Acharya College of Nursing

ACHARYA COLLEGE OF NURSING

CHOLANAGAR, BANGALORE-32

SYNOPSIS PRESENTATION ON

EFFECTIVENESS OF STRUCTURED TEACHING PROGRAMME ON KNOWLEDGE REGARDING PREVENTION OF CARCINOMA OF CERVIX AMONG WOMEN OF REPRODUCTIVE AGE GROUP (15-44 YEARS) IN SELECTED RURAL AREA AT BANGALORE.

SUBMITTED BY:-

MS. PUSPA REKHA KARN

M. SC. NURSING 1ST YEAR (OBG)

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,

BANGALORE, KARNATAKA

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

BRIEF RESUME OF THE INTENDED WORK:

“Woman is the only creature in nature that hunts down its hunters and devours the prey alive.”ABRAHAM MILLER.

6. INTRODUCTION

Cancer is the uncontrolled growth and spread of cells. It can affect almost any part of the body. The growths often invade surrounding tissue and can metastasize to distant sites. Many cancers can be prevented by avoiding exposure to common risk factors, such as tobacco smoke. In addition, a significant proportion of cancers can be cured, by surgery, radiotherapy or chemotherapy, especially if they are detected early.1

Cervical cancer is cancer that starts in the cervix, the lower part of the uterus (womb) that opens at the top of the vagina.Cancer that forms in tissues of the cervix (the organ connecting the uterus and vagina). It is usually a slow-growing cancer that may not have symptoms but can be found with regular Pap tests (a procedure in which cells are scraped from the cervix and looked at under a microscope). Cervical cancer is almost always caused by human papillomavirus (HPV) infection. Estimated new cases are 12,170 and deaths from cervical (uterine cervix) cancer are 4,220 in the United States in 2012.2

A woman's sexual habits and patterns can increase her risk for cervical cancer. Risky sexual practices include having sex at an early age, having multiple sexual partners, and having multiple partners or partners who participate in high-risk sexual activities.Risk factors for cervical cancer include: not getting the HPV vaccine, poor economic status, women whose mothers took the drug DES (diethylstilbestrol) during pregnancy in the early 1960s to prevent miscarriage, weakened immune system.

Most of the time, early cervical cancer has no symptoms. Symptoms that may occur can include: abnormal vaginal bleeding between periods, after intercourse, or after menopause, continuous vaginal discharge, which may be pale, watery, pink, brown, bloody, or foul-smelling, periods become heavier and last longer than usual.3

The first symptoms of established cervical carcinoma are: vaginal discharge; this varies greatly in amount and can be intermittent or continuous. Bleeding; this can be spontaneous but may occur after sex, micturition or defecation, in the early stages. Patients may ignore this if it is scanty and ascribe it to normal menstrual dysfunction. Occasionally, severe vaginal bleeding may necessitate emergency hospital admission.Late symptoms: Painless haematuria, Chronic urinary frequency, Painless fresh rectal bleeding, altered bowel habit, leg oedema, pain and hydronephrosis leading to renal failure are ominous, late signs indicating pelvic wall involvement. With more advanced disease, patients develop pelvic discomfort or pain that is poorly localized and described as dull or boring in the suprapubic or sacral regions. It is similar to menstrual discomfort, can be persistent or intermittent and may be confused with arthropathy.In early-stage cervical cancer, examination can be relatively normal: there may be white or red patches on the cervix. As the disease progresses, it can lead to an abnormal appearance of the cervix and vagina, due to erosion, ulcer or tumor, rectal examination may reveal a mass or bleeding due to erosion, bimanual palpation may reveal pelvic bulkiness/masses due to pelvic spread, leg oedema may develop due to lymphatic or vascular obstruction, hepatomegaly may develop in the case of liver metastases, pulmonary metastases are normally only detected if they cause pleural effusion or bronchial obstruction.The staging system of the International Federation of Gynecology and Obstetrics (FIGO) is most commonly used: 0: carcinoma in situ (pre-invasive), I: cervical carcinoma confined to the cervix (disregard extension to corpus), Ia: invasive carcinoma diagnosed only by microscopy (all visible lesions, even superficial ones are 1B), Ia1: stromal invasion to maximum 3 mm depth and 7 mm horizontal spread, Ia2: stromal invasion >3 to <5 mm with 7 mm horizontal spread, Ib: clinical visible lesions confined to the cervix or lesion visible on microscopy >IA2, Ib1: clinically visible lesion 4 cm in largest dimension, Ib2: clinically visible lesion >4 cm in largest dimension, II: tumour invades beyond the uterus but not to the pelvic wall or the lower third of the vagina, IIa: no parametrial invasion, IIA1: clinically visible lesion ≤4.0 cm in greatest dimension, IIA2:clinically visible lesion ≥4.0 cm in greatest dimension, IIb: parametrial invasion (but not the pelvic sidewall), III: tumour extends to the pelvic wall and/or involves the lower third of the vagina and/or causes hydronephrosis or the kidney not to function, IIIa: tumour involves the lower third of the vagina - no extension to the pelvic wall, IIIb: tumour extends to the pelvic wall and/or causes hydronephrosis or the kidney not to work, IV: further spread, IVa: tumour invades the mucosa of the bladder or rectum and/or extends beyond the true pelvis and IVb: distant metastases.4

A vaccine to prevent cervical cancer is now available. The vaccine called gardasil, which prevents infection against the two types of hpv responsible for most cervical cancer cases.Practicing safe sex (using condoms) also reduces risk of hpv and other sexually transmitted diseases. Hpv infection causes genital warts. These may be barely visible or several inches wide. If a woman sees warts on her partner's genitals, she should avoid intercourse with that person.To further reduce the risk of cervical cancer, women should limit their number of sexual partners and avoid partners who participate in high-risk sexual activities.Getting regular pap smears can help detect precancerous changes, which can be treated before they turn into cervical cancer. Pap smears effectively spot such changes, but they must be done regularly. Annual pelvic examinations, including a pap smear, should start when a woman becomes sexually active, or by the age of 20 in a nonsexually active woman.if you smoke, quit. Cigarette smoking is associated with an increased risk of cervical cancer.5

Based on Indian circumstances, three strategies of cytological screening have been suggested for the control of cervical cancer by Prabhakar (1992) - screening at five-year intervals, 10-year intervals, and single lifetime screening at 45 years. Considering the expenditure involved and lack of cytology manpower, screening at five and 10-year intervals appears to be a remote possibility in developing countries like India. Hence single lifetime appears to be a feasible approach as a strategy for control / downgrading of cervical cancer. According to WHO Recommendations (1986), screening at 45 years of age is the most correct approach, which could detect approximately 20% of the total cervical cancer.6

The preventive and early detection measure like Pap smear done every three years for asymptomatic women between ages of 18 to 69 years will detect about 92% of cervical cancer.7

6.1 NEED OF THE STUDY

According to the Coordinating Unit, National Cancer Registry Programme of India Cancer of the cervix is the most common cancer among women in India, constituting between one-sixth to one-half of all female cancers with an age-adjusted incidence rate ranging from 19.4 to 43.5 per 100,000 in the registries under the National Cancer Registry Programme.

It has been estimated that 100,000 new cases of cancer of the cervix occur in India every year, and 70% or more of these are Stage III or higher at diagnosis. On a Survival analysis carried out among 2121 patients diagnosed during 1982-89 in the population of Bangalore, India the survival was 34.4% and the relative survival 38.3%. Clinical stage at presentation was the single most important variable in predicting survival. The 5 year observed survival for stage I disease was 63.3%, for stage II 44.0%, for stage III 30.3% and for stage IV 5.7% .8

This Atlas gave an overview of patterns of cancer in different parts of India besides calculating estimates of cancer incidence. Cancer incidence is generally expressed as Age Adjusted or Age Standardised Incidence Rates (AAR) per 100,000 persons according to world standard population. Among females, the most common sites of cancers are breast and cervix. In older population based cancer registries (PBCR)4 Barshiand Chennai PBCRs have always recorded the highest incidence of cervix cancer. The report of the North Eastern PBCRs5 indicates an AAR of 25.4 per 100,000 in Aizawl district of Mizoram state followed by AARs in Imphal West district (20.5) and Kamrup Urban district (17.3).The decline in the AAR varies from 42.3 (in 1982-83) to 22.3 (in 2004-05) per 100,000 in Chennai to a marginal decline in Barshi from 23.5 (in 1988-89) to 22.8 (in 2004-05). Cancer of the cervix accounted for 16 per cent of all cancers in women in the urban registries in 2005. However, it constitutes 37 per cent of the cancers in females in Barshi. The highest age specific incidence rate of 98.2 per 100,000 for cancer cervix was seen in the 60-64 yrs. age group. Since over 70 per cent of the Indian population resides in the rural areas, cancer cervix still constitutes the number one cancer in either sex. Based on the data of the PBCRs, the estimated number of new cancers during 2007 in India was 907,086. The relative five year survival reported some time earlier averaged 48.7 per cent7. Hospital based cancer registries in the hospital based cancer registries (HBCRs), cancer of the cervix is the leading site of cancer in Bangalore and Chennai, the second leading site in Mumbai and Thiruvananthapuram and the third leading site in Dibrugarh. This site of cancer constitutes between 11.4 (Thiruvananthapuram) to 30.7 per cent (Chennai) of all cancers in women in these five HBCRs. The rise in the occurrence of cancer was at the later age in Thiruvananthapuram as compared to the other four HBCRs. Over 63 to 89 per cent of all cervical cancers had regional disease at the time of presentation. Around 40 per cent of all cervical cancer patients in Bangalore, Chennai and Mumbai did not receive treatment at the Reporting Institution despite having had a diagnosis of cervical cancer.9

Although one-third of the world cervical cancer burden is endured in India, Bangladesh, Nepal and Sri Lanka, there are important gaps in our knowledge of the distribution and determinants of the disease in addition to inadequate investments in screening, diagnosis and treatment in these countries. Prevalence of human papillomavirus (HPV) infection among the general populations varies from 7-14% and the age-specific prevalence across age groups is constant with no clear peak in young women. This observation may be the result of a low clearance rate of incident infections, frequent re-infection/reactivation, limited or no data in target high-risk age groups (teenagers), and sexual behavioural patterns in the population. High-risk HPV types were found in 97% of cervical cancers, and HPV-16 and 18 were found in 80% of cancers in India. Beyond research studies, demonstration projects and provincial efforts in selected districts, there are no serious initiatives to introduce population-based screening by public health authorities in these countries. Cervical cancer is a relatively neglected disease in terms of advocacy, screening and prevention from professional or public health organizations. Cytology, HPV testing and visual screenings with acetc acid (VIA) or Lugol’s iodine (VILI) is known to be accurate and effective methods to detect cervical cancer and could contribute to the reduction of disease in these countries. While HPV vaccination provides hope for the future, several barriers prohibit the introduction of prophylactic vaccines in these countries such as high costs and low public awareness of cervical cancer. Efforts to implement screening based on the research experiences in the region offer the only currently viable means of rapidly reducing the heavy burden of disease.10

In Bangladesh 200,000 new cases of cancer occur every year and among them 25,000 are cervical cancer cases. Cervical cancer constitutes about 22-29% of the genital tract cancer in different areas of the country.11

Cervical cancer is still the leading cause of women's deaths from malignant diseases worldwide. Every year about 500,000 women get cervical cancer and 250,000 die. There are 1.7 billion women at risk in the world, but only 10%, at average, get cervical cancer screening protection.12

In US each year 10,520 new cases are seen among them 3,900 will die per year and 50% are diagnosed between ages 35 and 55, 20% at the age of 65 or over. Study also showed that it rarely occurs in women younger than 20. 13

Globally, cervical cancer is the second most common cancer among women, with the burden of disease falling heavily on developing countries Developing countries account for 83% of global cases. The risk of cervical cancer for women aged up to 74 in developing countries is double that for women in the developed world. Cervical cancer accounts for 15% of all cancers in developing countries compared to 3.6% in developed countries.14

The prevalence of cervical cancer varies by region of the world, ranging from 8 to 23 per 100,000.Among Africans its prevalance is 23%, americans 13%, Europeans 8%, Asian 8%.Cancer of the cervix was the most common cancer among the women in India Indonesia, Srilanka and Thailand, though breast cancer is slightly higher in proportion than the cervical cancer among the woman in Srilanka and Thailand. In Bhutan cervical cancer accounts for 25% of all reported cases and also third most important cause of mortality. It is high in Columbia and has a low incidence in Japan. 15

Cervical cancer is one of the leading causes of women’s death in India. It is preventable as well as curable disease if diagnosed earlier and adopting some healthy behaviours among the women. At present most of the cancer institutions are engaged in awareness rising programs (like consciousness about early signs, disadvantages of smoking, alcohol and other high risk behaviours). But there is no proper research done preventive knowledge regarding cervical cancer in India. So the proposed study would like to explore the effectiveness of structured teaching programme on knowledge regarding prevention of carcinoma of cervix. The researcher personal experience is that while working in the gynae ward, a majority of the women who were admitted in the ward especially inmost cases the women who were unaware of the prevention of cervical carcinoma. All these factors prompted the researcherto assess the knowledge of the women and to structured teaching to improve the knowledge of prevention of cervical carcinoma.

6.2 REVIEW OF THE LITERATURE

A review of literature enables one to get an insight into the various aspects of the problem under study. It covers promising methodological tools, throws light on ways to improve the efficiency of data collection and suggests how to increase effectiveness of data analysis and interpretation. Review of literature is therefore an essential step in the development of the research project.

Cervical cancer is a disease in which the cells of the cervix become abnormal and start to grow uncontrollably, forming tumors. It is one of the leading causes of women’s death globally. It is preventable as well as curable disease if diagnosed earlier, although most of women are not conscious about the preventive practice regarding cervical cancer in developing countries like India. There are several risk factors, which can increase individual risk of having cervical cancer. If we can minimize those risk factors incidence of cervical cancer can be reduce. Without implementing the preventive activities regarding cervical cancer it is not possible to reduce the incidence of disease in India. So that it is most important to explore the different knowledge which adopted by women intentionally or unintentionally. During this study time, I read several published literature about the preventive practices, knowledge and risk factors regarding carcinoma of cervix which are as follows:

6.2.1 Review of literature related to cervical cancer among women.

6.2.2 Review of literature related to knowledge regarding cervical cancer among women.

6.2.3 Review of literature regarding effectiveness of structured teaching programme among the women.

6.2.1 Review of literature related to cervical cancer among women.

To investigate the role of sexual risk factors in cervical cancer among rural Indian women a hospital-based case-control study was carried out. Early age at first coitus, extramarital sex partners of women and the time interval since first exposure were associated with cervical cancer. The study showed that maximum risk in women who reported their first intercourse at less than 12 years of age, compared to that of women at more than 18 years. Increased risk was also seen for women who had extramarital sex relationships.16

A study conducted on Human papillomavirus infection in women with and without cervical cancer in Nepal - Cancer Cause and Control where cervical specimens were obtained from 932 married women aged 15–59years from the general population of Bharatpur, Nepal, as well as from 61 locally diagnosed invasive cervical cancers (ICC). Residence in slum housing, lower education level, ≥3 sexual partners in a woman's lifetime, and husband’s extramarital affairs were significantly associated with HPV positively.17

Retrospective study was conducted in Bangladesh to determine the proportion of cervical cancer among female cancer patients and explored some of the predisposing factors relating to a high proportion of this disease. The proportion of cervical cancer was quite high, mostly among women of low socioeconomic status. Factors such as early sexual activity, having the first child at a young age, multiple pregnancies, multiple sex partners, and poor genital hygiene were commonly the predisposing factors for cervical cancer.18