Table of Contents  
ORIGINAL ARTICLE
Year : 2014  |  Volume : 24  |  Issue : 2  |  Page : 49-52

Carcinoma of the cervix at a university teaching hospital in Eastern Nigeria


1 Department of Obstetrics and Gynecology, Imo State University Teaching Hospital, Orlu, Imo State, Nigeria
2 Department of Obstetrics and Gynecology, Abia State University Teaching Hospital, Aba, Abia State, Nigeria

Date of Acceptance10-Oct-2014
Date of Web Publication21-Jan-2015

Correspondence Address:
Emmanuel C Ojiyi
Department of Obstetrics and Gynecology, Imo State University Teaching Hospital, Orlu, Imo State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1116-5898.149603

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  Abstract 

Background: Cervical cancer is a preventable disease; however, the incidence is still regrettably high in most countries of sub-Saharan Africa. Aim: To ascertain the socio-epidemiological determinants of invasive cervical cancer at the Imo State University Teaching Hospital, Orlu. Patients and Methods: A retrospective analysis of all patients with histologically confirmed cancer of the cervix at the Department of Obstetrics and Gynecology of the Imo State University Teaching Hospital, Orlu from June 1, 2004 to December 31, 2013. Results: Cervical cancer accounted for 54.0% of all histologically confirmed cancers. The ages of the patients ranged from 21 to 90 years with a mean of 51.6 ± 3.2 years. Majority of the patients were aged 35-63 years. Most of the patients, 175 (88.8%) belonged to the poor socioeconomic class and 177, (89.3%) were married. The incidence of the disease increased with increasing parity with grand multiparous patients constituting 161, (81.4%) of the cases. The commonest symptom at presentation was abnormal vaginal discharge 84, (82.4%) with 70 (35.3%) of the patients presenting within 2-5 months of the onset of symptoms. Advanced disease, stage III and above, 66 (64.7%) was the commonest stage at presentation. Conclusion: The incidence of cervical cancer is still unacceptably high at Orlu. Opportunistic Cervical cancer screening needs to be adopted as an interim measure, while awaiting an organized systematic screening with a good call and recall system.

Keywords: Cervical cancer, orlu, Nigeria


How to cite this article:
Anolue FC, Ojiyi EC, Dike EI, Okeudo C, Ejikeme CE. Carcinoma of the cervix at a university teaching hospital in Eastern Nigeria. Niger J Surg Sci 2014;24:49-52

How to cite this URL:
Anolue FC, Ojiyi EC, Dike EI, Okeudo C, Ejikeme CE. Carcinoma of the cervix at a university teaching hospital in Eastern Nigeria. Niger J Surg Sci [serial online] 2014 [cited 2021 Apr 13];24:49-52. Available from: https://www.njssjournal.org/text.asp?2014/24/2/49/149603


  Introduction Top


Worldwide cervical cancer is the third most common cancer in women and the seventh most common in overall (in both sexes combined). [1] It is estimated to be responsible for 530,000 new cases of cancer in 2008 (nearly one in 10 [9%] of all cancers diagnosed in women). [1] Cervical cancer incidence rates are lowest in Western Asia and highest in Eastern Africa with a seven-fold variation in world age standardized incidence rates between the regions of the world. [1] It is the 12 th most common cancer among women in the United Kingdom, accounting for around 2% of all new cases of cancer in women. [2],[3]

It is the most common malignancy amongst women in Nigeria, and the rest of Sub-Saharan Africa with a very poor 5-year survival rate. [4],[5] It is accounted for 59.3% and 63.1% of all histologically confirmed gynecological malignancies in Awka [6] and Ilorin, [4] respectively, in Nigeria.

Cervical cancer is the leading cause of death per annum in women aged 35-45 years.

In western countries, there have been a downward decline of organized cervical cancer screening programs. [1],[2],[3] Cervical cancer incidence rates have decreased overall in Great Britain since the mid-1970s. [7],[8] European age specific incidence rates decreased by 49% from their peak in 1985 to 1987 (at 16 cases/100,000 women) to the lowest rate in 2003-2005 (at 8/100,000 women). The dramatic decrease in rates, since the late 1980s follows improvements to the national health service cervical screening program in the UK. [3] In the UK, around 19, 000 women were still alive at the end of - 2006, up to 10 years after being diagnosed with cervical cancer. [9] Worldwide, it is estimated that there were >1.55 million women still alive in 2008, up to 5-year after their diagnosis. [1]

The above scenario is in sharp contrast to the situation in the developing countries of the world, Nigeria inclusive, where the incidence, prevalence and mortality continue to be on the rise on account of unavailability of any organized cervical cancer screening programs with a good call and recall system. [4],[5],[6]

The risk of developing cervical cancer has been associated with a number of socio-epidemiological variables such as age, occupation, religion, socioeconomic status, educational level, sexual behaviors, etc. [10] Current cervical risk scoring systems are based on such socio-demographic variables and are often helpful in targeting of screening resources. [11] Even in the industrialized nations of the West, the emphasis is now on precise targeting of high-risk groups in order to improve the efficiency of cervical cancer screening programs and conserve resources. [11]

This study aims at assessing the socio-epidemiological determinants of the development of invasive cervical cancer at the Imo State University Teaching Hospital, Orlu.


  Patients and methods Top


The case records of all patients with histologically confirmed cervical cancer at the Department of Obstetrics and Gynecology of the Imo State University Teaching Hospital, Orlu from June 1, 2004 to December 31, 2013 were retrieved from the Medical Records Department of the Hospital for detailed study. Information extracted from the patients' case folders included parity, age, occupation, highest educational attainment, presenting symptoms, stage of the disease at presentation, and the histological sub-type of the disease. The social classes of the patients were deduced using their occupation and their highest educational attainment. SPSS version 17 statistical package (Illinois, USA )SPSS Inc., 233 South Wacker Drive, 11 th Floor, Chicago, IL 60606-6412 was used to analyze the data. The Chi-square (x 2 ) test was used to test for statistical significance and a P ≤ 0.05 was taken as being statistically significant.


  Results Top


Of the 198 histologically confirmed gynecological malignancies within the study period, 107 were invasive cancer of the cervix, giving a prevalence of 54.0%. However, only 102 case notes contained all the required information and were therefore analyzed.

The patient's ages ranged from 21 to 90 years with a mean of 51.6 ± 3.2 years. Most of the patients, 159 (80.1%) were aged 35-63 years with a peak incidence of 35-40 years. Majority of the patients, 176 (88.8%) were of the poor socio-economic strata of the society with 177, 89.3% being married. These values were significant statistically (P ≤ 0.05).

The prevalence of the disease increased proportionately with parity and grand multiparous women accounting for 171/198, (86.4%) of the cases. Only 5/198 (2.4%) of the cases were nulliparous. The parity differentials were also statistically significant (P=0.0038). Abnormal vaginal discharge was the commonest presenting symptom (84%) followed by abnormal vaginal bleeding [Table 1]. Most of the patients (64.7%) presented with Stage III of the disease and above [Table 2].
Table 1: Symptomatology and duration of symptoms*


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Table 2: Clinical stage


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The squamous cell variety was the most common histological subtype 91, (89.2%) and most of them were well differentiated 31, (37.3%) [Table 3].
Table 3: Histological type


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  Discussion Top


With a 54.0% prevalence rates in this study, cervical cancer is the leading female genital cancer in our environment. This high prevalence rate might be a reflection of the lack of an organized cervical cancer screening program in our environment as in the case in the industrialized nations of the West. This is also the observation of other researchers. [4],[5],[6]

Our study also showed that age is a significant risk factor for the development of cervical cancer in our environment. However, it does not follow the same pattern of increasing incidence with age seen for most cancers. There are two peaks in the age-specific incidence rates: The first in women aged 30-34 years (at 21/100,000 women) and the second in women aged 80-84 (at 13/100,000 women), [10],[12] giving rise to an increase in human papillomavirus (HPV) infections a significant cause of cervical cancer. [13] The second smaller peak is due to an increasing cancer incidence with age. In the UK between 2008 and 2010, an average of 20% of cervical cancer cases were diagnosed in women aged 65-year and above. [13]

Over three-quarter (78%) of cervical cancer cases occur in 25-64 years old. Women in England and Northern Ireland are currently offered cervical cancer screening at 3-5 year intervals between ages 25 and 64. [14],[15] For women in Wales, screening is offered between the ages of 20 and 64 every 3 years. [16]

In Scotland, women are offered screening every 3 years between the ages of 20 and 60 years. [17]

Multiparity was also significantly associated with cervical cancer in this series, with the risk of developing cervical cancer being the highest in grand multiparous patients. This is also the experience of other authors. [4],[5],[6] Early age of first pregnancy, early marriage, early sexual exposure, marital instability and subsequent multiple partners through remarriages or otherwise are all closely related with synergistic effects. They all increase the chances of acquiring sexually transmitted infections, including HPV.

Abnormal vaginal discharge was the commonest presenting symptom in this series. In Ilorin, irregular vaginal bleeding was the commonest symptom at presentation, [4] whereas in Zaria, abnormal vaginal bleeding was the commonest presenting symptom. [18] All these were the manifestations of advanced disease as our women hardly present early.

Women from the lower socioeconomic class were mostly affected. The underlying factor might be multiple sexual partners as those who engage in sexual promiscuity do so for economic reasons. [19] It has been stated that religion and socioeconomic orientation are the determinants of marital stability and stable sexual relationships, [20] with women from poor socioeconomic backgrounds being more liable to sexual promiscuity and early sexual exposure, hence greater predisposition to acquiring sexually transmitted infections, like cervical cancer, when compared to their more affluent counterparts. This effect is independent of race.

Majority of the patients (64.7%) presented with stage III disease and above. This is a common feature of cervical cancer in the less developed countries of the world. [4],[5],[6],[18]

The commonest histological subtype in this series was the squamous cell carcinoma (SCC) (89.2%) and majority of them (37.3%) were well differentiated. It has been estimated that around 15% are adenocarcinoma (with nearly all of the remainder of cases being registered as poorly specified). [21],[22],[23]

An analysis of cervical cancer incidence in Sweden has shown that an early age peak at 35-39 years is apparent for both SCC and adenocarcinoma. [24]

A study by the International Agency for Research on Cancer has reported an increase in adenocarcinoma and a downward trend in SCC in many countries worldwide. [1],[25]


  Conclusion Top


The incidence of invasive cancer of the cervix is still unacceptably high in our environment and late presentation is a common feature. The risk factors associated with the disease were age, multiparity and poor socioeconomic status.

In the absence of an organized cervical cancer screening program, as is the case in the industrialized countries of the world, an opportunistic screening targeted at those at risk should be introduced in the department as an interim measure.

 
  References Top

1.
Ferlay J, Shin HR, Bray F. GLOBOCAN 2008 v. 1.2, Cancer Incidence and Mortality Worldwide: IARC Cancer Base No. 10. Lyon, France: International Agency for Research on Cancer; 2010. Available from: http ://www.globocan.iarc.fr. [Last accessed on 2013 April 12].  Back to cited text no. 1
    
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National Cancer Intelligence Network. Available from: http ://www.globocan.iarc.fr. [Last accessed on 2013 Apr 12].  Back to cited text no. 2
    
3.
Trent Cancer Registry. Profile of Cervical Cancer in England Incidence: Mortality and Survival. Sheffield: Trent Cancer Registry/NHS Cancer Screening Programmes; 2012.  Back to cited text no. 3
    
4.
Ijaiya MA, Aboyeji PA, Buhari MO. Cancer of the cervix in Ilorin, Nigeria. West Afr J Med 2004;23:319-22.  Back to cited text no. 4
    
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Ojiyi EC, Dike EI, Nzewuihe AC, Ejikem EC. Epidemiology of cervical cancer at the Anambra State University Teaching Hospital, Awka. Trop J Med Sci 2012;1:10-3.  Back to cited text no. 6
    
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Patel A, Galaal K, Burnley C, Faulkner K, Martin-Hirsch P, Bland MJ, et al. Cervical cancer incidence in young women: A historical and geographic controlled UK regional population study. Br J Cancer 2012;106:1753-9.  Back to cited text no. 7
    
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Lancucki L, Sasieni P, Patnick J, Day TJ, Vessey MP. The impact of Jade Goody's diagnosis and death on the NHS Cervical Screening Programme. J Med Screen 2012;19:89-93.  Back to cited text no. 8
    
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National Cancer Intelligence Network. One, five and ten-year Cancer prevalence. London: NCIN; 2010.  Back to cited text no. 9
    
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Foley G, Alston R, Geraci M, Brabin L, Kitchener H, Birch J. Increasing rates of cervical cancer in young women in England: An analysis of national data 1982-2006. Br J Cancer 2011;105:177-84.  Back to cited text no. 10
    
11.
Wilkinson CE, Peters TJ, Stott NC, Harvey IM. Prospective evaluation of a risk scoring system for cervical neoplasia in primary care. Br J Gen Pract 1994;44:341-4.  Back to cited text no. 11
    
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Tripp J, Viner R. Sexual health, contraception, and teenage pregnancy. BMJ 2005;330:590-3.  Back to cited text no. 12
    
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Bosch FX, Lorincz A, Muñoz N, Meijer CJ, Shah KV. The causal relation between human papillomavirus and cervical cancer. J Clin Pathol 2002;55:244-65.  Back to cited text no. 13
    
14.
The NHS cervical screening programme criteria for evaluating cervical cytology: Comparison of the new with the old. Cytopathol 2012;23:349-352.  Back to cited text no. 14
    
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Herbert A. Cervical screening in England and Wales: its effect has been underestimated. Cytopathol 2000;11:471-9.  Back to cited text no. 15
    
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Parkin DM, Nguyen-Dinh X, Day NE. The impact of screening on the incidence of cervical cancer in England and Wales. Br J Obstet Gynaecol 1985; 92:150-7.  Back to cited text no. 16
[PUBMED]    
17.
Walker JJ, Brewster D, Gould A, Raab GM. Trends in incidence of and mortality from invasive cancer of the uterine cervix in Scotland. Public Healt 1998;112:373-8.  Back to cited text no. 17
    
18.
Emembolu JO, Ekwempu CC. Carcinoma of the cervix uteri in Zaria: Etiological factors. Int J Gynaecol Obstet 1988;26:265-9.  Back to cited text no. 18
    
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Gardner HL, Dampeer TK, Dukes CD. The prevalence of vaginitis; a study in incidence. Am J Obstet Gynecol 1957;73:1080-5.  Back to cited text no. 19
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20.
Martin CE. Epidemiology of cancer of the cervix. II. Marital and coital factors in cervical cancer. Am J Public Health Nations Health 1967;57:803-14.  Back to cited text no. 20
    
21.
Vizcaino AP, Moreno V, Bosch FX, Muñoz N, Barros-Dios XM, Borras J, et al. International trends in incidence of cervical cancer: II. Squamous-cell carcinoma. Int J Cancer 2000;86:429-35.  Back to cited text no. 21
    
22.
Vizcaino AP, Moreno V, Bosch FX, Muñoz N, Barros-Dios XM, Parkin DM. International trends in the incidence of cervical cancer: I. Adenocarcinoma and adenosquamous cell carcinomas. Int J Cancer 1998;75:536-45.  Back to cited text no. 22
    
23.
Quinn M, Babb P, Brock A. Cancer Trends in England and Wales 1950-1999. London Office for National Statistics; 2001.  Back to cited text no. 23
    
24.
Hemminki K, Li X, Mutanen P. Age-incidence relationships and time trends in cervical cancer in Sweden. Eur J Epidemiol 2001;17:323-8.  Back to cited text no. 24
    
25.
International Agency for Research on Cancer. World Cancer Report 2008. Lyon: IARC; 2008.  Back to cited text no. 25
    



 
 
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