Chapter 1 Final Durga
Chapter 1 Final Durga
Chapter 1 Final Durga
INTRODUCTION
“ It is often the small steps, not the giant leaps, that brings about
the most lasting change.”
HRM QUEEN ELIZABETH II
Cancer is a group of many diseases. All cancers begin in cells, the body’s basic
building blocks. Normally, cells grow and multiply in an orderly way. However,
damaged genes can cause them to behave abnormally. They may grow into a lump
called a tumor, which may be benign (not cancer) or malignant (cancer). Polyps,
cysts and genital warts are types of benign growths on the cervix. A malignant tumor
is made up of cancer cells, which if are not treated may spread beyond their normal
boundaries and into surrounding tissues by metastasis, becoming invasive cancer.
There are five main types of gynecologic cancers that affect women reproductive
organs: cervical, ovarian, uterine, vaginal and vulvar. Cervical cancer (or cancer of the
cervix) arises from the tissues of the cervix, which is the lower part of the uterus that
connects to the vagina. The function of the cervix include: (i) Producing some of the
moistnessthat lubricate the vagina, (ii) producing the mucus that helps sperm travel up
to the fallopian tube to fertilize an egg from the ovary and (iii) holding a developing
baby in the uterus during pregnancy. During childbirth, the cervix widens to allow the
baby to pass down into the birth canal (vagina). The endocervix (the upper part which
is close to uterus) is covered by glandular cells and the ectocervix (the lower part
which is close to vagina) is covered by squamous cells.The transformation zone
(squamouscolumnar junction) refers to the place where these two regions meet.
There are different types of cervical cancers classified on the basis of where they
develop in the cervix. Cancer that develops in the ectocervix is called squamous cell
carcinoma & around 80-90% cervical cancer cases (> 90% in India) are of this type.
All women are at risk for cervical cancer. It occurs most often in women over age 30.
The Human papillomavirus(HPV), which is passed from one person to another during
sex, is the main cause of cervical cancer. In addition, other things can increase the risk
of cervical cancer include, smoking, having Human immunodeficiency virus(HIV),
using birth control pills for a long time and having given birth to more children’s.
According to GLOBOCAN 2012, with 528,000 new cases every year, cervical cancer
th
is the 4 most common cancer affecting women worldwide, after breast, colorectal
th th
and lung cancers and 7 overall. It is also the 4 most common cause of cancer death
(266,000) deaths in 2012) on women worldwide, accounting for 7.5% of all female
cancer deaths. Almost 445,000 cases of the global burden of cervical cancer falls in
area with lower level of development, leading to 230,000 deaths in 2012. In India
[1]
122,844 new cervical cases are diagnosed annually in India. It’s crude incidence
rate in cervical cancer is 20.2, compared to 15.1 of the world. India’s age standardized
incidence rate in cervical cancer is22.0, compared to 14.0 of the world. Cervical
cancer ranks as the second cause of female cancer in India. India, China, Brazil,
Bangladesh and Nigeria represents more than half of the global burden of cervical
cancer deaths according to Cancer Global Crisis Card released by the cervical cancer
free coalition. The highest number of deaths(72,825) because of cervical cancer was
in India, followed by China(33,914), Brazil(11,055), Bangladesh(10,364),
Nigeria(9659), Indonesia(7493), Pakistan(7311), etc.
Cervical cancer is a disease that is largely preventable, but is one of the leading causes
of death from cancer in women globally. In low and middle-income countries, most
deaths occur. Persistent or chronic infection with one or more of the high-risk (or
oncogenic) HPV forms is the primary cause of cervicalpre-cancer and cancer. HPV is
the most common infection acquired through sexual intercourse, typically early in
sexual life. For the majority of women and men who are infected with HPV of the
reported more than 311 000 cervical cancer deaths per year, more than 85% occur in
low- and middle-income countries. Compared to women without HIV, women living
with HIV are six times more likely to get cervical cancer, and an estimated 5% of all
cases of cervical cancer are due to HIV. Programs that enable girls to be vaccinated
against HPV and women to be screened regularly are in place in high-income
countries. Screening facilitates the detection of pre-cancerous lesions at stages where
they can effectively be treated.
Cancer of the cervix has its peak incidence among women between the ages of 35 and
50 years and is associated with the following risk factors:
The risk of endometrial cancer increase after the age of 50 year, especially among
those women taking estrogens without the additions of progesterone for 5 or more
years during and after menopause, other risk factors include early menarche, late
menopause, never having been pregnant (nulliparity), and obesity. Cervical and
endometrial cancers probably begin as pre-malignant lesions that later undergo
malignant changes. The localized malignancy is referred to as carcinoma in situ.
Untreated, it subsequently invades other areas of the uterus and adjacent tissue.
Cervical cancer is the commonest cancer cause of death among women in developing
countries. Every year in India, 122,844 women are diagnosed with cervical cancer and
67,477 die from the disease. India has a population of 432.2 million women aged 15
years and older who are at risk of developing cancer. It is the second most common
cancer in women aged 15-44 years. India also has the highest age standardized
incidence of cervical cancer in South Asia at 22, compared to 19.2 in Bangladesh, 13
in Sri Lanka, and 2.8 in Iran. Therefore, it is vital to understand the epidemiology of
cervical cancer in India.
In 1998, there were approximately 13,700 cases of invasive cervical cancer diagnosed
and approximately 4900 women in the United States died from cervical cancer. The
mortality rate was twice as high for African- American women as compared with
Caucasian women (a group of people having European ancestry). The incidence is
also higher among Hispanic women (a person who is from, or whose parents and
grandparents are from, a Spanish speaking country) than Caucasian women. An
increased risk of cervical cancer is associated with low economic status, early sexual
activity (before 17 years of age), multiple sexual partners, infection with HPV, and
smoking.
The number of deaths from cervical cancer has fallen steadily over the past 40 years.
This is attributable to better and earlier diagnosis with widespread use of the Pap test.
In addition to cancer, the Pap test detect precancerous changes called cervical
intraepithelial neoplasia (CIN) or dysplasia. By treating dysplasia, progression to
cervical cancer can be prevented.The American Cancer Society recommends annual
Pap test beginning with the onset of sexual activity. Following three negative Pap
tests, less frequent tests may be recommended by the health care provider.
India has a national program for cancer since 1975, when the emphasis was on
equipping premier cancer institutions which by 1984-1985, shifted to primary
prevention and early detection of cancer cases and, by 1990-1991, to the district
cancer control program. As of 2008, creation/recognition of new regional cancer
centers, strengthening of existing regional cancer centers, development of oncology in
medical college hospitals, the district cancer control program, and the decentralized
NGO(non-governmental organization) scheme were the priorities of the program. In
2010, cancer control became a part of a more comprehensive, larger program on non
varied from 6.9% in Kerala to 0.006% and 0.002% in the western state of Maharashtra
and southern state of Tamil Nadu, respectively. Most of the cases (85%) present in
advanced and late stages, and more than half (63%-89%) have regional
disease at the time of presentation. Cervical cancer diagnosis and treatment in the
advanced stages makes it a costly exercise, with a poor prognosis resulting in poor
[5]
compliance. Five-year survival rates in Mumbai population-based cancer registry in
1992-1994 were 47.7% for cervical cancer. Survival was determined by age and the
extent of disease, with younger women having longer survival . In the 1980s the
Bangalore registry reported a 5-year survival of 34.4% and relative survival of
awareness levels.
Eastern and South Africa, Central and South America and the Caribbeans to
report very high incidence of cervical cancer.
Every year cervical cancer is diagnosed in about 500,000 women globally and
is responsible for more than 280,000 deaths annually.
There is a wide variation in the incidence of cervical cancer across the globe.
In the west, early detection through regular screening has aided to significantly
control the prevalence of this disease, thereby, lowering its incidence.
In the last 50 years in the United States, the Pap smear tests have reduced the
deaths related to cervical cancer by three-quarters. At one time cervical cancer
was one of the most dreaded cancer and the leading causes of death in women
in the US but now it is the eighth most common cancer there.
80% of the new cervical cancer cases occur in developing countries, like
India, which reports approximately one fourth of the world's cases of cervical
cancer each year. The number of deaths due to cervical cancer is estimated to
rise to 79,000 by the year 2010.
In urban areas, cancer of the cervix account for over 40% of cancers while in
rural areas it accounts for 65% of cancers as per the information from the
cancer registry in Barshi.
In particular, it recommends an HPV -DNA based test as the preferred method, rather
than visual inspection with acetic acid (VIA) or cytology (commonly known as a 'Pap
smear'), currently the most commonly used methods globally to detect pre-cancer
lesions. HPV-DNA testing detects high-risk strains of HPV which cause almost all
cervical cancers. Unlike tests that rely on visual inspection, HPV-DNA testing is an
objective diagnostic, leaving no space for interpretation of results. Although the
process for a healthcare provider obtaining a cervical sample is similar with both
cytology or HPV-DNA testing, HPV-DNA testing is simpler, prevents more pre-
cancers and cancer, and saves more lives than VIA or cytology. In addition, it is more
[7]
cost-effective. More access to commodities and self-sampling is an other route to
consider for reaching the global strategy target of 70% testing by 2030.
WHO suggests that self-collected samples can be used when providing HPV- DNA
testing. Studies show that women often feel more comfortable taking their own
samples, for instance in the comfort of their own home, rather than going to see a
provider for screening. However, women need to receive appropriate support to feel
confident in managing the process. In recognition of this, the new guideline include
recommendations which are specific for women living with HIV (Human
immunodeficiency virus). This includes using an HPV- DNA primary screening test
followed by a triage test if results are positive for HPV, to evaluate the results for risk
of cervical cancer and need for treatment.
The global recommendations also advise that screening start at an earlier age (25
years of age) than for the general population of women (30 years of age). Women
living with HIV also need to be retested after a shorter time interval following a
positive test and following " treatment than women without HIV.
"With these new guidelines, we must leverage the platforms already developed for
HIV care and treatment to better integrate cervical cancer screening and treatment to
meet the health needs and rights of the diverse group of women living with HIV to
increase access, improve coverage and save lives" Dr. Meg Doherty, Director, WHO
Department of Global HIV, Hepatitis and Sexually Transmitted Infections
Programmes. Human papilloma virus (HPV) is the most common viral infection of
the reproductive tract.
The peak time for acquiring infection for both women and men is shortly after
becoming sexually active. HPV is sexually transmitted, but penetrative sex is not
required for transmission. Skin-to-skin genital contact in a well-recognized mode of
transmission. There are many types of HPV and many do not cause problems. HPV
infections usually clear up without any intervention within a few months after
acquisition, and about 90% clear within 2 years. A small proportion of infections with
certain types of HPV can persist and progress to cervical cancer.
Cervical cancer is by far the most common HPV-related disease. Nearly all cases of
cervical cancer can be attribute able to HPV infection. The infection with certain HPV
types also causes a proportion of cancers of the anus, vulva, vagina, penis which are
preventable using similar primary prevention strategies as those for cervical
cancer.Non-cancer causing types of HPV (especially types 6 and 11) can cause genital
warts and respiratory papillomatosis (a disease in which tumors grow in the air
passages leading from the nose and mouth into the lungs). Although these conditions
very rarely result in death, they may cause significant occurrence of disease. Genital
warts are very common, highly infectious and affect sexual life.
only 5 to 10 years in women with weakened immune systems, such as those with
untreated HIV infection.
HPV type its oncogenicity or cancer-causing strength; Immune status - people who
are immune compromised, such as those living with HIV, are more likely to have
persistent HPV infections and a more rapid progression to pre-cancer and cancer, Co-
infection with other sexually transmitted agents, such as those that cause herpes
Primary prevention is the most cost effective prevention program asit aims to reduce the
incidence of cancer by risk factor modification.Fifty percent of all cancers in males are
tobacco related and a largeproportion of them can be prevented by anti-tobacco programs.
Thishas to be publicized more widely. Teen age students need to betargeted as most of
them pick up habits at this time. The schoolcurricula should involve messages for a
healthy life style and warnabout the harmful effects of tobacco and alcohol. Legislation
has tobe enforced for prohibiting tobacco advertisement and sale of tobaccoto youngsters.
A proportion of cancers are considered to be relatedto the dietary practices and the
importance of a healthy diet rich ingreen and yellow vegetables and fruits has to be
highlighted. Cancerof the uterine cervix can be controlled to a certain extent by
practicinggenital hygiene and safe sexual practices.
answers to our problems through methods which are feasible and evaluable in the
Indian context.
Late stage at presentation is the main reason for the poor survival from cancer in
India. The late presentation is mainly due to the lackof diagnostic facilities at the
peripheral levels. District hospitals in India have the services of specialists and
provide reasonable services.
These hospitals can have a 'Cancer Detection and Prevention Clinic', which will
provide diagnostic services and minimal treatment. The diagnostic services set up in
the hospital can also be of use to all the patients who attend this hospital. Cost
recovery may be attempted from the beginning and an experience in Kerala has
demonstrated that such services are feasible and sustainable. The services as wells the
organ gram of such a centers. This centre in Kerala provides a good range of services
and the cytology services have helped to diagnose cancers at an early stage. Provision
ofPalliative Care services has also been accepted by the community. Capital funding
may be raised through people's participation and from various other sources
and once established, the income generated by the various investigations is sufficient
to run the programme.Existing staff of the hospital can be trained to provide the
services. Regional Cancer Centres can set up cancer detection and prevention centres
in District hospitals.
needed to plan themost appropriate treatment. Radiotherapy services are still the
mainstay of treatment giventhe large proportion of advanced epithelial cancers in
India. Giventhe long waiting lists and the distance that patients
have to travel toreach treatment facilities, optimal strategies have to be identified.
Patients for palliative treatment and curative treatment need to be identified
at the beginning of the treatment plan and palliation may be achieved with the
minimum machine time. An essential drug list has to be prepared for cancer
chemotherapy and chemotherapy services for common cancers have to be made
available in all centres. Advanced facilities for high intensity chemotherapy for
leukemia’s and other cancers were chemotherapy is the mainstay of treatment need be
provided at the Regional Cancer Centres.
Evaluation of the programme has to be undertaken with reliable dataon the incidence
and mortality from cancer. A network of cancerregistries have to be set up towards
this end. Death registration anddeath certification are inadequate and incomplete at
present andcancer registries are the only means of obtaining data on the disease.To
start with hospital based cancer registries can be initiated by the regional cancer
centres and they can later on be expanded topopulation based cancer registries.
Registries under the Indian Councilor Medical research as well as those outside can be
networked. Cancer control programmes may be initiated in Registry areas sothat
effective strategies can be identified by monitoring the registry data.
From the above studies it is clear that there is need to motivate and improve the
knowledge of urban women regarding cervical cancer. The investigator felt the need
To assess the level of knowledge through information booklet regarding
immunization for cervical cancer among school going children’s its cause, risk
factor, warning signs and symptoms, diagnostic evaluation, treatment and prevention.
So that there knowledge can be improved through information booklet. Thus cervical
cancer can be prevented by taking appropriate measure.
Problem statement
OBJECTIVES :-
Operational definition
4. Cervical cancer- Cervical cancer is a cancer arising from the cervix. It is due
to abnormal growth of cells that have the ability to invade or spread to other
part of body.
5. School going children’s – children’s studies in the government higher
secondary school kumhari Raipur, CG. with the age between 6 to 13 years.
Assumption- Women of urban areas may have some knowledge regarding cervical
cancer. Socio demographic variable may influence the women knowledge regarding
regarding immunization for cervical cancer can be improved by an information
booklet.
Delimitation-
• School going children’s who are willing to participate in the research program
CONCEPTUAL FRAMEWORK
A conceptual framework is the abstract, logical structure of meaning that guides the
development of the study and enables the researcher to link the finding to nursing
body of knowledge. Since the study is intended to assess the knowledge regarding
immunization for cervical cancer among school going children’s at selected
Government higher secondary school Kumhari Raipur Chhattisgarh.. in a view with
information booklet.
Conceptual frame work used in this study is based on modified Ludwing Von
Bertalaniffy’s general system of theory. According to the general theory a system
consist of a set of interaction components that are the building blocks of a theory.
The conceptual framework of the present study was developed by the investigator
based on Ludwing Von Bertalaniffy’s general system theory. Bertalaniffy’s general
system theory (1968) describes a set of interacting components of a boundary that
filters the type and late exchange of energy, materials and information with the
environment.
Major concepts:
1. Input
2. Throughput
3. Output
4. Feedback
Input- Input is any form of energy, information material or human that enter into a
system through its boundaries in this study the input refers to urban women with their
characteristics like women age, sex, religion, , father education, father occupation,
family income, previous knowledge , , source of information.
Throughput – Throughput is a process that occurs in between the input and output
process which enable the input to be transferred as output in such a way that it can be
readily used by the system the throughput in this study refers to the self administered
interview schedule To assess the Level of knowledge regarding immunization for
cervical cancer among school going children’s at selected Government higher
secondary school Kumhari Raipur Chhattisgarh.
Output- In this study output refers to the level of knowledge regarding cervical
cancer among urban women such as adequately, moderately adequate and inadequate.
This chapter deals with introduction, need for study, and statement of the problem,
objectives, operational definitions, assumptions, research hypothesis, delimitation, and
conceptual framework.
INPUT Throughput Output
FEEDBACK
Fig 1.1 Conceptual framework based on Ludwin von bertalanffys general system theory 1968