP en los últimos dos años. Conclusiones: Tener conocimientos sobre CaCu y VPH se asoció con haberse realizado un PAP en los últimos dos años.

Palabras claves:
Neoplasias del Cuello Uterino; Prueba de Papanicolaou; Papillomaviridae; Conocimien tos; Actitudes y Práctica en Salud

Abstract

Objetives:

To estimate the association between having knowledge about cervical cancer (CC) and having a Pap test (PAP) in Peruvian women over 30 years old.

Materials and Methods:

A secondary analysis of the Demographic and Family Health Survey of the years 2015 to 2017 was carried out. The level of knowledge was evaluated using the questions, do you think that cancer can be prevented?, Have you ever heard of CC?, Have you ever heard of human papillomavirus (HPV)? And do you think HPV can cause CC? The dependent variable was the realization of a PAP in the last two years. To estimate the association, generalized linear models of the raw and adjusted Poisson family were used. The measure of association was the adjusted prevalence ratio (aPR) with its respective 95% confidence intervals (95% CI).

Results:

Data from 21 563 women were analyzed. The prevalence of having performed a PAP in the last two years was 52.4%. It was found that, those who responded that cancer can be prevented (aPR = 1.09; 95% CI: 1.01-1.17), who had heard of CC (aPR = 1.27; 95% CI: 1.14-1 , 40) or HPV (aPR = 1.20; 95% CI: 1.13-1.28) or who responded that HPV could cause CC (aPR = 1.21; 95% CI: 1.11-1.33) had a higher prevalence of having performed a PAP in the last two years.

Conclusions:

Having knowledge about CC and HPV has been associated with having performed a PAP in the last two years.

Keywords:
Uterine Cervical Neoplasms; Papanicolaou Test; Papillomaviridae; Health Knowledge; Atti tudes; Practice

INTRODUCTION

Cervical cancer (CC) is a worldwide public health problem. In 2018, there were 570,000 cases (equivalent to 6.6% of all cancers in women) and a total of 311,000 deaths, making it the fourth most frequently diagnosed cancer in women and also the fourth most deadly. Approximately 90% of deaths caused by CC occurred in low- and middle-income countries ¹1. World Health Organization. Cervical Cancer 2019. Available from: https://www.who.int/cancer/prevention/diagnosis-screening/cervical-cancer/en/.
https://www.who.int/cancer/prevention/di... ^,22. International Agency for Research on Cancer. Global Cancer Observatory 2019. Available from: http://gco.iarc.fr/.
http://gco.iarc.fr/... .

By 2018, 4,103 new cases of cervical cancer were diagnosed in Peru, with an age-adjusted annual incidence rate of 23.2 per 100,000 women, second only to breast cancer, in women ³3. ICO/IARC. Human Papillomavirus and Related Diseases Report. World. 2019.. CC causes high mortality in Peru, with an estimate of 1,836 deaths in 2018 (age-adjusted annual mortality rate of 10.2 per 100 000 women). Therefore, as a cause for mortality in Peru, CC is ranked as the third leading cause overall, and as the leading cause in women aged 15-44 years ³3. ICO/IARC. Human Papillomavirus and Related Diseases Report. World. 2019..

Early diagnosis is an important measure in controlling the disease burden of CC. When a disease is detected in its early stages, accompanied by access to effective treatments, the prognosis and survival of patients improve ⁴4. World Health Organization. WHO guidance note: comprehensive cervical cancer prevention and control: a healthier future for girls and women. 2013.. An early diagnosis could prevent 40% of CC cases, especially in women not vaccinated against human papillomavirus (HPV) ⁴4. World Health Organization. WHO guidance note: comprehensive cervical cancer prevention and control: a healthier future for girls and women. 2013.. Several inter ventions are available for CC screening, and the Papanicolaou (PAP) test is one of the most cost-effective tools, especially in low-income countries ⁵5. Chen MK, Hung HF, Duffy S, Yen AMF, Chen HH. Cost-effectiveness analysis for Pap smear screening and human papillomavirus DNA testing and vaccination. Journal of evaluation in clinical practice. 2011;17(6):1050-8. doi: 10.1111/j.1365-2753.2010.01453.x.
https://doi.org/10.1111/j.1365-2753.2010... .

Despite the heavy disease burden from CC, the screening coverage is insufficient. In low- and middle-income countries, lab oratory and equipment requirements face logistics problems, these, added to the performance of the PAP test itself (sensitivity of approximately 50%), are factors that limit the screening effectiveness ⁶6. Nanda K, McCrory DC, Myers ER, Bastian LA, Hasselblad V, Hickey JD, et al. Accuracy of the Papanicolaou test in screening for and follow-up of cervical cytologic abnormalities: a systematic review. Ann Intern Med. 2000;132(10):810-9.. Educational interventions have been proposed to increase the level of knowledge about CC, and also to increase the number of periodic screening (including PAP tests) to identify this disease. It has been described that PAP test screening reduces mortality caused by this neoplasia in an average of 2.6% per year ⁷7. Black ME, Yamada J, Mann V. A systematic literature review of the effectiveness of communitybased strategies to increase cervical cancer screening. Can J Public Health. 2002;93(5):386-93.^,88. Demirtas B. Review of strategies in promoting attendance for cervical screening. Asian Pac J Cancer Prev. 2013;14(5):3263-7..

Therefore, the objective of the study was to estimate the relation between knowledge about CC and getting a PAP test in a representative sample of Peruvian women.

MATERIALS AND METHODS

Population, sample and sampling

A secondary analysis was conducted on data obtained from the Demographic and Family Health Survey (ENDES in Spanish) for 2015, 2016 and 2017. The ENDES is an annual survey conducted by the National Institute of Statistics and Information (INEI in Spanish) in order to obtain information concerning the demographic and health status of mothers and children under five years old. The sampling used in the ENDES is probabilistic, balanced, two-stage, stratified and independent, by regions and by urban and rural areas. The ENDES estimates are represented nationally by year, according to its urban/rural areas, by geographical do main (Metropolitan Lima, Coast, Andean and Jungle) and for the 24 regions of Peru and the constitutional province of Callao ⁹9. Instituto Nacional de Estadística e Informática. Diseño muestral. Encuesta Demográfica y de Salud Familiar 2017 2017. Available from: http://iinei.inei.gob.pe/iinei/srienaho/Descarga/FichaTecnica/605-Ficha.pdf.
http://iinei.inei.gob.pe/iinei/srienaho/... . Access to the ENDES databases is free and they are available on the INEI web portal (http://iinei.inei.gob.pe/microdatos).

Eligibility criteria

For the age groups included in the analysis, a total of 104,788 women aged 15-49 were surveyed. However, only women over 30 years old were included because questions on cervical cancer prevention were part of the health questionnaire, which was fulfilled by a subsample of 21,950 women over 30 years old. Participants who reported having more than one healthcare insur ance and women who did not have complete data on the variables of interest were excluded.

Variables and measurements

The dependent variable was “completion of the PAP test in the last two years” with the categories yes/no. The question (QS412U) “Have you ever had a PAP test done by a doctor or other health professional in your life?” and the question (QS411) “How long ago did you have a PAP test for last time?” were used to establish which participants had a PAP test in the last two years.

Knowledge regarding CC and HPV was assessed through four questions: (QS401) “Is it possible to prevent cancer?” and (QS402) “Have you ever heard of cervical cancer?,” which were asked of the entire subsample; and the questions (QS403) “Have you ever heard of HPV?” and (QS404) “Do you think HPV can cause cervical cancer” were asked only if the partici pant answered yes to question QS402. For this reason, the analysis of these last two variables was conducted with a sample size of 19,813 and 14,740 participants, respectively.

The following confounding variables were considered based on the reported literature ¹⁰10. Gutiérrez C, Romaní F, Ramos J, Alarcón E, Wong P. Factores asociados con el conocimiento y tamizaje para cáncer de cuello uterino (examen de Papanicolaou) en mujeres peruanas en edad fértil. Análisis del periodo 1996-2008. Revista peruana de epidemiología. 2010;14(1):39-49.: woman’s age and number of chil dren, as numerical variables; and the degree of education (none/primary, secondary, higher), marital status (married, single), welfare index (very low, low, medium, high, very high), region of origin (Metropolitan Lima, rest of the coast, andean, jungle), area of residence (urban, rural), use of modern contraceptives (yes, no) and the type of insurance: none, Integral Health In surance (SIS), Peruvian Social Health Insurance (EsSalud), Armed Forces and Police, provider entity and private insurance; as categorical variables.

Statistical analysis

The data modules were downloaded directly from the INEI portal, imported and linked through the R v3.4 program (https://www.r-project.org/). All the analyses were carried out taking into account the design of complex samples by specifying the strata, weights and the primary sampling unit with the svydesign command of the survey library.

The prevalence of the dependent variable and the independent variables were reported with their respective 95% confi dence intervals (95% CI). The characteristics of the population were described in proportions, for categorical variables, and in means, for numerical variables. Likewise, bivariate analyses were performed to compare the prevalence of performing a PAP test in the last few years among the strata of the categorical variables or to compare averages between the numerical variables.

To determine the association between the independent and the dependent variables, prevalence ratios (PR) with their 95% CIs were calculated using generalized linear models of the Poisson family, crude and adjusted. We also considered the adjust ment of the 95% CIs due to the use of subpopulations. A separate regression analysis was performed for each of the indepen dent variables. An epidemiological criterion was used to enter confounding variables into the adjusted model. Collinearity was evaluated among all variables in a conceptual way and by means of the variance inflation factor (VIF), a VIF value lower than 4 was considered as absence of collinearity.

Ethical aspects

The databases are available without information that can identify the participants. Prior to the survey, informed consent was obtained from each household.

RESULTS

The ENDES surveyed a total of 36,655 women evaluated in 2015, 34,131 in 2016 and 34,002 in 2017, of whom only 7,238, 7,301 and 7,411 answered the questionnaires with the questions about cervical cancer prevention in those years, respectively. Thus, 21,950 women were included, of whom 387 had to be excluded because they had more than one health insurance policy, leaving 21,563 women included for the analysis (Figure 1).

A total of 57.6% of the population evaluated was between 30 and 40 years of age, 32.1% had a higher degree of education, 70.2% of the population included was married, 8 out of every 10 women resided in an urban area, and 13.6% lived in the jungle (Table 1).

52.4% of the women had a PAP test in the last two years, while 83.2% had a PAP test at some point in her life. 89.6% of the respondents believed that cancer was preventable, 77.8% had heard of HPV at some time, and 91.9% believed that HPV could cause CC (Table 2).

A higher prevalence of having a PAP test in the last 2 years was found among those who considered cancer preventable (53.2% vs. 45.9%; p<0.001), those who had heard of cervical cancer at some time (53.5% vs. 37.2%; p<0.001), those who had heard of HPV (56.1% vs. 44.6%; p<0.001), and those who believed HPV could cause cervical cancer (57.0% vs. 45.7%; p<0.001) (Table 3).

Likewise, a lower prevalence of PAP was found in the last two years among women over 45 years of age, with primary education, very low welfare index, no children, single, rural resident, from the andean or jungle region, and without health insurance (Table 3).

In the crude analysis, a higher prevalence of PAP test was evident in those who believed cancer could be prevented (PR=1.16, 95% CI: 1.07-1.25), in those who had heard of cervical cancer (PR=1.44, 95% CI: 1.29-1.60) or HPV (PR=1.26, 95%

CI: 1.19-1.33), as well as in those who considered that HPV could cause CC (PR=1.25, 95% CI: 1.13-1.37) (Table 4).

In the adjusted analysis, a higher prevalence of PAP test was also found in the group that considered cancer preventable (PR=1.09, 95% CI: 1.01-1.17), in those who had ever heard of cervical cancer (PR=1.27, 95% CI: 1.14-1.40), in women who had heard of HPV (PR=1.20, 95% CI: 1.13-1.28), and in those who thought HPV could cause cervical cancer (PR=1.21, 95% CI: 1.11-1.33) (Table 4).

DISCUSSION

In the present article, we sought to estimate the association between knowing about CC and getting a PAP test in the last two years in a representative sample of Peruvian women. Approximately 5 out of 10 of the women evaluated reported having been screened for CC with a PAP test in the last two years, while 8 out of 10 reported to have been screened for CC at some point in their lives. In addition, it was found that women who knew that cancer is preventable, who had heard about CC or HPV, and those who knew that HPV is associated with CC were more likely to get a PAP test in the last two years. However, while there is a correct direction for this association, the magnitude of the association is no more than 50% for any of the questions that show evidence of CC or HPV.

Half of Peruvian women of childbearing age were not screened with a PAP test in the last two years. Previous studies show that, less than 50% of the population was screened with PAP tests in Peru, and this figure was lower in the andean and jungle regions and in rural areas ⁽²2. International Agency for Research on Cancer. Global Cancer Observatory 2019. Available from: http://gco.iarc.fr/.
http://gco.iarc.fr/... ^,1010. Gutiérrez C, Romaní F, Ramos J, Alarcón E, Wong P. Factores asociados con el conocimiento y tamizaje para cáncer de cuello uterino (examen de Papanicolaou) en mujeres peruanas en edad fértil. Análisis del periodo 1996-2008. Revista peruana de epidemiología. 2010;14(1):39-49.

11. Castro M, Morfin R, Sánchez S, Roca J, Sánchez E, Williams M. Nivel de conocimiento sobre el cáncer cervical y el Papanicolaou en relación al temor, estrés o vergüenza al tamizaje: Un estudio transversal en una comunidad pobre de Lima. Rev Peru Ginecol Obstet. 2005;51(2):94-9.

12. Paz Soldan VA, Lee FH, Carcamo C, Holmes KK, Garnett GP, Garcia P. Who is getting Pap smears in urban Peru?. Int J Epidemiol. 2008;37(4):862-9.^-1313. Ministerio de Salud. Plan nacional para la prevención y control de cáncer de cuello uterino 2017- 2021 2017. Available from: http://bvs.minsa.gob.pe/local/MINSA/4232.pdf.
http://bvs.minsa.gob.pe/local/MINSA/4232... . Studies in Peru have described scarce knowledge of what a PAP test is and why it is useful ^{(10, 11, 14)}, Low educational level, and inadequate history of PAP test use are associated with scarce knowledge and negative attitude towards the PAP test use among women in Lima ¹⁵15. Huamaní C, Hurtado-Ortega A, Guardia-Ricra M, Roca-Mendoza J. Conocimientos y actitudes sobre la toma de papanicolaou en mujeres de Lima, Perú 2007. Rev Peru Med Exp Salud Publica. 2008;25(1):44-50.. In addition, factors such as distance from the testing facility and fear of the procedure have been described as limiting women’s ability to have a PAP test in Peru ^{(12, 16)}. Other problems reported for the control of CC include the failure to perform tests such as visual inspection with acetic acid (VIAA) or cryotherapy due to a lack of supplies or equipment, as well as the need to refer patients for procedures that require specialists, which are often only available in hospitals ¹³13. Ministerio de Salud. Plan nacional para la prevención y control de cáncer de cuello uterino 2017- 2021 2017. Available from: http://bvs.minsa.gob.pe/local/MINSA/4232.pdf.
http://bvs.minsa.gob.pe/local/MINSA/4232... . The panorama of CC screening in Peru, to the date presents problems in terms of coverage and availability of resources, which emphasizes the need for strategies that improve the processes and access to screening tests.

In the present study, about 90% of the women of childbearing age considered cancer to be preventable and have heard about CC. In this regard, it has been reported that women with a low level of health literacy present lower levels of knowledge about CC screening ⁽¹⁹19. Lindau ST, Tomori C, Lyons T, Langseth L, Bennett CL, Garcia P. The association of health literacy with cervical cancer prevention knowledge and health behaviors in a multiethnic cohort of women. Am J Obstet Gynecol. 2002;186(5):938-43.. In addition, women with a primary education level had a lower prevalence of having a PAP test in the last two years. Some studies on the Peruvian population indicate that the proportion of women who know about CC is low and that there are no alternatives for cancer treatment ¹⁴14. Luque JS, Maupin JN, Ferris DG, Condorhuaman WSG. Reaching women in the Peruvian Andes through cervical cancer screening campaigns: Assessing attitudes of stakeholders and patients. Patient Prefer Adherence. 2016;10:2107.^,2020. Robles SC, Ferreccio C, Tsu V, Winkler J, Almonte M, Bingham A, et al. Assessing participation of women in a cervical cancer screening program in Peru. Rev Panam Salud Publica. 2009;25:189-95..

Studies in Latin American countries find that knowledge about CC may or may not be associated with the practice of a PAP test ¹⁷17. Garcés IC, Rubio DC, Scarinci IC. Factores asociados con el tamizaje de cáncer de cuello uterino en mujeres de nivel socioeconómico medio y bajo en Bogotá, Colombia. Rev Fac Nac Salud Publica. 2012;30(1):7-16.^,1818. Rodríguez G, Caviglia C, Alonso R, Sica A, Segredo S, León I, et al. Conocimientos, actitudes y prácticas sobre el test de Papanicolaou y estadificación del cáncer de cuello uterino. Rev Med Urug. 2015;31(4):231-40.^,2121. Aguilar-Pérez JA, Leyva-López AG, Angulo-Nájera D, Salinas A, Lazcano-Ponce EC. Tamizaje en cáncer cervical: conocimiento de la utilidad y uso de citología cervical en México. Rev Saúde Pública. 2003;37:100-6.. Therefore, the promotion of educational interventions aimed at increasing knowledge about CC and tools for its prevention and early detection could be useful. However, the effectiveness of these educational programs needs to be evaluated to verify their usefulness in the Peruvian population. Likewise, having described a low proportion of women picking-up the test results, the pick-up of the PAP test results should be encouraged ²²22. Ferris DG, Chen J, Isaac A, Braithwaite E, Beideck E, Mikail N, et al. Reimbursement Incentives to Improve Adherence to Follow-Up of Cervical Cancer Cytology Screening Results in Peru. J Low Genit Tract Dis. 2019;23(2):116-23. doi: 10.1097/LGT.0000000000000459.
https://doi.org/10.1097/LGT.000000000000... ^,2323. Musa J, Achenbach CJ, O'Dwyer LC, Evans CT, McHugh M, Hou L, et al. Effect of cervical cancer education and provider recommendation for screening on screening rates: A systematic review and meta-analysis. PloS one. 2017;12(9):e0183924. doi: 10.1371/journal.pone.0183924.
https://doi.org/10.1371/journal.pone.018... . Given the fact that the user approaches the health system at different times, this interaction would be an important opportunity to provide health education about the PAP test and the CC, which is not being used in Peru ²⁴24. Bayer AM, Nussbaum L, Cabrera L, Paz-Soldan VA. Missed opportunities for health education on Pap smears in Peru. Health Educ Behav. 2011;38(2):198-209. doi: 10.1177/1090198110379580.
https://doi.org/10.1177/1090198110379580... . At the local level, strategies such as secondary prevention programs that facil itate the population’s access to health services or HPV self-screening are seen as opportunities to increase the empowerment of the population, the knowledge about CC, and the number of women screened ¹⁴14. Luque JS, Maupin JN, Ferris DG, Condorhuaman WSG. Reaching women in the Peruvian Andes through cervical cancer screening campaigns: Assessing attitudes of stakeholders and patients. Patient Prefer Adherence. 2016;10:2107.^,2525. Ferris DG, Shapiro J, Fowler C, Cutler C, Waller J, Condorhuaman WSG. The Impact of Accessible Cervical Cancer Screening in Peru-The Día del Mercado Project. J Low Genit Tract Dis. 2015;19(3):229-33. doi: 10.1097/LGT.0000000000000112.
https://doi.org/10.1097/LGT.000000000000... ^,2626. Morán F, Cárcamo C, Valderrama M, García PJ. Preferencias y satisfacción hacia un programa de tamizaje con pruebas autoadministradas de detección del virus de papiloma humano. Rev Peru Med Exp Salud Publica. 2017;34(2):228-32. doi: 10.17843/rpmesp.2017.342.2453.
https://doi.org/10.17843/rpmesp.2017.342... .

Regarding HPV, 9 out of 10 women recognized the relationship between HPV and CC. The literature reports generally low awareness of HPV and its relationship to CC development in countries at all income levels²⁷27. Haesebaert J, Lutringer-Magnin D, Kalecinski J, Barone G, Jacquard A-C, Régnier V, et al. French women's knowledge of and attitudes towards cervical cancer prevention and the acceptability of HPV vaccination among those with 14-18 year old daughters: a quantitative-qualitative study. BMC public health. 2012;12(1):1034.

28. Charakorn C, Rattanasiri S, LERTKHACHONSUK Aa, Thanapprapasr D, Chittithaworn S, Wilailak S. Knowledge of Pap smear, HPV and the HPV vaccine and the acceptability of the HPV vaccine by Thai women. Asia Pac J Clin Oncol. 2011;7(2):160-7. doi: 10.1111/j.1743-7563.2011.01392.x.
https://doi.org/10.1111/j.1743-7563.2011... ^-2929. Moreira E, Oliveira B, Ferraz F, Costa S, Costa Filho J, Karic G. Knowledge and attitudes about human papillomavirus, Pap smears, and cervical cancer among young women in Brazil: implications for health education and prevention. Int J Gynecol Cancer. 2006;16(2):599-603.. Similarly, even a high level of knowl edge about HPV (greater than 50% of the population) is not necessarily related to an understanding of the relationship between HPV infection and the development of CC³⁰30. Kobetz E, Kornfeld J, Vanderpool RC, Finney Rutten LJ, Parekh N, O'Bryan G, et al. Knowledge of HPV among United States Hispanic women: opportunities and challenges for cancer prevention. J Health Commun. 2010;15(sup3):22-9. doi: 10.1080/10810730.2010.522695.
https://doi.org/10.1080/10810730.2010.52... .

Having little information on preventive issues detracts from the usefulness of screening measures. Therefore, it is neces sary to promote education in the Peruvian population, mainly with girls who receive the HPV vaccine and who should be screened in the future, and also by women, parents, and the community, so that greater knowledge about HPV and the HPV vaccine could have an additional benefit in increasing the acceptability of vaccinating girls against HPV ²⁷27. Haesebaert J, Lutringer-Magnin D, Kalecinski J, Barone G, Jacquard A-C, Régnier V, et al. French women's knowledge of and attitudes towards cervical cancer prevention and the acceptability of HPV vaccination among those with 14-18 year old daughters: a quantitative-qualitative study. BMC public health. 2012;12(1):1034.^,2828. Charakorn C, Rattanasiri S, LERTKHACHONSUK Aa, Thanapprapasr D, Chittithaworn S, Wilailak S. Knowledge of Pap smear, HPV and the HPV vaccine and the acceptability of the HPV vaccine by Thai women. Asia Pac J Clin Oncol. 2011;7(2):160-7. doi: 10.1111/j.1743-7563.2011.01392.x.
https://doi.org/10.1111/j.1743-7563.2011... .

The HPV vaccine has been distributed in more than 70 countries since 2007. In Peru, it was introduced in 2015 to the National Vaccination Scheme, as a strategy to prevent cancer in the population. The HPV vaccine is applied to girls in the fifth year of primary school; or 10-year-old girls, if they do not assist to school. Therefore, it is important to reinforce the knowledge about HPV, its relation with CC and its prevention through vaccination to favor the use of preventive measures and increase control of the disease.

The World Health Organization (WHO) promotes screening for precancerous signs, and recommends the PAP, HPV tests and VIAA as tools for this process, in order to detect the disease in the greatest proportion of women at risk ¹1. World Health Organization. Cervical Cancer 2019. Available from: https://www.who.int/cancer/prevention/diagnosis-screening/cervical-cancer/en/.
https://www.who.int/cancer/prevention/di... . In Peru, the 2019 “Health Directive for the Prevention of Cervical Cancer through Early Detection and Treatment of Pre-Malignant Lesions including Carcinoma in Situ” seeks to reduce the incidence of morbidity and mortality from CC through stan dardization of preventive and care processes. This directive recognizes that screening should be performed in all women between 25 and 64 years of age free of charge, nationwide, and it also recognizes the PAP test and the VIAA as ways for detecting cervical lesions in addition to HPV detection with molecular tests. This way, the PAP test is the most important tool for the detection of CC given its current wide availability for use in the Peruvian health care environment.

However, in our study half of the population was PAP screened in the last two years, so why have morbidity and mortality rates due to CC not decreased? Part of this problem lies in the diagnostic capacity of the PAP test, with sensitivity ranging from 22.1% in a Chilean national study ⁽³¹31. Ferreccio C. Nuevas estrategias de prevención y control de cáncer de cuello uterino en Chile. Salud pública Méx. 2018;60:713-21. doi: 10.21149/8577.
https://doi.org/10.21149/8577... ⁾ to 50% according to the Cuzick study ³²32. Cuzick J, Arbyn M, Sankaranarayanan R, Tsu V, Ronco G, Mayrand MH, et al. Overview of human papillomavirus-based and other novel options for cervical cancer screening in developed and developing countries. Vaccine. 2008;26 Suppl 10:K29-41., in low- and middle-income countries. Thus, despite the fact that half of the population was PAP screened, the methodology applied allowed a large number of women to be false negatives. It is expected that progressively, the use of VIAA and molecular tests for detecting HPV in the Peruvian population will increase. For example, molecular tests for HPV have a sensitivity of 98% for the identification of high-risk genotypes, allowing more treatment options to be offered³³33. Saville M, Sultana F, Malloy MJ, Velentzis LS, Caruana M, Ip ELO, et al. Clinical Validation of the cobas HPV Test on the cobas 6800 System for the Purpose of Cervical Screening. J Clin Microbiol. 2019;57(2). doi: 10.1128/JCM.01239-18.
https://doi.org/10.1128/JCM.01239-18.... . In addition, another feature of molecular testing is automation, unlike PAP testing, which is operator-dependent. However, it is not yet possible to massively implement this technology in our country due to the limited resources of the Peruvian health system.

This study has some limitations that may affect the interpretability of the results. The cross-sectional design does not allow estab lishing causal relationships between the independent variables and the proposed dependent variable. Likewise, there is the possibility of reverse causality between the proposed associations. Due to the latter, it was decided to operationalize the dependent variable using the last two years as a time frame. Similarly, there is a possibility of measurement bias due to the fact that the variables were self-reported, which makes memory bias or social desirability bias possible. On the other hand, no validated instrument was used to measure the level of knowledge about CC and HPV. The questions in the survey only explore the person’s familiarity with the terms, but do not delve into knowledge of the issues. Nonetheless, we believe that the study’s findings are useful in providing an overview of PAP screening and the association with familiarity of women of childbearing age with HPV and CC prevention issues.

In conclusion, it was found that one out of every two women of childbearing age got a PAP test in the last two years. Know ing that cancer can be prevented, having heard about CC or HPV, and associating HPV with the development of CC were associated with an increased likelihood of getting a PAP test in the last two years. Therefore, the implementation of educational strategies about HPV, CC, and PAP test knowledge, could increase the number of women undergoing the PAP test, a CC screening test, which is useful for Peruvian women because of the low availability of other types of tests used for this purpose.

References

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History