TREND AMONG DOCTORS REGARDINGTHEIR OWN CERVICAL CANCER SCREENING

Background: Cervical cancer can be prevented, by regular screening by a test, called Pap smearand the most important risk factor for cervical cancer is “never having been screened”. Screening for cancer of the cervix remains a neglected health care issue in Pakistan. Objective: To assess the practices/ trends and attitude about personal Pap smear among female doctors working in field of obstetrics and gynecology. Study Design: Cross sectional descriptive study Place of study: Obstetrics and Gynaecology Department, Lahore General Hospital Lahore. Methodology: Five hundred lady doctors working in field of obstetrics and gynaecology were interviewed using a questionnaire. Data collected was analyzed by SPSS version 10. Results: Only 3.60% of lady doctors ever had Pap smear and 1.40% had regular Pap smear.Mean age of respondents was 36 year. Only 08%were of parity more than five, mean age of marriage was 26 years and 1.4% were married twice. Oralcontraceptive pills user were 14.6%.The most common reasons of not having Pap smear were embarrassment (16%), busy schedule and considering that they do not have risk of cervical cancer (14 %)and lack of counseling / reminder (11.20%). Conclusion : Female health professionals working in the field of obstetrics and gynaecology have negligible uptake of cervical cancer screening for their own selves despite being exposed to some of theimportant risk factors for carcinomacervix, which reflects their perception regarding importance of cervical cancer screening for women’s well-being. The results of this study may serve as a baseline for future comparisons. A larger community-based study may establish the exact trend, and will guide further planning in this regard


INTRODUCTION
Cervical cancer is the fourth most common cancer worldwide, with 528000 new cases and 266000 deaths in year 2012. Globally 85% of disease burden is in less developed countries. [1] WHO project for cancer-related research, reveals that in Pakistani women, cervical cancer incidence is 19.5 per 100,000 in 2008 as compared to less than 9 per 100,000 in2002. The same study shows deaths from the cancer at 12.9 per 100,000 [2] The incidence of cervical cancer in Pakistan is lower than in various western countries, but the mortality is higher. This higher rate of mortality is attributed to the late presentation. [3] Cervical cancer constitute a disease continuum ranging from cervical intra-epithelial neoplasia (CIN) grades I, II and III to micro invasive and finally fully invasive cancer.The long premalignant period provides an opportunity for screening and treating before it turns to be invasive [4] Pap smear is universally accepted screening test. Survival rates for cancer of the uterine cervix have improved over the last 40 years largely because of the impact of screening. [5] The morbidity and mortality due to cervical cancer has come down drastically in countries with wellestablished screening programs [6] .It has been shown that the degrees to which the incidence rate falls in a population is related to the percentage of the population that has been screened and length of the screening interval.
In low resource settings accessibility for preventive program is low. Currently cervical cancer screening coverage is only 1.9% in Pakistan. [7] In another study, it was reported that only 5 percent of women in Pakistan were aware of screening and only 2.6 percent of women actually had Pap smear once in a lifetime [8] Objective of this study was to find out the trend among Obstetricians and Gynaecologists regarding their own Cervical Cancer screening and the reasonsbehind underutilization ornon-utilization of this simple but effective tool. This will reflect upon their conviction regarding importance of Pap smear. Sothat health care providers and healthcare seekers both remain healthy, hurdles are identified and removed by remedial measures.

Methodology
This cross-sectional descriptive study was conducted in the Department of Obstetrics and Gynaecology, Lahore General Hospital, Lahore in year 2011.
The study population consisted of married doctors practicing Gynae and obstetrics who gave voluntary informed consent. Subjects who had gynecological malignancy or hysterectomy were excluded from study.
We interviewed a total of 500 medical doctors regarding cervical cancer screening. Confidentiality of the subjects was maintained by not disclosing the identity and their privacy was also maintained during interview.
The predesigned proforma was used to collect data.Questionnaire consisted of three sections. The first section was ofdemographic data. Second section was regarding the practices aspect if the subjects ever had Pap smear, frequency and the interval from lastsmear. Third section was related to barriers and reasons of irregularity or no screening.
The data was analyzed by Statistical analysis Computer software SPSS version. 10.The demographic and outcome variables were summarized in form of proportions and percentages

RESULTS
A total of 500 doctors completed the Questionnaire. The data collected on the Proforma was analyzed. The demographic information revealed that majority of the respondents were between age 20-39 year (81.20%)with mean age of 36 years.only 8% of cases were of Parity >5, all were Muslims.61% of the subjects were having postgraduate qualifications in the field of Obstetrics&Gynecology. About 5%of the subjectswere married before 20 years and mean age at marriage was 26 -years and1.5% were married twice. Only 38%.of the couples used barrier method of contraception,whereas 14.6% used Oral Contraceptive Pills and2% were smokersas well. (Table I).

DISCUSSION
Cervical cancer is preventable by detection of precancerous lesions by an effective screening strategy. Papanicolaou and Trout first proposed cytological evaluation of cells obtained from the cervix in 1940's as a method of detection of cervical cancer and its precursor lesions. Since that time cervical cytology has proved to be the most efficacious and cost effective method of cancer screening. The reason that Papanicolaou smear screening is so effective in preventing cervical cancer is that a pre cancer lesion precedes the majority of cancers.
In developed countries national cervical screening program are implemented which recommends and encourages women to have Pap smear regularly but this concept is nonexistent in under resourced countries, where main focus is on prevention and treatment of infectious diseases, like Diarrhea, Respiratory tract infections, Measles, Dengue, Tuberculosis. Only opportunistic screening are carried out which can hardly contribute in decline of this disease and its associated morbidity and mortality.
This study was aimed to find out the practices of Pap smear and to identify the reasons for not beingscreened for carcinoma cervix among the health care providers working in the field of obstetrics and gynecology, Overall majority of the doctors remained unscreened and there was no association between being knowledgeable about screening methodology and screening practices.
Only 03.60% health professionalshad Papsmear onceand 1.40% had regular uptake of test. Thususe of Pap smear is disappointingly low among health care providers who are working in the field of Obstetrics and Gynaecology. The subjects being women, are exposed to most of the risk factors for cervical cancer as do other women in the community, most important of which is not having cervical screening. Besides they have to play a crucial role in public health education .Unless they are convinced of the importance of cervical cancer screening, (proof of which is their own participation in this screening program) how can they be effective counsellors for the same? There is an urgent need to address this problem among health professionals. It is suggested that by practically participating in a regular screening program they will become a role model, which is easy for others to follow and their own health will be ensured at the same time. This will also add passion to their teaching/ counseling / motivation of medical / paramedical staff specifically and women in general.
The most common reasons of not having Pap smear were embarrassment (16%), busy schedule and considering that they do not have risk of cervical cancer (14%) and lack of counseling / reminder (11.20%) A study conducted in India reveals that 70%of health professionals never had pap smear; most common reasons being not thought about it (28.6%) or no time for it (17.8%). but uptake was higher than our results although the subjects of this study was nurses in contrast to our group of doctors working in field of gynaecology. [9] Similar findings of surprisingly low uptake of cervical screening are shared by authors who have conducted studies on utilization of cervical screening services by health workers. [10][11][12][13] From the literature review, the most common reasons in women who avoid Pap smear were fear of vaginal examination, embarrassment and no concern of being at risk [14][15][16][17][18][19] Women's perceived susceptibility to cervical cancer predicts their screening behavior. Some important risk factors for the development of most cervical carcinomas are considered tobe oncogenic types of HPV. Other risk factors for CIN include, early age atmarriage, multiple marriages of self or spouse,multiparity, prolonged use of contraceptives and smoking [20] After scrutinizing the demographic details of the subjects under study it is evident that some of the important risk factors are present in them as well.
About 14% of our subject did not consider themselves at risk of cervical cancer in contrastto 30% as quoted by Aneya. [21] . Denial (as when someonethinks that such medical problem cannot happen to her as she is not at risk) can be categorized as the root cause of the cases of the cancers that present late and at a stage when hope for cure is far from reality.Hence this attitude of denial can end up in the catastrophe of invasive cancer in healthcare providers.
Cost of Pap smear was a reason of not being screened in 2% of subjects in this study,this was a problem faced by doctors who wanted to be screened at best private facility (cost was reported to be Rs 5000 per test),whereas Pap test costs merely Rs 100 ( less than even one dollar) in public sector healthcare facility. This was a barrier in 16% of cases in Georgian physicians as well. [22] The findings showed that major structural barriers were time factorsalong withlack of reminders. The main psychosocial barriers were embarrassment and denial.
The limitation of this study is that it is a small descriptive study which cannot be a true representative of all the lady doctors in this field. Further multicenter research on this subject is required to explore the frequency of uptake of cervical cancer screening and reason of not opting for this cheap, simple and effective and easily available test despite being knowledgeable and working in health facilities.

CONCLUSION
The present study concludes that attitudes and practices of the health professionals working in the field of gynaecology towards screening were negative, despite having knowledge of the gravity of cervical cancer and prevention by screening, using a Pap smear. The medical workers who should be responsible for opportunistic screening of women they care for, are not keen on getting screened themselves.

Suggestions:
There is need to understand and explainthe reasons of these attitudes and practices and identify possible interventions to change them.
The situation calls forreview of curricula of undergraduate and post graduate trainees to lay emphasis on preventive aspect of gynaecology and practical skills on cervical cancer screening so that young doctors are equipped with adequate knowledge and skills to be able to effectively screen women for cervical cancer wherever they go to practice Regular three yearly mandatory screening of Healthcare providers regarding cervical cancer should be ensured by reminder calls at national level.
There is alsoan urgent need to introduce systematic screening against cervical cancer and treatment of precursor lesions at all levels of health care delivery system in Pakistan. A national policy guideline should be urgently drawn addressing specifically frequency of screening and at what age to start screening.