ABSTRACT

Objective

To assess cervical cancer prevalence and associated mortality in Grenada, West Indies during 2000–2010.

Methods

Records of visits to hospital and clinical facilities were obtained from the histopathology laboratory of the Grenada General Hospital. Records were de-identified and electronically compiled. Cervical cancer prevalence was assessed via cross-sectional analysis of this secondary data. Of a total 12 012 records, 2 527 were selected for analysis using sampling without replacement. Cases were matched to corresponding patient data from death registries, where possible, and used to calculate associated mortality rates.

Results

The observed prevalence of cervical cancer was 52.4 per 100 000 women (ages 15 and above). The highest rates of cervical cancer occurred in the 35–44 age group, with the second highest among 45–64-year-olds. A total of 65 deaths were attributable to cervical cancer during 2000–2010, more than 50% of which were among women > 65 years old. The observed mortality rate was 16.7 per 100 000, almost twice the rate estimated by WHO for the region.

Conclusions

This study demonstrates the need for a comprehensive cervical cancer-screening program in Grenada. Results should contribute to informing future studies on how to appropriately generate and execute public health policy for education, screening, prevention, and control of cervical cancer in Grenada.

Key words
Papillomavirus infections; public health policy; cervix uteri; uterine cervical diseases; squamous intraepithelial lesions of the cervix; Grenada

RESUMEN

Objetivo

Evaluar la prevalencia del cáncer cervicouterino y la mortalidad asociada en Granada, Antillas Menores, entre el 2000 y el 2010.

Métodos

Se obtuvieron los registros de las visitas al hospital y a consultorios clínicos a partir del laboratorio de histopatología del Hospital General de Granada. Se borraron los datos personales de los registros y se los compiló electrónicamente. La prevalencia de cáncer cervicouterino se evaluó por medio del análisis transversal de estos datos secundarios. De un total de 12 012 registros, fueron seleccionados para el análisis 2 527 mediante un método de muestreo sin reemplazo. Los casos se compararon con los datos correspondientes de pacientes en los registros de defunciones, cuando fue posible, y se usaron para calcular las tasas de mortalidad asociadas.

Resultados

La prevalencia observada de cáncer cervicouterino fue 52,4 por 100 000 mujeres (de 15 años o más). Las tasas más elevadas de cáncer cervicouterino se observaron en el grupo de edad de 35 a 44 años, seguido por el grupo de 45 a 64 años. Del 2000 al 2010, 65 defunciones fueron atribuibles al cáncer cervicouterino, más del 50% en mujeres mayores de 65 años. La tasa de mortalidad observada fue 16,7 por 100 000, casi el doble de la calculada por la Organización Mundial de la Salud para la región.

Conclusiones

Este estudio indica la necesidad de establecer un programa integral de detección del cáncer cervicouterino en Granada. Los resultados deben servir como base para estudios futuros sobre cómo generar y ejecutar apropiadamente políticas de salud pública para la educación en la materia, la detección, la prevención y el control del cáncer cervicouterino en Granada.

Palabras clave
Infecciones por papillomavirus; políticas públicas de salud; cuello del utero; lesiones intraepiteliales escamosas de cuello uterino; neoplasias del cuello uterino; Grenada

Human papillomaviruses (HPVs) are sexually transmitted infections which may result in malignant disease; they contribute significantly to morbidity and mortality worldwide (¹1 Moscicki AB. Impact of HPV infection in adolescent populations. J Adolescent Health. 2005;37 Suppl 6:S3–9.). HPVs are common and easily transmissible; infection may result from a single exposure to an infected individual (²2 Ley C, Bauer HM, Reingold A, Schiffman MH, Chambers JC, Tashiro CJ, et al. Determinants of genital human papillomavirus infection in young women. J Natl Cancer I. 1991;83:997–1003.). In fact, approximately 80% of the sexually active population becomes infected with at least one HPV subtype (³3 Alba A, Cararach M, Rodriguez-Cerdeira C. The Human Papillomavirus (HPV) in Human Pathology: Description, Pathogenesis, Oncogenic Role, Epidemiology and Detection Techniques. Open Dermatol J. 2009;3:90–102.). However, most individuals are asymptomatic, as immunological processes may limit or reduce viral load, often to undetectable levels (¹1 Moscicki AB. Impact of HPV infection in adolescent populations. J Adolescent Health. 2005;37 Suppl 6:S3–9., ⁴4 Castellsague X. Natural history and epidemiology of HPV infection and cervical cancer. Gynecol Oncol. 2008;110 3 Suppl 2:S4–7.–⁷7 Wu X, Watson M, Wilson R, Saraiya M, Cleveland JL, Markowitz L. Human Papillomavirus - Associated Cancers - United States, 2004–2008. MMWR. 2012; 61:258–61.). HPV subtypes are termed “low-risk” (LR) or “high-risk” (HR), based on their propensity to cause cancer (⁸8 Munoz N, Bosch FX, de Sanjose S, Herrero R, Castellsagué X, Shah KV, et al. Epidemiological classification of human papillomavirus types associated with cervical cancer. New Engl J Med. 2003;348: 518–27.). When HR-HPV sequences persist and viral oncoproteins are expressed, dysregulation of the host cell may result in lesions that may progress to cancer (⁹9 Moscicki AB, Ellenberg JH, Farhat S, Xu J. Persistence of human papillomavirus infection in HIV-infected and -uninfected adolescent girls: risk factors and differences, by phylogenetic type. J Infect Dis. 2004;190:37–45., ¹⁰10 Schiffman M, Kjaer SK. Chapter 2: Natural history of anogenital human papillomavirus infection and neoplasia. J Natl Cancer Inst Monogr. 2003;31:14–9.).

Cervical cancer is the fourth most commonly diagnosed cancer among women worldwide, and disproportionately affects women in developing countries (¹¹11 Bruni L, Barrionuevo-Rosas L, Albero G, Aldea M, Serrano B, Valencia S, et al. Human Papillomavirus and Related Diseases in the World. Summary Report. Barcelona: ICO Information Centre on HPV and Cancer (HPV Information Centre); 2015.). Incidence rates in Latin America and the Caribbean are among the highest in the world (¹²12 Parkin DM, Almonte M, Bruni L, Clifford G, Curado MP, Pineros M. Burden and trends of type-specific human papillomavirus infections and related diseases in the Latin America and Caribbean region. Vaccine. 2008;26 Suppl 11:L1–15., ¹³13 Forman D, de Martel C, Lacey CJ, Soerjomataram I, Lortet-Tieulent J, Bruni L, et al. Global burden of human papillomavirus and related diseases. Vaccine 2012;30 Suppl 5:F12–23.); regionally, it is the second-most frequently diagnosed cancer among women between 15 and 44 (¹²12 Parkin DM, Almonte M, Bruni L, Clifford G, Curado MP, Pineros M. Burden and trends of type-specific human papillomavirus infections and related diseases in the Latin America and Caribbean region. Vaccine. 2008;26 Suppl 11:L1–15., ¹⁴14 WHO/ICO Information Centre on HPV and Cervical Cancer (HPV Information Centre). Human Papillomavirus and Related Cancers in World. Summary Report 2010. Barcelona: WHO/ICO Information Centre on HPV and Cervical Cancer (HPV Information Centre); 2010.). Globally, 80 to 85% of deaths due to cervical cancer occur in low- or middle-income countries. Although estimates exist for the Caribbean region, little is known about the burden of cervical cancer in the Eastern Caribbean, including Grenada, and current WHO data are unavailable for either the region or country (¹⁵15 WHO. World Health Organization – Noncommunicable Diseases (NCD) Country Profile, 2014. Grenada. [cited 2015 Feb 14] Available from: http://www.who.int/nmh/countries/grd_en.pdf.
http://www.who.int/nmh/countries/grd_en.... , ¹⁶16 WHO. World Health Organization – Cancer Country Profiles, 2014. Grenada. [cited 2015 Feb 14]. Available from: http://www.who.int/cancer/country-profiles/grd_en.pdf?ua=1.
http://www.who.int/cancer/country-profil... ).

Grenada is a tri-island state in the Caribbean, comprised of Grenada, Carriacou and Petite Martinique, with a population of approximately 100 000; of these, 39 035 are women aged 15 years and older who are at risk for cervical cancer (¹⁷17 Government of Grenada. Grenada National Strategic Plan for Health 2007–2011. St. George’s: Government of Grenada; 2006., ¹⁸18 Bruni L, Barrionuevo-Rosas L, Albero G, Aldea M, Serrano B, Valencia S, et al. Human Papillomavirus and Related Diseases Report - Grenada. Summary Report. Barcelona: ICO Information Centre on HPV and Cancer (HPV Information Centre); 2015.). A 1998 survey classified 31% of the population as poor, of which 51% were women (¹⁷17 Government of Grenada. Grenada National Strategic Plan for Health 2007–2011. St. George’s: Government of Grenada; 2006.).

Earlier investigations into cancer rates in Grenada (1990–2000) estimated the incidence of cervical and uterine cancer at 60.7 per 100 000, higher than regional estimates (¹⁹19 Asulin Y, McCann TJ, McCarty CW, Hage RW, Rooney PJ, Macpherson CN. Cancer incidence and mortality in Grenada 1990–2000. West Indian Med J. 2004;53:368–73.). No other cervical cancer estimates have been published for Grenada and few publications focus on HPV-associated disease or cervical cancer mortality in the region (¹⁸18 Bruni L, Barrionuevo-Rosas L, Albero G, Aldea M, Serrano B, Valencia S, et al. Human Papillomavirus and Related Diseases Report - Grenada. Summary Report. Barcelona: ICO Information Centre on HPV and Cancer (HPV Information Centre); 2015., ²⁰20 WHO. Human Papillomavirus and Related Cancers - Americas. Summary Report 2010. Barcelona: WHO/ICO Information Centre on HPV and Cervical Cancer (HPV Information Centre); Institut Catala d’Oncologia (ICO, Catalan Institute of Oncology), 2010., ²¹21 WHO. Human Papillomavirus and Related Cancers - Cuba. Summary Report 2010. Barcelona: WHO/ICO Information Centre on HPV and Cervical Cancer (HPV Information Centre); Institut Catala d’Oncologia (ICO, Catalan Institute of Oncology), 2010.). Factors limiting the availability of regional information likely include a lack of comprehensive cervical cancer screening programs and incomplete reporting, which may result partly from limited epidemiological data and difficulty accessing records which are primarily hand-written.

It is important to measure the burden of HPV-associated disease and co-morbidities in Grenada (²²22 Coward S. UN Calls for More Sex Education in Caribbean Schools to Curb Spread of HIV/AIDS. Caribbean Press Releases. 2008.). This study assesses current prevalence of cervical cancer and associated mortality using de-identified histopathology records of women seeking care at local hospitals and clinics from 2000 to 2010, supplemented by death registry records.

MATERIALS AND METHODS

Data Sources

Ten years of hand-written records (12 012 entries) from the histopathology logbooks of the Grenada General Hospital were compiled into an electronic master sheet covering the period from January 1, 2000 to December 31, 2009. Data was entered and analyzed in Excel v 12.3.1 (Microsoft, Redmond, USA). Subjects were self-selected, having sought treatment for medical reasons. Patient records were de-identified and assigned random codes. Logbook data was used to estimate prevalence of cervical lesions and cervical cancer (see Figure 1), as described below. Diagnoses for lesion stage and cancer were used as selection criteria for inclusion in further analyses, and sample size was a function of the number of hospital record entries over the ten-year study period.

Logbook data was supplemented with data from multiple other sources, including birth and death records from the Ministry of Health and the Ministry of Finance Statistical Office.

Population and age distribution data were obtained from census records for the period from January 2001 to December 2008 (²³23 Central Statistical Office Ministry of Finance. Mid-Year Population Estimates 2000–2008. St. George’s: Central Statistical Office Ministry of Finance; 2011.). Mid-year population estimates were used for standardized rate calculations and analyses in this cross-sectional study. The median year of 2005 was used as the basis for calculating prevalence rates. Mortality data was collected for 2000–2010.

Inclusion and classification criteria

The analysis encompassed squamous cell carcinomas (in-situ, invasive, infiltrating, and differentiating) and sarcomas. These cancers were previously examined in a retrospective analysis of cervical cancer in the Dutch Caribbean Antilles (1983–1998) and in electronic database statistics (Surveillance, Epidemiology, and End Results, SEER) in the United States, where various diagnoses of carcinomas of the cervix were compared (²⁴24 Bax A, Voigt RR, Coronel CC, Putter H, de Bie Leuving Tjeenk RM, van Marwijk HW. Incidence of cervical carcinoma in a high-risk, non-screened area results of a retrospective analysis on the Dutch Caribbean Antilles from 1983 to 1998. West Indian Med J. 2004;53:150–4., ²⁵25 Bansal S, Lewin SN, Burke WM, Deutsch I, Sun X, Herzog TJ, et al. Sarcoma of the cervix: natural history and outcomes. Gynecol Oncol. 2010;118:134–8.). Prevalence of cervical lesions was estimated using cytological data from Pap smears. Low-grade dysplasia (cervical intraepithelial neoplasia, CIN, grade I/II), severe dysplasia (CIN III) and prevalence of cervical cancer were recorded from logbook records, using classifications based on the Bethesda System of histopathology and cytology (²⁶26 Cuschieri KS, Cubie HA. The role of human papillomavirus testing in cervical screening. J Clin Virol. 2005;32 Suppl 1:S34–42.).

Cervical lesions were categorized by age group, grade, and type. A similar model was previously used to analyze cervical lesion prevalence in the Dutch Antilles (1983–1998) (²⁴24 Bax A, Voigt RR, Coronel CC, Putter H, de Bie Leuving Tjeenk RM, van Marwijk HW. Incidence of cervical carcinoma in a high-risk, non-screened area results of a retrospective analysis on the Dutch Caribbean Antilles from 1983 to 1998. West Indian Med J. 2004;53:150–4.). Reports of colposcopic-directed cervical biopsies and endocervical curettings, qualifying statements of cervical lesions and squamous intraepithelial (SIL) changes were collected from surgical records. A similar categorization and analysis was previously used in a study of cervico-vaginal Pap smears in girls under 18 in Barbados (1995–1999) (²⁷27 Prussia PR, Gay GH, Bruce A. Analysis of cervico-vaginal (Papanicolaou) smears, in girls 18 years and under. West Indian Med J. 2002;51:37–9.).

Data management

A comprehensive database was created and all data were standardized and categorized by lesion type and age group. All samples were classified by organ site and coded for severity on a scale from 0–4, with “0” being no indicator or least severe and “4” being cancer. Where a patient had multiple listings, one record was entered per organ site, representing the earliest year in which that patient received their most severe diagnosis for that site.

Entries with duplicate names were cross-matched and re-verified with documentation from the logbooks, individual sample sheet records, formal hard-copy typed lab results, and cytology record cards where available. Data were divided into three equal spreadsheets and checked by three coders to minimize interpretation error. This process was repeated twice to verify data accuracy and correct errors.

Of the 12 012 entries, 9 023 were female. Some represented multiple visits by a single individual; in total, 7 172 females between the ages of 0 and 99 years were represented. For the selected sample, ages ranged from 8–94 years. Records were de-identified and given random identification numbers. Allowing one diagnosis per patient per organ location resulted in 2 527 relevant histopathology logbook entries for inclusion in the study (see Figure 1).

Two hundred and four cervical cancer cases identified in the secondary review were matched to corresponding patient data from death registries collected from the Ministry of Health and used to calculate associated mortality rates. Mortality data were obtained for the period from January 1, 2000 to December 31, 2010. Data were cross-referenced with de-identified data from the logbooks to create an electronic file and identifier list. This sampling methodology follows similar previous work (¹⁹19 Asulin Y, McCann TJ, McCarty CW, Hage RW, Rooney PJ, Macpherson CN. Cancer incidence and mortality in Grenada 1990–2000. West Indian Med J. 2004;53:368–73., ²⁴24 Bax A, Voigt RR, Coronel CC, Putter H, de Bie Leuving Tjeenk RM, van Marwijk HW. Incidence of cervical carcinoma in a high-risk, non-screened area results of a retrospective analysis on the Dutch Caribbean Antilles from 1983 to 1998. West Indian Med J. 2004;53:150–4., ²⁶26 Cuschieri KS, Cubie HA. The role of human papillomavirus testing in cervical screening. J Clin Virol. 2005;32 Suppl 1:S34–42., ²⁷27 Prussia PR, Gay GH, Bruce A. Analysis of cervico-vaginal (Papanicolaou) smears, in girls 18 years and under. West Indian Med J. 2002;51:37–9.).

Statistical analysis

This study reports 95% confidence intervals (CIs); the margin of error for proportions used in hypothesis testing is +/− 1.2%. The significance level is set at α = 0.05, as used in an analysis of cancer prevalence and mortality for Grenada in the previous decade (¹⁹19 Asulin Y, McCann TJ, McCarty CW, Hage RW, Rooney PJ, Macpherson CN. Cancer incidence and mortality in Grenada 1990–2000. West Indian Med J. 2004;53:368–73.). All reported rates were adjusted with reference to the World Standard Population to obtain age-standardized rates (ASRs) per 100 000 persons per year (²⁸28 Ahmad OB, Boschi-Pinto C, Lopez AD, Murray CJ, Lozano R, Inoue M. Age Standardization of Rates: A New WHO Standard. Geneva: World Health Organization; 2001., ²⁹29 Hong Kong Cancer Registry Hospital Authority. The Meaning and Use of the Age-Standardized Rate (ASR) [cited 2016 Feb 9, 2016]. Available from: http://www3.ha.org.hk/cancereg/e_asr.asp.
http://www3.ha.org.hk/cancereg/e_asr.asp... ). Prevalence rates for cervical cancer and mortality due to cervical cancer were compared to incidence rates reported for the greater Caribbean region and the world.

Ethical review

Approval was obtained prior to the study from the St. George’s University Human Subjects Institutional Review Board (IRB) [No. 12 005] and the Research Oversight Committee (ROC) of the Ministry of Health, Grenada, to ensure the ethical acceptability of this human subjects research.

RESULTS

From 12 012 records at the Grenada General Hospital in the period from 2000 to 2010, 9 023 female patient entries were identified, representing 7 172 self-selected female patients (ages 8–94 years). Of these, 726 involved cervical lesions (including cancer).

Patients diagnosed with cervical lesions ranged from 12 to 92 years old, with a mean of 44.6 years. Table 1 shows the distribution of cervical diagnoses by severity and age group.

Of the 726 patients with cervical lesions, 204 were diagnosed as having cancer. Cervical cancer prevalence was highest in 2001, followed by 2000 and 2002 (Figure 2), and in the 35–44 age group, followed by the 45–64 age group (Table 1).

The observed prevalence rate of cervical cancer was 52.4 per 100 000 women aged 15 and above. Combining cervical and uterine cancers, as in the initial incidence study, prevalence was calculated at 74.3 per 100 000, higher than the 60.7 observed during the previous decade for Grenada (¹⁹19 Asulin Y, McCann TJ, McCarty CW, Hage RW, Rooney PJ, Macpherson CN. Cancer incidence and mortality in Grenada 1990–2000. West Indian Med J. 2004;53:368–73.).

Cervical cancer was the primary cause of death in 65 instances during the study period. A majority of these deaths were in women over 65 years old. Of the 65, 21 were identified through hospital records and 44 through death registries. The largest number of deaths was seen in 2008 (n = 13), but cervical cancer mortality varied widely over the ten-year period (Figure 3). The observed mortality rate was 16.7 per 100 000, higher than the incidence estimated by WHO for the larger region or than reported for the previous decade (¹⁹19 Asulin Y, McCann TJ, McCarty CW, Hage RW, Rooney PJ, Macpherson CN. Cancer incidence and mortality in Grenada 1990–2000. West Indian Med J. 2004;53:368–73.), (Table 2). Although these rates are not directly comparable, it is clear that cervical cancer and associated mortality is higher in Grenada than in WHO regional estimates.

DISCUSSION

The objective of this study was to determine the prevalence of cervical cancer and associated mortality in Grenada during 2000–2010. Cervical cancer rates and associated deaths are known to be highest in low- to middle-income countries (³⁰30 Ferlay J, Soerjomataram I, Ervik M, Dikshit R, Eser S, Mathers C, et al. GLOBOCAN 2012 v1.0, Cancer Incidence and Mortality Worldwide: IARC CancerBase No. 11 [Internet]. Lyon: International Agency for Research on Cancer; 2013 [accessed Jan 15, 2014]. Available from: http://globocan.iarc.fr.
http://globocan.iarc.fr... ); the burden of disease is disproportionate for these populations (¹¹11 Bruni L, Barrionuevo-Rosas L, Albero G, Aldea M, Serrano B, Valencia S, et al. Human Papillomavirus and Related Diseases in the World. Summary Report. Barcelona: ICO Information Centre on HPV and Cancer (HPV Information Centre); 2015.). Data are lacking on rates of cervical cancer for the Eastern Caribbean, including Grenada. This study observed a cervical cancer prevalence of 52.4 per 100 000 in this population. This is higher than the WHO incidence estimates for the region of 23.6 per 100 000 (Table 2) (¹¹11 Bruni L, Barrionuevo-Rosas L, Albero G, Aldea M, Serrano B, Valencia S, et al. Human Papillomavirus and Related Diseases in the World. Summary Report. Barcelona: ICO Information Centre on HPV and Cancer (HPV Information Centre); 2015.).

The highest overall prevalence of cervical cancer in this study was in the 35–44 age group, which is typical for disease progression to cancer in this population of women (³¹31 Schiffman M, Castle PE. The promise of global cervical-cancer prevention. N Engl J Med. 2005;353:2101–4.). In this study, the youngest individual with invasive squamous cell carcinoma was 19 years old. These results reflect the typical distribution of disease in both developing and developed nations (³¹31 Schiffman M, Castle PE. The promise of global cervical-cancer prevention. N Engl J Med. 2005;353:2101–4., ³²32 National Cancer Institute. Cervical Cancer Screening 2013 [accessed April 16, 2013]. Available from: http:www.cancer.gov/
http:www.cancer.gov/... ). A decline in cervical lesion and cancer prevalence was observed in women over 65 years of age, although they experienced the greatest cancer mortality.

A high incidence of cervical cancer was noted for 2001; this was likely attributable to multiple sensitization efforts about Pap smears and reproductive health conducted during that year, which resulted in the screening of a large number of women. Conversely, in 2004 and 2005, the island experienced hurricanes Ivan and Emily and many of the hospital’s resources were redirected to survival efforts and rebuilding communities, resulting in a decrease in screening.

The morbidity associated with high-risk (HR) HPV infections, such as cervical cancer, is much greater when lesions are discovered later in disease progression. Treatment of more-advanced lesions can be quite costly. In some cases, limited financial resources may cause women to defer medical interventions in an effort to provide food and shelter for their dependents (³³33 Pollack AE, Balkin MS, Denny L. Cervical cancer: a call for political will. Int J Gynaecol Obstet. 2006;94:333–42.). However, this phenomenon has primarily been documented in developed countries; no comparable estimates are available for the Eastern Caribbean, which also faces substantial economic burdens (³⁴34 Eltoum IA, Roberson J. Impact of HPV testing, HPV vaccine development, and changing screening frequency on national Pap test volume: projections from the National Health Interview Survey (NHIS). Cancer. 2007;111:34–40.–³⁸38 Congressional Budget Office. Senate Report 106-323: Breast and Cervical Cancer Prevention and Treament Act. Congressional Budget Office Cost Estimate - Breast and Cervical Cancer Prevention and Treatment Act of 2000, S.662. Washington DC: 106th Congress; 2000.).

A knowledge and attitudes assessment in the 1990s reported that approximately twenty new cases of cervical and/or uterine cancer were diagnosed per year among Grenadian women (unpublished data, 39). This was not observed in the current study, where new cancer cases varied widely over the ten-year period, largely coinciding with times when screening efforts were implemented and emphasized. Cervical and uterine cancer incidence rates from 1990 to 2000 were estimated at 60.7 per 100 000 in a previous study in Grenada. This study by Asulin et al. featured a relatively small sample size, combined cervical and uterine cancer diagnoses, and sampled only five years out of the ten-year period (¹⁹19 Asulin Y, McCann TJ, McCarty CW, Hage RW, Rooney PJ, Macpherson CN. Cancer incidence and mortality in Grenada 1990–2000. West Indian Med J. 2004;53:368–73.). The current study observed a cervical cancer prevalence in Grenada of 52.4 per 100 000 women for 2000–2010, higher than estimated WHO incidence rates for the region (Table 2). Combined cervical and uterine cancer prevalence was estimated at 74.3 per 100 000. Due to differences in study design, the current results are not directly comparable with Asulin et al. (¹⁹19 Asulin Y, McCann TJ, McCarty CW, Hage RW, Rooney PJ, Macpherson CN. Cancer incidence and mortality in Grenada 1990–2000. West Indian Med J. 2004;53:368–73.).

A total of 65 cervical cancer deaths were observed during the study period; the overall cervical cancer mortality rate was 16.7 per 100 000 women. This is nearly twice the rate calculated for 1990–2000, and is also higher than global (7.6) and developing countries (8.1) rates from the WHO (Table 2) (¹¹11 Bruni L, Barrionuevo-Rosas L, Albero G, Aldea M, Serrano B, Valencia S, et al. Human Papillomavirus and Related Diseases in the World. Summary Report. Barcelona: ICO Information Centre on HPV and Cancer (HPV Information Centre); 2015., ¹⁹19 Asulin Y, McCann TJ, McCarty CW, Hage RW, Rooney PJ, Macpherson CN. Cancer incidence and mortality in Grenada 1990–2000. West Indian Med J. 2004;53:368–73.). The rates for the previous decade may not be truly representative due to small sample size (as noted above, these two studies cannot be directly compared). The WHO estimates cervical cancer mortality for the Caribbean at 10.6 per 100 000. This study finds prevalence rates in Grenada nearly twice as high as in developing countries and globally, and almost four times the rate reported for a similar ethnic group in the United States, highlighting the severity of disease and the burden associated with cervical cancer in Grenada.

Cervical cancer screening has been shown to be simple to perform, fast, and inexpensive, and has significantly contributed to disease reduction where effectively implemented (⁵5 Luciani S, Prieto-Lara E, Vicari A. Providing vaccines against human papillomavirus to adolescent girls in the Americas: battling cervical cancer, improving overall health. Health Aff (Millwood). 2011;30: 1089–95., ³⁹39 Richards C. Assessment of Knowledge and Attitudes of Women in Grenada towards Cervical Cancer. St. George’s: St. George’s University; 2001., ⁴⁰40 Kitchener HC, Castle PE, Cox JT. Chapter 7: Achievements and limitations of cervical cytology screening. Vaccine. 2006;24 Suppl 3:63–70.–⁴¹41 de Cremoux P, Coste J, Sastre-Garau X, Thioux M, Bouillac C, Labbe S, et al. Efficiency of the hybrid capture 2 HPV DNA test in cervical cancer screening. A study by the French Society of Clinical Cytology. Am J Clin Pathol. 2003;120:492–9.). Historically, women in the Caribbean (including Grenada) have not participated in routine Pap tests. One regional study from Jamaica indicated that 90% of women who died of cervical cancer were never screened, and most women who had heard of the Pap smear believed it was for the sole “purpose of detecting rather than preventing cervical cancer” (⁴²42 Bourne PA, Charles CAD, Francis CG, South-Bourne N, Peters R. Perception, attitude and practices of women towards pelvic examination and pap smear in Jamaica. North Am J Med Sci. 2010;2:478–86., ⁴³43 Fletcher H. Screening for cervical cancer in Jamaica. Caribb Health. 1999;2:9–11.). Screening options such as the Pap smear are available in Grenada and cost-free in outpatient clinics. In spite of this, many women do not go in for regular visits or consultations due to stigmas and taboos associated with pelvic examinations and disease affecting the genital region (³²32 National Cancer Institute. Cervical Cancer Screening 2013 [accessed April 16, 2013]. Available from: http:www.cancer.gov/
http:www.cancer.gov/... , ⁴⁴44 Perrotte N, Gomez A, Mason G, Stroup D. An assessment of knowledge, attitudes and behaviour regarding the human papillomavirus. West Indian Med J. 2012;61:58–63.); this could, in part, explain the high rates of cervical cancer observed in this study.

Limitations of this study include the potential for misclassification of mortality arising from variations in the interpretation and reporting of causes of death by physicians on death certificates (⁴⁵45 Bingham J. One in four deaths ‘not properly recorded’. The Telegraph. 2012 Aug 10.). Moreover, the return to Grenada of retirees from the baby-boomer generation and the fact that some locally-diagnosed patients leave Grenada to pursue treatment abroad, could each affect the accuracy of estimates of cervical cancer and associated mortality. Another limitation is the lack of a random sample of the population, as data was retrospectively gathered from records of patients seeking medical care. Accordingly, these results may not accurately represent the general population of women in Grenada; cervical cancer rates may be different than observed in this assessment. Despite these limitations, the cervical cancer prevalence and associated mortality rates presented in this study, abstracted from all available hand-written documentation on the island, are novel for Grenada.

Conclusions

The prevalence of cervical cancer and associated mortality during 2000–2010 in Grenada are considerably higher than in both developed countries and in WHO estimates for the region. With more than 50% of Grenada’s population at risk, it is of vital importance to promote and encourage awareness, cervical cancer screening, education, and uptake of vaccination programs. The onus lies on policymakers, healthcare providers and researchers in Grenada to create a comprehensive screening and prevention program to reduce cervical cancer and its devastating effects.

If left unaddressed, the current situation could have profound implications for the quality and sustainability of life of women in Grenada. An effective, active screening and vaccination program should be introduced as quickly as possible. HR-HPV testing and HPV vaccination are not yet available in Grenada; implementation of both these cervical cancer reduction measures should be a priority. Additionally, adding measures to ensure patient compliance and cervical lesion/disease management, and introducing more qualified specialists on the island to provide expert consultations for advanced stage disease would help reduce the current burden of cervical disease. Together, these policy measures would reduce the future burden of HPV-associated disease, including cervical cancer, and its associated healthcare costs in Grenada.

Acknowledgment

The authors would like to acknowledge the members of the Histopathology Lab at the General Hospital, St. George’s Grenada, and Dr. Alister Antoine and his team from The Ministry of Health for accessing the medical data for this project. They would also like to thank the Department of Microbiology for its support and scholarship award to complete this study.

Conflicts of interest

None.

Disclaimer

Authors hold sole responsibility for the views expressed in the manuscript, which may not necessarily reflect the opinion or policy of PAJPH and/or PAHO/WHO.

REFERENCES

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