|Ahead of print
Prevalence and determinants of breast and cervical cancer screening among women aged between 30 and 49 years in India: Secondary data analysis of National Family Health Survey – 4
Yuvaraj Krishnamoorthy1, Karthika Ganesh1, Manikandanesan Sakthivel2
1 Department of Preventive and Social Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
2 State Program and Technical Manager, Cap TB Project, AP/TS Unit, Solidarity and Action Against The HIV Infection in India (SAATHII)
|Date of Submission||25-Jun-2019|
|Date of Decision||18-Jul-2019|
|Date of Acceptance||25-Jul-2019|
|Date of Web Publication||27-Jan-2021|
Department of Preventive and Social Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry
Source of Support: None, Conflict of Interest: None
Background: Breast and cervical cancers are the two leading causes of cancer-related morbidity and mortality in India. Early diagnosis of these cancers through screening offers the best chance to achieve successful treatment outcomes. Hence, the current study was done to determine the prevalence and predictors of breast and cervical cancer screening among women aged 30-49 years in India.
Methods: We have analyzed the most recent National Family Health Survey-4 data (NFHS-4) gathered from Demographic Health Survey program. Stratification and clustering in the sample design were accounted using svyset command. Adjusted prevalence ratio (aPR) with 95% confidence interval (CI) was reported.
Results: In total, 336,777 women aged 30-49 years were included. Proportion of women aged 30-49 years with history of breast cancer examination in their lifetime was 12.9% (95% CI: 12.6-13.2%), while it was 29.8% (95% CI: 29.3-30.3%) for cervical cancer. It was found that women aged 45-49 years (aPR=1.09), married (aPR=2.18), higher educational level (aPR=1.28), richest quantile (aPR=1.96), no history of pill use (aPR=1.24), obese (aPR=1.06), and healthy dietary habits (aPR=1.47) were more likely to be screened for breast cancer. Predictors for cervical cancer screening were higher age group (aPR=1.06), married (aPR=2.94), secondary educational level (aPR=1.05), richest quantile (aPR=2.24), nonpill user (aPR=1.24), nontobacco user (aPR=1.07), and lower parity (aPR=1.09).
Conclusion: A total of 1 out of 10 women in reproductive age group were screened for breast cancer while less than one in three for cervical cancer. Hence, it is important to spread awareness and increase access to screening services to achieve early diagnosis and better treatment outcomes.
Keywords: Breast cancer, cervical cancer, early detection of cancer, mass screeningKey Message Only one in ten women were screened for breast cancer and less than on-third for cervical cancer. This implicates the need to spread awareness and improve access to screening services.
|How to cite this URL:|
Krishnamoorthy Y, Ganesh K, Sakthivel M. Prevalence and determinants of breast and cervical cancer screening among women aged between 30 and 49 years in India: Secondary data analysis of National Family Health Survey – 4. Indian J Cancer [Epub ahead of print] [cited 2021 Jul 25]. Available from: https://www.indianjcancer.com/preprintarticle.asp?id=308044
| » Introduction|| |
Cancer is a major public health problem due its burden in terms of morbidity and mortality. Among women, breast and cervical cancers are the two common cancers occurring worldwide. Breast cancer is the most common cancer among women contributing for almost 25% of the new cancer cases in 2018, whereas cervical cancer is the fourth most common cancer accounting for about 5% of the total new cases. About half of these cases due to breast and cervical cancer occur in Asian countries. Of the cancer-related deaths among women in 2018, breast cancer and cervical cancer deaths together accounted for about 1 million deaths worldwide with majority occurring in Asian countries. In India, breast cancer is the leading cause of cancer incidence and mortality followed by cervical cancer as per GLOBOCAN 2018. Both cancers combined contributed for about 2.5 lakh cases and nearly 1 lakh deaths in India.
Development of a community-based screening program would be an effective way of reducing the morbidity and mortality as studies have shown that regular screening for breast cancer reduces mortality rate by about 30–40%.,, Breast self-examination (BSE) is an easy way for detection of abnormality of breast at early stage. Among women aged more than 20 years, monthly BSE has been reported to play a major role in the early detection of breast cancer. Recommendation suggested is to screen all women aged 40-60 years at least once every 3 years and awareness regarding breast cancer screening being promoted at 30 years onward.
For cervical cancer, the primary causative agent being human papilloma virus infects nearly 7% of the women in India. Nearly, 80% of invasive cervical cancers can be prevented by screening programs. World Health Organization (WHO) in 1992 devised the cervical cancer screening recommendations for women living in low-resource settings with the motive to screen every woman at least once over their lifetime at the age of 40, with priority on ages 30-49 years who should be screened every 5 years. Mortality due to cervical cancer has decreased in the past 40 years due to introduction of preventive screening programs. However, screening in India is still remaining opportunistic which leads to late diagnosis of majority of breast and cervical cancer cases. The data from hospital-based registry have shown that only 25% of breast cancers and 21% of cervix cancers were diagnosed when the cancer is still localized to the site.
Government of India has recommended a population-based screening program (in addition to the opportunistic screening) with an intention to create awareness about the common cancers, for detecting precancerous lesions and early diagnosis of breast and cervical cancer through clinical breast examination and visual inspection of cervix with 5% acetic acid (VIA) and with Lugol's iodine (VILI) by frontline health workers. However, the reporting of coverage of various screening programs are not done regularly in India. This necessitates the need to find the coverage status of screening programs for common cancers in India. Screening for detection of breast and cervical cancer by targeting high-risk groups is more important as they have higher risk of developing cancer when compared to general population. In addition, it has
better yield of cases and involves low costs and resources when compared to mass screening strategy.
A recent study by Van Dyne has reported the baseline cervical cancer screening status in India using the NFHS-4 data. However, current study also focuses on breast cancer screening status and predictors of breast and cervical cancer screening with special focus on the high-risk groups. Hence, the current study was done to determine the prevalence and predictors of breast and cervical cancer screening among women aged between 30 and 49 years in India.
| » Methods|| |
India is the second largest country in terms of population in the world located in South Asia with a population of about 130 crores. The country is divided into 28 states and 8 union territories (UTs). Each state and UT is further divided into districts. Districts are subdivided into census enumeration block and wards in urban area and villages/taluk in rural area.
The government of India has launched a national program for the prevention and control of cancer, diabetes, cardiovascular diseases, and stroke. This program implements the interventions up to the district level and focuses on health promotion, screening, diagnosis, treatment, and referral for appropriate management of cancer patients. The Government of India has also recommended a program for population level screening for common cancers like oral, cervix, and breast cancer in addition to the opportunistic screening.
Study design and study population
We have conducted a cross-sectional analytical study by doing secondary data analysis on the most recent National Family Health Survey-4 data (NFHS-4) 2015-16 gathered from Demographic Health Survey (DHS) program. Initially, a proposal was submitted to DHS to conduct a secondary data analysis on breast and cervical cancer screening among women aged 30-49 years, after which authorization to use data was obtained. NFHS survey has been conducted to capture data on health and welfare of the Indian population through nationally representative sample. Participants who are female and in the age group between 30 and 49 years were taken as study population for the current study analysis.
Sample size and sampling technique
The NFHS procedure has a two-stage sampling approach for the selection of villages and census enumeration blocks. In rural and urban areas and selection of households, validation and usage of household questionnaire, data collection procedure, and data validation have been comprehensively described and published as separate study elsewhere. Women of reproductive age group between 15 and 49 years and men in the age group 15-54 years were eligible to participate in the survey in all the selected households. Among women, 723,875 of reproductive age group were identified to be eligible for the survey, out of which 699,686 women completed the questionnaire with response rate of 97%. Among them, 336,777 participants were in the age group between 30 and 49 years. Since the current study focuses on the breast and cervical screening among this age group, only these 336,777 participants were included in the analysis.
Data variables and data sources
Independent variables included sociodemographic characteristics, such as age, education, occupation, wealth index, marital status, type of residence, religion, caste/tribe, risk factors of breast cancer such as history of oral contraceptive pill (OCP) use, body mass index (BMI), history of fruit intake, fried food intake, alcohol use, age at first pregnancy and risk factors of cervical cancer, such as age at first sexual contact, tobacco use, history of intrauterine device (IUD) use, parity, and history of sexually transmitted infection (STI). Dependent variable was history of breast and cervical cancer screening among the women aged 30-49 years. Data on the above mentioned variables were obtained from NFHS-4 dataset.
Breast and cervical cancer screening were assessed in the survey based on “yes” or “no” response to the question whether the respondent has ever undergone clinical breast examination and ever undergone cervix examination in their lifetime.
We conducted analysis on national level data for capturing the prevalence estimates and predictors of breast and cervical screening among women aged 30-49 years in India. Analysis was done using STATA 14.2 (StataCorp, College Station, TX, USA). Sampling weights were included in the analysis to account for the differential probabilities of participation and selection. Stratification and clustering in the sample design were also accounted, after which svyset command was used to declare the NFHS datasets as survey type from two stage cluster sampling: the selection of villages and census enumeration areas based on a probability proportionate to area size and random selection of household from complete list of households within the selected villages and enumeration areas. Point estimates were reported with 95% confidence interval (CI). Poisson regression model was done to assess the predictors of breast and cervical cancer screening. Sociodemographic variables, such as age, education, occupation, wealth index, marital status, type of residence, religion, caste/tribe, risk factors of breast cancer, such as history of OCP use, BMI, history of fruit intake, fried food intake, alcohol use, age at first pregnancy were considered as covariates for predictors of breast cancer screening. Risk factors of cervical cancer such as age at first sexual contact, tobacco use, history of IUD use, parity, and history of STI in addition to sociodemographic variables were considered as covariates for predictors of cervical cancer screening. Unadjusted and adjusted prevalence ratio (PR) with 95% CI was reported. Variables with P value less than 0.05 were considered statistically significant and considered into the multivariate regression model. Models were applied after adjusting for sampling weights and design using the svyset command in STATA.
NFHS dataset was available for download through data distribution system of demographic health survey. All the datasets in DHS are accessible for free and downloaded for further use after registration process. Informed consent for all the respondents was obtained during the survey. The result obtained in the current study is based on the secondary analysis of existing NFHS survey data and does not contain patient name or any other identifiers.
| » Results|| |
In total, 699,686 women aged between 15 and 49 years have participated in the survey. Among them, 336,777 participants are in the age group between 30 and 49 years and were included in the analysis. Sociodemographic characteristics of the study participants are described in [Table 1]. About 28.4% of the study participants belonged to the age group between 30 and 34 years. More than 90% were currently married and more than 80% were Hindu by religion. Majority (41.4%) did not have any formal education. Participants were almost equally distributed across all the five quantiles of wealth index. Only 5% of the participants were employed and almost two-third belonged to rural area.
|Table 1: Sociodemographic characteristics of women aged 30.49 years covered in NFHS-4 in India, n=336,777|
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[Table 2] shows the distribution of risk factors related to breast and cervical cancer among the study participants. History of OCP use, a common risk factor for breast and cervical cancer, was present among almost 10% of the study participants. Regarding the risk factors of breast cancer, almost half of the study participants belonged to overweight and obese category; only 1.7% had habit of alcohol use; about 4.7% had history of first birth after 10 years of marriage; only 12.2% were regularly taking fruits. Regarding the risk factors of cervical cancer; more than one-fourth had history of first sexual contact before 18 years; about 10.5% were tobacco users; almost half of the study participants had high parity (more than two deliveries); about 4% have history of IUD usage.
|Table 2: Distribution of risk factors related to breast and cervical cancer among the study participants, n=336,777|
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[Table 3] shows the details regarding the breast and cervical cancer examination among the study participants. Proportion of women aged between 30 and 49 years with history of breast cancer examination in their lifetime was 12.9% (95% CI: 12.6-13.2%). Women with history of cervical cancer examination was comparatively higher as 29.8% (95% CI: 29.3-30.3%) had undergone examination at least once in their lifetime.
|Table 3: Status of breast and cervical cancer screening among women aged 30.49 years in India covered in NFHS-4 (n=336,777)|
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Predictors of breast cancer screening among women aged 30-49 years in India are described in [Table 4]. It was found that women in higher age group between 45 and 49 years had 1.09 times higher chance of undergoing breast cancer examination when compared to women in age group between 30 and 34 years and it was statistically significant (P < 0.001). Women who were married had higher chance of undergoing breast cancer examination adjusted Prevalence ratio (aPR) = 2.18, P =0.001) when compared to those who were never married. Women belonging to higher educational level were found to have higher chance of undergoing breast cancer examination (aPR=1.28, P < 0.001) when compared to women with no formal education. Women belonging to other religions like Sikh, Buddhist, Jain, Jewish had higher chance of undergoing breast cancer screening (aPR=1.51, P < 0.001) when compared to Hindus, Muslims, and Christians. Participants in the richest quantile had more proportion of women undergoing breast cancer screening (aPR= 1.96, P < 0.001) when compared to those in poorest quantile. Women with no history of OCP use had higher proportion of participants undergoing breast cancer screening (aPR=1.24, P < 0.001) when compared to those with history of OCP use. Women in obese category had higher proportion of women undergoing screening (aPR=1.06, P = 0.02) when compared to women in underweight category. Women with history of daily fruit intake and never takes fried food were 1.47 times higher chance of getting screened for breast cancer and it was statistically significant (P < 0.001). There was no significant difference in screening with respect to place of residence and alcohol use.
|Table 4: Determinants of breast cancer screening among women aged 30-49 years in India, n=336,777|
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[Table 5] shows the predictors of cervical cancer screening among women aged 30-49 years in India. Similar to breast cancer screening, women in higher age group (45-49 years) had higher proportion undergoing cervical cancer screening (aPR=1.06, P < 0.001) when compared to women in 30-34 years age group. Currently, married women had higher proportion undergoing cervical cancer screening (aPR=2.94, P < 0.001) when compared to those who were never married. Women belonging to other religions like Sikh, Buddhist, Jain, and Jewish had higher chance of undergoing cervical cancer screening (aPR=1.30, P < 0.001) when compared to Hindus, Muslims, and Christians. Women who belonged to secondary educational level had higher chance of undergoing cervical cancer screening (aPR=1.05, P < 0.001) compared to those with no formal education. Women living in urban area had 8% less chance of undergoing cervical cancer screening (aPR=0.92, P < 0.001) compared to those living in rural areas. Women belonging to richest quantile had 2.24 times higher proportion undergoing cervical cancer screening compared to those in poorest quantile (P < 0.001). Women with no history of OCP use had higher chance of undergoing cervical cancer screening (aPR=1.24, P < 0.001) compared to those who had history of OCP use. Women with history of STI had higher chance of undergoing cervical cancer screening (aPR=1.24, P < 0.001) compared to those with no history of STI. Women who do not use tobacco had higher chance of undergoing cervical cancer screening (aPR=1.07, P < 0.001) compared to female tobacco users. Women with lower parity had higher proportion undergoing screening (aPR=1.09, P < 0.001) compared to those with higher parity. There was no significant difference in screening with respect to age at first sexual contact.
|Table 5: Determinants of cervical cancer screening among women aged 30-49 years in India, n=336,777|
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| » Discussion|| |
NFHS-4 data provide sufficient opportunity to study about screening of common cancers especially breast and cervical cancer among women aged 30-49 years. This particular age group is selected for the current analysis as the World Health Organization (WHO) has recommended that all the women in this age group should be screened at least once for both breast and cervical cancer. Prevalence estimates for the screening obtained using this data can be reliable as it involves a large representative sample taken throughout the country. In addition to the point estimates, it is also important to find out whether the people in high-risk group for both cancers are screened more, as understanding these predictors of breast and cervical screening have important policy implications.
The overall proportion of women aged 30-49 years has ever undergone breast cancer screening in India was 12.9%. This coverage is far less when compared to western countries like United States (US) or United Kingdom (UK) where the coverage is more than 80%. In addition, we found that the coverage was further less in high-risk groups, such as those women who were illiterate, belonging to poor socioeconomic status, having history of OCP intake or poorer dietary habits. This shows why majority of women, i.e., more than 70% present with advanced stage of breast cancer in India.
Although the status of cervical cancer screening is slightly better than breast cancer, it is still less (29.8%) when compared to western countries. However, there has been an increase in coverage when compared to the previous surveys conducted in India which showed only 5.3% of women between 25 and 64 years were screened for cervical cancer. Similar to breast cancer screening, women with high-risk of cervical cancer such as those belonging to poor socioeconomic background, OCP users, tobacco users, and higher parity were less likely to be screened. This shows why nearly 70% of patients with cervical cancer in India present at stages III and IV and around 20% of them die within the first year of diagnosis.
Early diagnosis of cancer through screening offers the best chance to achieve successful treatment outcomes. Although population as a whole need to be screened, target groups such as OCP users, tobacco, alcohol users, or women with early sexual contact, higher parity should be particularly screened as they have higher chance of developing these cancers.,,, However, screening status was found to be poor among these high-risk groups when compared to general population. Prioritizing high-risk groups with lower screening coverage might help the policymakers to progress toward India's national goal of universal coverage of breast and cervical cancer screening.
The study has several strengths. First, it is based on NFHS-4 data which covers nationwide representative samples from rural, urban, and tribal regions. Second, the high response rate in the NFHS-4 reported from this study (97%) enables the study findings to be more generalizable for the Indian context. Third, large numbers of representative women interviewed in the NFHS-4 give adequate power to examine the relationship with multiple predictor variables. Fourth, the complex sampling frame adapted in the study design is adjusted using the appropriate statistical modeling techniques. Current study also contributes to the limited evidence available regarding the screening status of reproductive age group women in India especially among high-risk groups.
The study has following limitations. The cross-sectional nature of the survey makes it difficult to infer causal relationship between the exposure and outcome. The data on screening of cancers were obtained without any specific time points. Hence, there is a possibility of recall bias and underestimation of women undergoing cervical or breast cancer screening. The reported examination especially for cervical cancer may or may not have been for screening, as often women may have undergone a pelvic examination for STIs. Hence, this question is being used as a proxy indicator and this assumption may have led to over estimation of proportion screened. Hence, the survey questions in the next round of NFHS should address this issue and differentiate between screening and diagnostic examination.
Despite these limitations, this study results have several programmatic implications. The national estimates of breast and cervical cancer screening in this study can be used for roll out of the program, implementation benchmarks, and program evaluation in accordance with the WHO cervical cancer indicator for women aged 30–49 years. Findings of the current study can be used to plan and evaluate breast and cervical cancer screening program, evaluation of facility readiness, and to perform cost-effectiveness analyses.
The wide gap in the coverage of screening programs necessitates the need for decentralized testing and treating policy. The inequities found in the current study have to be addressed while planning for health care service delivery. There should be a mechanism to utilize the missed opportunities for screening against common cancers among reproductive age group women, such as visit to family planning, well baby clinic, and postpartum clinic and routine outpatient department visits. Evidences have shown that the screening by peripheral health workers causes significant reduction in cancer mortality and hence sensitization of them toward active screening is important. Possibilities of utilizing the existing community women support groups such as Mahila Arogya Samithi to raise awareness, consequences of common cancers, and facilities available for screening and treatment should be explored. Strong surveillance system including national surveys, cancer registries, or registries measuring screening combined with modeling are all important in ensuring that breast and cervical cancer can be eliminated as a public health problem in India.
| » Conclusion|| |
Only 1 in 10 women aged 30-49 years is screened for breast cancer, while less than one in three women is screened for cervical cancer in India. Women in high-risk groups, such as those in poor socioeconomic conditions, illiterates, OCP users, tobacco users, higher parity, and poor dietary habits are less likely to be screened when compared to women without any risk factors. Hence, it is important to spread awareness and increase access to screening services among these target groups to achieve early diagnosis of breast and cervical cancer and better treatment outcomes.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.ORCID iDs
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]