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Knowledge and Awareness on Cervical Cancer and Its Prevention amongst Women in a Tertiary Care Hospital in Dhaka, Bangladesh Introduction Worldwide, cervical cancer is one of the most common malignancies amongst women. 1 Cervical cancer is caused by a change in the cells that line the wall of the cervix (the lower part of the womb which connects the uterus to the vagina, or birth canal). These cells begin as normal, and then gradually change to precancerous cells, which appear as lesions on the cervical wall. The cells may eventually become cancerous, however in over 50% of women with pre-cancerous lesions, the cells remain benign (pre-cancerous). Early cervical cancer generally produces no signs or symptoms. Early signs may include abnormal vaginal bleeding, especially irregular heavy bleeding, bleeding after menopause, bleeding or spotting between periods, bleeding after sexual intercourse, pelvic (lower abdominal), pain or pressure on the bladder or rectum, unexplained bladder irritation, and unexplained vaginal discharge (particularly when it is thick or foul-smelling). The most common risk factor for cervical cancer is exposure to certain strains of the Human Papilloma Virus (HPV). HPV is a sexually transmitted infection (STI), which may or may not be accompanied by symptoms because HPV is often asymptomatic; it can go for long periods without being detected. Other co-factors such as multiple sexual partners of the male as well as the female and early age of first intercourse are also involved at the critical etiological step of progression from low-grade to high-grade lesions. Other risk factors include cigarette smoking, oral contraceptive usage, certain nutritional deficiencies and poor personal hygiene. However, there is no consistency in the independent effect of these factors on the development of low-to-high grade lesions of cervix. There is a similarity in the patterns of risk between pre-cancerous lesions of the cervix and cervical cancer. The World Health Organization (WHO) recognizes two main histological types of invasive cancer, Squamous-Carcinoma (which constitute about 85% of all cases) and AdenoCarcinoma (which constitute about 10-12% of all cases). Several other types of carcinoma e.g. Adenosquamous Carcinoma, Adenoid Cystic Carcinoma, Metastatic Carcinoma make up the remaining 3-5% of all cases. Epidemiologists working in the early 20th century noted that cervical cancer behaved like a sexually transmitted disease. In summary: •

Cervical cancer was common in female sex workers.

It was rare in nuns, except for those who had been sexually active before entering the convent. (Rigoni in 1841)

It was more common in the second wives of men whose first wives had died from cervical cancer.

It was rare in Jewish women.

In 1935, Syverton and Berry discovered a relationship between RPV (Rabbit Papilloma Virus) and skin cancer in rabbits. (HPV is species-specific and therefore cannot be transmitted) to rabbits

This led to the suspicion that cervical cancer could be caused by a sexually transmitted agent. Initial research in the 1940s and 1950s put the blame on smegma (e. g. Heins et al. 1958). During the 1960s and 1970s it was suspected that infection with herpes simplex virus was the cause of the disease. It was not until the 1980s that human papillomavirus (HPV) was identified in cervical cancer tissue. Cervical cancer is one of the leading causes of morbidity and mortality amongst the gynecological cancers worldwide. In today's world, cervical cancer is primarily a disease found in low-income countries. Of the nearly 500,000 new cases that occur annually, 83% are in the developing world, as are 85% of the 274,000 deaths associated with cervical cancer. In the United States in 2010, approximately 12,200 women were expected to be diagnosed with cervical cancer, and 4,210 women were expected to die. Assuming no change in risk, approximately 0.68 percent of women born today will be diagnosed with cervical cancer at some time during their lifetime, and the risk of dying from the disease is 0.24 percent. The incidence of cervical cancer and associated mortality has both decreased by over 40 percent since 1973. Cervical screening programs have reduced the incidence mortality of cervical cancer dramatically in many different places as well, e.g., British Columbia, Aberdeen Scotland, Cali Columbia, Nordic European countries, and more recently Chile. Cervical cancer which affects lower third of uterus (also called cervix) is the most common cancer in women in Bangladesh. It constitutes about one fourth of the total number of female cancers patient in Bangladesh. An estimated about 13,000 new cases and 6600 deaths occur every year in Bangladesh. Most of these deaths are preventable if they would be detected early. Cervical cancer can be detected by different screening tests called Pap smear test and HPV test, Visual Inspection of Cervix with Acetic Acid (VIA). Among the methods, VIA has been introduced by the Government of Bangladesh to screen mass population due to its cost effectiveness and easy to use method. Most women with cervical cancer experience a long asymptomatic period before the disease becomes clinically evident. Therefore, early recognition of abnormal cytologic changes through regular screening may prevent progression from pre invasive to invasive disease. Identifying women at risk for developing invasive cervical cancer enables physicians to appropriately select patients who require continual screening rather than annual screening. Lack of knowledge and awareness is definitely a key reason for the higher rate of cervical cancer incidence in developing countries. It has been estimated that only about 5% of women in developing countries have been screened for cervical dysplasia in the past 5 years, compared with 40% to 50% of women in developed countries. Cervical cancer prevention efforts worldwide have focused on screening women at risk of the disease using Papanicolaou (Pap) smears and treating precancerous lesions. Where screening quality and coverage have been high, these efforts have reduced the incidence of invasive cervical cancer by as much as 90%. Justification Every citizen has the right to enjoy the highest possible level of health care and every woman has the right to maintain her reproductive health. Cervical cancer is an important reproductive health problem in Bangladesh. Most of the cancer patients in Bangladesh usually attend in the hospital in an advanced stage, resulting in the decrease of survival and the increase of mortality rate. So it can be said that cervical cancer is one of the most rapidly growing public health problem causing a huge health and economic loss to the community and the country as a whole.

The present study is designed to ascertain some risk factors with special focus on cervical cancer. Early marriage, early age of first pregnancy, too many and repeated child birth, poor socio- economic status have been associated with the increasing risk of cervical cancer. Fortunately, it is possible to detect it early during a pre-invasive curable stage by the Pap smear test and take measures to prevent it from progressing into a life threatening illness. There is lack of information about what Bangladeshi women know about cervical cancer and what approach to screening for cervical cancer is feasible and acceptable. Secondary prevention i.e. early detection and treatment still remains the main strategy to control this cancer. Along with little information on incidence and mortality due to cervical cancer in Bangladesh, very little is known about the factors influencing preventive screening behaviors. In order to combat any disease, it is a must to collect the most recent data regarding the disease along with initiating intelligent strategies of action. Through this research it would be possible to get equipped with the most up-to-date knowledge to fight cervical cancer in the context of Bangladesh. OPERATIONAL DEFINITION Cervical Cancer Cervix is a female reproductive organ that forms the lower portion of the uterus or womb. The surface layer of the cervix is mostly composed of squamous cells. The squamous cells of the cervix merge with the glandular cells lining the cervical canal of the uterus. The area of merging is called the squamo-collumnar junction and the area on the cervix outside the junction is called the transformation zone. Cervical Cancer occurs when cervical cells grow out of control, typically in the transformation zone. These cells don’t suddenly change into cancer. Instead, the normal cells of the cervix first gradually develop pre-cancerous changes that turn into cancer. Invasive Cancer Cervical cancer is when cancer cells develop in the lining of a woman’s cervix. It does take time for cervical cancer to develop which is why early screening is important. When cancer develops normal cells begin to deform and change into abnormal cells or cancer cells. If abnormal cells spread deeper into the cervix or to the other tissues or organs, the disease is then called invasive cervical cancer. Cervix Cervix is a female reproductive organ that forms the lower portion of the uterus or womb. The uterus and cervix lie in the pelvis, on top of the vagina, in between the rectum and bladder. The cervix forms the part of the birth canal that opens to the vagina. HPV HPV stands for human papillomavirus. There are more than 100 types of HPV. About 40 types of HPV can infect the genital area. Genital HPV infections are very common. HPV is so common that about half of all men and more than 3 out of 4 women have HPV at some points in their lives. Most HPV infections have no harmful effect at all and go away by themselves. These are called low- risk types of HPV. But high risk types of HPV don’t go away over many years and increases the risk of cervical cancer. Abnormal cells can develop

when high risk types of HPV don’t go away. If these types of cells are not detected and treated, they can lead to cervical cancer. Cervical intraepithelial neoplasia Cervical cancer develops in the lining of the cervix, the lower part of the uterus that enters the vagina. This condition usually develops overtime. Normal cervical cells may gradually undergo changes to become precancerous and then cancerous. Cervical intraepithelial neoplasia (CIN) is the term used to describe these abnormal changes. CIN is classified according to the degree of cell abnormality. It has following stages: Stage 0: Precancerous lesion involves only the cells on the surface of the cervix. Stage I: Cancer is confined to the cervix, and may be evident only under microscopic evaluation (stage IA) or apparent by visible or physical examination (stage IB). Stage II: Cancer spreads beyond the cervix to involve the tissues surrounding the cervix or the upper portion of the vagina. Stage III: Cancer spreads beyond the cervix to the lower vagina or to the sides of the pelvis, or causes a blockage of drainage from the kidney, a condition called hydronephrosis. Stage IV: Cancer invades structures adjacent to the cervix such as the bladder or rectum or spreads to the other parts of the body such as the liver or lungs. Pap smear The Pap smear is a method of examining cells from the cervix. The cervix is located at the lower end of the uterus. To perform a Pap smear, a doctor or nurse will perform a pelvic exam and use a small brush or spatula to collect cells from the cervix. The cells are smeared on a glass slide (called a traditional Pap smear) or added to a preservative fluid (called liquidbased, thin layer testing). VIA Screening VIA involves inserting a vaginal speculum and swabbing the cervix with 3% to 5% acetic acid solution before doing a cervical inspection. Normal squamous epithelium is light pink in color and the columnar epithelium is red. CIN lesions will turn white for a few minutes after application of acetic acid. The effect of acetic acid is thought to depend on the amount of nuclear proteins and cytokeratins present in the cervical epithelium, which increases in CIN. The health care provider doing the test identifies one of the three categories for results: the test is positive with an acetowhite area present (VIA-positive), negative with no acetowhite areas (VIA-negative), or suspicious for cervical cancer. LITERATURE REVIEW The proposed study of literature has mostly been reviewed from the online reports published in relevant sites. The gathered information can be arranged into basic information on cervical cancer, its country scenario and global aspects, the study designs and measuring tools used in other reputed studies to assess the level of knowledge and awareness on cervical cancer and its prevention. Approximately 13,000 new cases of cervical cancer and 4,100 cervical cancer-related deaths were projected to occur in 2002 in the United States. Rates in the U.S. have decreased from

14.2 new cases per 100,000 women in 1973 to 7.8 cases per 100,000 women in 1994. Despite falling incidence, cervical cancer remains the tenth leading cause of cancer death.21 The Healthy People 2010 target for cervical cancer is a reduction in mortality to 2.0 deaths per 100,000 women. Since 1998, the rate remains near 3.0 deaths per100, 000 women. 22 Incidence and mortality in cervical cancer have decreased quite substantially, particularly in more developed countries, where there are long-standing screening programmes. Decreases are also seen in some less developed countries, particularly in China where the estimated agestandardized incidence rate in 2000 was 5.2, compared with an estimated 17.8 in 1985.23Although some of the differences reflect changing data sources, cancer-registry results also indicate a fairly dramatic decrease in rates in recent years. 24As a result of these trends, cervical cancer has ceded its place as the leading cancer in less developed countries to breast cancer, and only in sub-Saharan Africa, Central America, south-central Asia, and Melanesia is it now the main cancer of women. Bangladesh has a population of 50.19 million women ages 15 years and older who are at risk of developing cervical cancer. Current estimates indicate that every year 17686 women are diagnosed with cervical cancer and 10364 die from the disease. Cervical cancer ranks as the 2nd most frequent cancer among women in Bangladesh, and the 2nd most frequent cancer among women between 15 and 44 years of age. Data is not yet available on the HPV burden in the general population of Bangladesh. However, in Southern Asia, the region Bangladesh belongs to, about 7.9% of women in the general population are estimated to harbour cervical HPV infection at a given time.25 HPV plays a central role in the development of cervical cancer. Using modern HPV detection methods, 95% to 100% of squamous cell cervical cancer and 75% to 95% of high-grade CIN lesions have detectable HPV DNA.26-28 HPV is a double-stranded DNA virus. The virus is transmitted to the cervix and vaginal tissues primarily by sexual intercourse. 29, 30 HPV can infect and persist in vulvar, vaginal, and cervical tissue throughout a lifetime. This family of viruses includes those responsible for genital condylomata or warts, squamous cell carcinomas of the genital tract including vaginal and vulvar cancers, and cervical cancer. More than 70 strains or types of HPV have been classified. The best characterized types associated with cervical cancer are Types 16 and 18. 31These are officially recognized by the International Agency for Research on Cancer (IARC) and the World Health Organization (WHO) as carcinogenic infectious agents. HPV is a necessary but not sufficient precursor of squamous cell carcinoma of the cervix. Among women without cervical cytology abnormalities at baseline, those with high-risk HPV types have a relative risk of developing high-grade cervical lesions (CIN 2 - 3, CIS) that is 58- to 71-fold higher than the risk for those without detectable HPV.32, 33 In a recent study, more than 99% of cases of cervical cancer worldwide were estimated to contain HPV DNA. The virus infects the cells of the cervix and slowly causes precancerous cellular changes (dysplasia) that can progress. These cellular changes can be relatively mild and often do not progress or may regress.34Larger, deeper lesions (severe dysplasia) are more likely to progress to cancer.35,36 Women generally are infected with HPV in their teens, 20s, or 30s; it can take as long as 20 years after HPV infection for the cancer to develop. Cervical cancer starts with an in situ stage that can be treated, but it then progresses to invasive disease that is always fatal in countries where appropriate surgery and radiotherapy are unavailable. The risk of developing carcinoma of the cervix in women infected with human papillomavirus (HPV) was estimated in a nested case-control analysis of 33 cancers (invasive and in situ) and 113 controls, matched by age and sex, from an ongoing cohort study of

lifestyle and cancer in a rural population of Northeast Thailand. Oncogenic HPV types were present in 10.8% of control women and in 31/33 of the carcinoma cases, corresponding to an odds ratio of 130.6 (95% CI 11.7-1457.0). There was no significant difference in risk between prevalent cancer cases (diagnosed less than 3 months after HPV testing) and incident cases (diagnosed an average of 2.1 years later). HPV 16 and 18 were the most prevalent Oncogenic HPV types present. The results confirm that some two of three of cervical cancer cases in this population of Northeast Thailand are caused by HPV 16 and 18.37 Persistent high-risk type Human papillomavirus (HPV) infection is recognized as a necessary cause of cervical cancer. This study aimed to compare the HPV prevalence and risk factors between women residing in Hong Kong (HK) and Guangzhou (GZ) region of China. A total of 1,570 and 1,369 women were recruited from HK and GZ, respectively. The cytology samples were collected and tested for HPV infection. The overall and type-specific HPV prevalence and the potential risk factors for acquisition of HPV infection were studied. Women with normal cytology in the GZ cohort had significantly higher HPV prevalence (10%) than those in the HK cohort (6.2%, p<0.001). The patterns of the age-specific HPV prevalence were also different between the two cohorts. In the HK cohort, women at the age of 20-29 years old had the highest prevalence and a second peak was observed in the age of ≼60 years old. In the GZ cohort, the highest HPV prevalence was also observed in 20-29 years old but declined as the age increased and a second peak was not seen. HPV16 and HPV52 were the most common high-risk types found in the HK and GZ cohorts, respectively. Age was the most consistently observed independent risk factor for HPV infection in the HK, while the number of sexual partners had association in the GZ cohort. The study provides the current status and the epidemiological characteristics of HPV prevalence in Southern Chinese women. The results strongly suggested that population education and the effective cervical cancer screening would be vital in the prevention of cervical cancer.38 In many ways, cervical cancer behaves as a sexually transmitted disease. The major risk factors are multiple sexual partners and early onset of sexual activity. Although high-risk types human papillomaviruses (HPVs) play an important role in the development of nearly all cases of cervical cancer, other sexually transmitted infectious agents may be cofactors. Herpes simplex virus type 2 (HSV-2) is transmitted primarily by sexual contact and therefore has been implicated as a risk factor. Several independent studies suggest thatHSV-2 infections correlate with a higher than normal incidence of cervical cancer. In contrast, other epidemiological studies have concluded that infection with HSV-2 is not a major risk factor. Two separate transforming domains have been identified within the HSV-2 genome, but continued viral gene expression apparently is not necessary for neoplastic transformation. HSV infections lead to unscheduled cellular DNA synthesis, chromosomal amplifications, and mutations. These observations suggest that HSV-2 is not a typical DNA tumor virus. It is hypothesized that persistent or abortive infections induce permanent genetic alterations that interfere with differentiate of cervical epithelium and subsequently induce abnormal proliferation. Thus, HSV-2 may be a cofactor in some but not all cases of cervical cancer.39 High parity has been suspected of being associated with an increased risk of cervical cancer for decades.40 Confounding with sexual behavior, specifically with age at first sexual intercourse, was, however, thought to account for the apparent adverse effect of multiparity. 41 Nevertheless, results of a few case-control studies of cervical carcinoma confirmed an independent role for high parity after allowance for several indicators of sexual habits: the risk of cervical cancer was increased by more than two-fold in women who had four children or more compared with those who had one or none. 42,43 Information about the role of

interrupted pregnancies and various menstrual factors in the cause of cervical cancer is less abundant, but what evidence there is suggests that these variables have little effect, if any. Age at marriage has been recognized as a major risk factor associated with cervical cancer. Over the past 8 decades there has been a rise in age at marriage varying from 14 years in 1901 to 18 years in 1981. Consequently the proportion of women married in the age group 15-19 years has fallen from 88% in 1941 to 45% in 1981. It has been attempted to study the effect of change in proportion married below 17 years on cervical cancer incidence for the year 1985 in India. The proportion of married women in the age group 15-19 years was constant around 88% from 1901-41 and from 1951 onwards the reduction in the proportion married has been observed. During the last 35 years, after the start of reduction in the proportion married in the age group (15-19) years, a reduction of 2097 cervical cancer cases or 6.3 percent reduction in the incidence of invasive cervical cancer is observed. It may be postulated that it will take a long time to expect a significant reduction in the incidence of cervical cancer if the primary prevention of rising the age at marriage above 18 years is adopted as a strategy for control of cervical cancer. Evidence shows that long-term use of OCs (5 or more years) may be associated with an increased risk of cancer of the cervix (the narrow, lower portion of the uterus). Although OC use may increase the risk of cervical cancer, human papillomavirus (HPV) is recognized as the major cause of this disease. Approximately 14 types of HPV have been identified as having the potential to cause cancer, and HPVs have been found in 99 percent of cervical cancer biopsy specimens worldwide. A 2003 analysis by the International Agency for Research on Cancer (IARC) found an increased risk of cervical cancer with longer use of OCs. Researchers analyzed data from 28 studies that included 12,531 women with cervical cancer. The data suggested that the risk of cervical cancer may decrease after OC use stops. 46 In another IARC report; data from eight studies were combined to assess the effect of OC use on cervical cancer risk in HPV-positive women. Researchers found a fourfold increase in risk among women who had used OCs for longer than 5 years. Risk was also increased among women who began using OCs before age 20 and women who had used OCs within the past 5 years.47 The IARC is planning a study to reanalyze all data related to OC use and cervical cancer risk. Overall, cervical cancer is relatively uncommon in the developed countries of the world, where intensive screening programs are in place. Since the advent and widespread use of screening Papanicolaou (Pap) smears, which detect asymptomatic pre invasive lesions at the earliest stages, the incidence of cervical cancer has dramatically decreased from 32 cases per 100,000 women in the 1940s to 8.3 cases per 100,000 women in the 1980s. 48 Detection of cervical cancer in its earliest stages is lifesaving, as survival of cancer of the cervix uteri depends heavily on stage at diagnosis. Although 92% of women will survive 5 years when the cancer is localized, only 13% will survive distant disease.49 Introduction of screening programs to populations na誰ve to screening reduces cervical cancer rates by 60% to 90% within 3 years of implementation. 50,51 This reduction of mortality and morbidity with introduction of the Pap test is consistent and dramatic across populations. Although no prospective trial of Pap screening has ever been conducted, correlation studies of cervical cancer trends in countries in North America and Europe demonstrate dramatic reductions in incidence of invasive cervical cancer and a 20% to 60% reduction in cervical cancer mortality. The human papillomavirus (HPV) deoxyribonucleic acid (DNA) test is currently recommended for use in cervical cancer screening.52 Squamous cell carcinoma of the cervix

and its cytologic precursors occur among women who are sexually active. Infection with high-risk types of HPV, acquired sexually, is the most important risk factor for cervical cancer. Based on sensitive HPV detection methods, 95 to 100 percent of squamous cell cervical cancer and 75 to 95 percent of CIN2-3 lesions have detectable HPV DNA. 53,54 In the United States, peak incidence and prevalence of HPV infection occur among women younger than age 25 years,55-57 but most infections in younger women are transient. HPV infections in older women are much less prevalent, but may carry a higher risk of progression to cervical neoplasia.58 As such, the American Cancer Society currently recommends that HPV testing be limited to women aged 30 years and older as part of a strategy of combination screening with cytology. 52 HPV DNA tests currently approved for use in the United States include the Cervista HPV HR (Hologic, Inc., Bedford, MA), the Cervista HPV 16/18 (Hologic, Inc., Bedford, MA), and the Hybrid Capture 2 (HC2) high-risk HPV DNA test (Qiagen Inc., Germantown, MD). In its previous recommendations, the USPSTF concluded that the evidence was insufficient to recommend for or against the routine use of HPV testing as a screening test for cervical cancer, although the U.S. Food and Drug Administration approved the use of HPV DNA testing for triage of atypical squamous cells of undetermined significance (ASC-US) or in conjunction with cytology for women aged 30 years or older. Quantifying the harms and benefits of HPV testing in order to inform any changes to the existing recommendations is one focus of this report. For the purposes of this report, HPV testing refers to use of the HC2 test only. Currently, the USPSTF recommends that women begin screening within 3 years of onset of sexual activity or at age 21 years (whichever comes first), and that screening be conducted at least every 3 years. 59 In terms of the age at which to end screening, the USPSTF recommendation states that screening should not be routinely recommended for women aged 65 years or older who have a history of normal Pap tests and are not otherwise at high risk for cervical cancer. Screening for cervical neoplasia in Bangladesh using visual inspection with acetic acid was offered by trained medical personnel to healthy women attending healthcare facilities in 44 districts. Colposcopy and/or directed biopsies were performed on VIA-positive women at Bangabandhu Sheikh Mujib Medical University (BSMMU) or medical college hospitals. The numbers of screened and VIA-positive women as well as the results of colposcopy, biopsy, and treatment of those with cervical intraepithelial neoplasia (CIN) attending BSMMU are reported. From January, 2005, to June, 2008, 104098 women underwent VIA screening. Among them, 5013 (4.8%) women were positive, of whom 4371 (87.2%) attended colposcopy clinics in different hospitals. Of the 2188 that underwent colposcopy at BSMMU, 157 were diagnosed with CIN 2-3 and 123 with invasive cancer. For 2065 women (excluding the cancer cases), results for sensitivity, specificity, and positive predictive value of VIA to detect CIN 2-3 lesions were 93.6%, 58.3%, and 15.6%, respectively. Almost half the women with CIN 2 or 3 lesions had treatment. A VIA-based program would facilitate the development of screening, diagnosis, and treatment of cervical neoplasia and improve awareness of cervical cancer prevention in Bangladesh. The awareness of, and the attitude towards screening for, cervical cancer in Bangladesh was performed using focus group discussions (FGD) in a study done by AC Ansika et al. The framework approach to qualitative analysis was used. The study was performed in the catchment areas of Addin Hospital, Jessore, Southern Bangladesh (peri-urban) and LAMB hospital, Parbatipur, North West Bangladesh (rural). A total of 220 men, women and adolescents participated in 28 FGDs. Awareness of cervical cancer was widespread. Knowledge about causes was often inadequate. The perceived consequences of cervical cancer were numerous and awareness of the need for cervical cancer treatment was present. Barriers to accessing care include: low priority for seeking help for symptoms, limited

availability of health services and cost. Most women were unaware of the possibility of screening via speculum examination, which was considered acceptable to women (and men), as long as the examination was done by a female healthcare provider in an environment with sufficient privacy. In conclusion, adequate gynaecological services are not available or accessible for most women in rural and peri-urban Bangladesh. However, awareness of cervical cancer is widespread. Screening for cervical cancer in these communities is acceptable if done by a female healthcare provider under conditions with sufficient privacy. The U.S. Food and Drug Administration (FDA) have approved two vaccines to prevent HPV infection: Gardasil速 and Cervarix速. Both vaccines are highly effective in preventing persistent infections with HPV types 16 and 18, two high-risk HPVs that cause most (70 percent) cervical cancers.62 Gardasil and Cervarix are highly effective in preventing infection with the types of HPV they target. Studies have shown that both Gardasil and Cervarix prevent nearly 100 percent of the precancerous cervical cell changes caused by the types of HPV targeted by the vaccine for up to 4 years after vaccination among women who were not infected at the time of vaccination.63-65 Widespread vaccination has the potential to reduce cervical cancer deaths around the world by as much as two-thirds, if all women were to get the vaccine and if protection turns out to be long-term. In addition, the vaccines can reduce the need for medical care, biopsies, and invasive procedures associated with follow-up from abnormal Pap tests, thus helping to reduce health care costs and anxieties related to abnormal Pap tests and follow-up procedures. Evidence on whether condoms protect against HPV infection is mixed, but they may protect against genital warts and the precursors to cervical cancer. They also provide protection against other STDs, such as HIV and Chlamydia, which are associated with greater risks of developing cervical cancer. Condoms may also be useful in treating potentially precancerous changes in the cervix. Exposure to semen appears to increase the risk of precancerous changes (CIN 3), and use of condoms helps to cause these changes to regress and helps clear HPV.68 One study suggests that prostaglandin in semen may fuel the growth of cervical and uterine tumors and that affected women may benefit from the use of condoms. Higher levels of vegetable consumption were associated with a 54% decrease risk of HPV persistence.71 A small (n~=500) case-control study of a narrow ethnic group (Native Americans in New Mexico) assessed serum micro-nutrients as risk factors for cervical dysplasia. Subjects in the lowest serum retinol quartile were at increased risk of CIN I compared with women in the highest quartile.72 However, the study population had low overall serum retinol, suggesting deficiency. A study of serum retinol in a well-nourished population reveals that the bottom 20% had serum retinol close to that of the highest levels in this New Mexico sub-population. Risk of type-specific, persistent HPV infection was lower among women reporting intake values of vitamin C in the upper quartile compared with those reporting intake in the lowest quartile.HPV clearance time was significantly shorter among women with the highest compared with the lowest serum levels of tocopherols, but significant trends in these associations were limited to infections lasting </=120 days. Clearance of persistent HPV infection (lasting >120 days) was not significantly associated with circulating levels of tocopherols. Results from this investigation support an association of micronutrients with the rapid clearance of incident oncogenic HPV infection of the uterine cervix. A statistically significantly lower level of alpha-tocopherols was observed in the blood serum of HPVpositive patients with cervical intraepithelial neoplasia. The risk of dysplasia was four times higher for an alpha-tocopherols level < 7.95 mumol/l.

Higher folate status was inversely associated with becoming HPV test-positive. Women with higher folate status were significantly less likely to be repeatedly HPV test-positive and more likely to become test-negative. Studies have shown that lower levels of antioxidants coexisting with low levels of folic acid increases the risk of CIN development. Improving folate status in subjects at risk of getting infected or already infected with high-risk HPV may have a beneficial impact in the prevention of cervical cancer.77,78 The likelihood of clearing an oncogenic HPV infection is significantly higher with increasing levels of lycopenes.79 A 56% reduction in HPV persistence risk was observed in women with the highest plasma [lycopene] concentrations compared with women with the lowest plasma lycopene concentrations. These data suggests that vegetable consumption and circulating lycopene may be protective against HPV persistence. STUDY OBJECTIVES GENERAL OBJECTIVE To assess the present level of knowledge and awareness on cervical cancer and its preventive practices among the women participated in the study. 2. SPECIFIC OBJECTIVES •

To describe the socio-demographic factors related to cervical cancer

To assess the knowledge about the incidence of cervical cancer

To find out the awareness about the importance of screening for cervical cancer

To assess the factors related to care-seeking centers of cervical cancer

To grow an attitude of preventive practice towards cervical cancer

To assess the effectiveness of a counseling program on cervical cancer in the health care facilities

3. CONCEPTUAL FRAMEWORK Independent variable

Dependent variable

Socio-demographic factors: Age, marital status, parity, occupation, education, family member, income etc. Education and knowledge on cervical cancer: Perceptions regarding cervical cancer, media, books, self education, social perspectives etc. Factors related to care-seeking center of cervical cancer: Availability, transport facility, provider’s behavior, provider’s experience, perceived quality of screening service etc.

Knowledge and awareness on Cervical Cancer Prevention

Attitude on preventive practice: Sexual behavior, preventive vaccination, screening etc.

STUDY DESIGN The study will be descriptive cross sectional and will be conducted among the women attending the outpatient department of the National Institute of Cancer Research & Hospital. PLACE OF STUDY The study will be carried out in National Institute of Cancer Research & Hospital situated in Dhaka, Bangladesh. It is the only specialized institute where cancer and suspected cancer patients come from all over the country. STUDY POPULATION The women coming to the institution will willingly participate in the research study. STUDY PERIOD The study will be conducted from June, 2011 to August, 2011.

SAMPLING TECHNIQUE Purposive sampling technique will be considered to include all available cases. INCLUSION AND EXCLUSION CRITERIA Inclusion Criteria Age limit 20-50 years Women who will give consent willingly Participant must be selected from the study area Exclusion Criteria Women who will be unwilling to take part in the interview. Age below 20 and above 50 years Women who may refuse to give consent Women who may be unable to give information SAMPLE SIZE The desired sample size will be estimated by the following criteria:

Where, n= Desired sample size z= standard normal deviate Usually set at 1.96 which corresponds to 95% CI P= Proportion of target population q= 1-p, 1-0.5= 0.5 d= degree of precision, usually at 5% For 95% level of confidence and 5% errors (to be allowed), the target sample size for p 50% was set at:

= 384 For convenience a total of 422 respondents would be selected. DATA COLLECTION TOOLS

A formatted questionnaire will be used as a data collection tool in the study. Pre-testing of the check list will be done to ensure its adequacy, appropriateness as well as collection of quality data. DATA COLLECTION METHOD Information will be collected directly by the researcher by interviewing the women coming to the outpatient department of the hospital. Data will be collected in every working day. Their verbal consent will be taken and the questionnaire will be filled out according to their response in order to get large amount of detailed information regarding their knowledge and awareness of cervical cancer and its prevention. DATA MANAGEMENT AND ANALYSIS When data collection field work will be completed, data will be checked again and verified for any omission or error and will also be corrected properly. The corrected data will be edited and processed manually by using SPSS computer program. All descriptive statistics will be done. Finally, appropriate statistical test such as chi-square test, z test will be applied where necessary. ETHICAL CONSIDERATION All respondents will be asked for their consent prior to participation in the research. All information will be kept anonymous and confidential and the respondent’s identity will never be disclosed or shared without their written permission. QUALITY CONTROL AND QUALITY ASSURANCE As the researcher will be analyzing the data, there will be least possibility of quality deviation and bias. The researcher will stay in the hospital regularly during work hours and will be responsible for providing workload and examining work performance. The researcher will monitor and supervise the process throughout the study. To ensure the quality of the data, specific measures will be taken before, during and at the end of the data collection period. LIMITATIONS OF THE STUDY •

All respondents may not give consent

Few respondents may refuse to continue the interview

It may take long time to complete the interview for all samples

Since the study will be done in Dhaka, so the result may not be a perfect reflection of the whole country

EXPECTED OUTCOME After the completion of this study, the depth of current knowledge and awareness regarding cervical cancer amongst women in Bangladesh would be very clear and evident to us. The acquired information can also be used to bolster and strengthen the preventive measures against cervical cancer. Despite all social barriers, women will be able to create a positive attitude towards cervical cancer. They will also be able to reduce the risk factors through early screening test and vaccination. It is expected that this study will be helpful to the

government as well as other organizations in fighting cervical cancer more effectively as well as efficiently.

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