Screening for Early Detection of Cervical Cancer with Papsmear Examination During the Covid 19 Pandemic in Medan

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CrossMark RESEARCH ARTICLE | MAY 24 2023

Screening for early detection of cervical cancer with pap- smear examination during the Covid 19 pandemic in Medan

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Fatwa Imelda; Heru Santosa; Sarma Lumbanraja; ... et. al

AIP Conference Proceedings 2626, 050004 (2023) https://doi.org/10.1063/5.0136049

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Screening for Early Detection of Cervical Cancer with Pap- smear Examination During the Covid 19 Pandemic in

Medan

Fatwa Imelda

^{1, a)}

, Heru Santosa

²

, Sarma Lumbanraja

³

and Namora Lumongga

¹

1Faculty of Nursing, Universitas Sumatera Utara, Medan 20155, Indonesia

2Faculty of Public Health, Universitas Sumatera Utara, Medan 20155, Indonesia

3Faculty of Medicine, Universitas Sumatera Utara, Medan 20155, Indonesia

a)Corresponding author: [email protected]

Abstract.Cervical cancer become an issue in women’s health in Indonesia. The current condition of the Covid-19 pandemic needs special attention, especially in providing optimal health services to the community. An effective screening that can be used is Pap-smear to detect precancerous lesions. This study was to see the description of the Pap- smear in women at risk of cervical cancer. This study was descriptive that conducted with 150 women of childbearing age. The results show that age of first sexual intercourse above 20 years, no multiple partners, never smoked, husband, does not smoke, parity was 1-2, does not use contraception, does not use vaginal soap, uses modern sanitary napkins, menstrual age is over 12 years, no history families with cancer and the majority of pap-smear results are normal. It is hoped that health workers can improve education and health promotion about cervical cancer prevention by holding seminars or cervical cancer detection examinations by conducting a pap-smear, and women who have had a pap-smear with normal results can have a repeat pap-smear a year later, and on the results of the pap-smear abnormal smears can repeat the pap-smear at 6 months after the previous pap-smear.

INTRODUCTION

The World Health Organization (WHO) states that the incidence of cervical cancer in the world in 2018 reached 570,000 women and around 311,000 people died from this disease [1]. Data obtained from Dharmais Cancer Hospital shows that the incidence of cervical cancer in Indonesia is the second-highest among other cancer cases with an incidence rate of 10.69% [2]. Cervical cancer in developed countries ranks fourth after breast, colorectal and endometrial cancer, while in developing countries it ranks first [3]. Various risk factors have been identified that can increase the risk of cervical cancer, namely sexual intercourse, partner characteristics, gynecological history, diethylstilbesterol, infectious agents, human papillomavirus, herpes simplex virus, smoking, and several other risk factors that are estimated the factors that increase the risk of cervical cancer are oral contraceptives, diet, ethnicity, and social and occupational factors. The human papillomavirus as the cause of cervical cancer was found in 99.7%

of cervical cancer cases. The reason for WHO to assign HPV 16 and HVP 18 can be carcinogenic agents in humans [4].

Cancer cells are the accumulation of several genetic changes that play a role in the incidence of tumorigenesis, tumor progression, and resistance to chemotherapy. Most of these genetic changes result in cell cycle regulation.

Loss of several molecular checkpoints can be found in the development of some tumors because the cell cycle progression becomes dysregulated. The accumulation of genetic changes plays a role in the emergence of chemoresistance which results in the ability of DNA to respond to damage. Detection of damaged DNA is regulated by tumor suppressor p53, if the DNA damage is severe enough, p53 will initiate a program of cell death (apoptosis) [5].

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Cervical cancer patients often come to check themselves after complaints arise and the results of the examination show malignancy at an advanced stage. This can happen due to the lack of public awareness to carry out regular inspections of reproductive organs for the early detection of cervical cancer. Cervical cancer can be prevented through early detection of cervical cancer using the pap-smear.

Women at risk of cervical cancer are recommended for screening. Effective screening programs and often used is pap-smear to detect precancerous lesions have reduced the number of cancer cases in the country has grown but not in developing countries. The sensitivity and specificity of the pap-smear depend on the skill of observation to recognize and classify variations of abnormal cells. For this reason, pap-smears should be performed on women at risk for HPV infection to prevent or control the development of cervical cancer.

METHODS

Design, Location, and Time

This study was a cross-sectional study design using the design of the study by taking measurements or observations of the research subjects at the same time or at a time. It was carried out from June to August 2021 in the Medan Johor.

Sampling

The sample selection was carried out by purposive sampling with the criteria of being willing to participate, women of childbearing age, and negative COVID-19 status at the time of data collection. Based on the minimum subject size calculation formula, a total of 150 respondents were recruited.

Data Collection

Primary data includes the characteristics of respondents namely gender, age, last education, occupation, income in the family, and ethnicity. Pap smear examination was carried out at the Medan Sunggal Health Center.

Respondents who will carry out Pap smear examinations must meet the following requirements: not menstruating, not using vaginal cleaning fluid for 3 days before the Pap smear examination, not having sexual relations for 2 days before the Papsemar examination. Then the respondent cleans the vaginal area and wears special clothes, and the problem is on the examination table, the officer takes cervical fluid by opening the respondent's vagina using a disposable speculum and uterine cervical fluid is taken using a cotton swab and smeared on a glass object and the sample is sent to the pathology laboratory Faculty of Medicine Univeritas Sumatera Utara to read the results of the Papsemar examination. Pasmear's examination results came out one week after the examination. If the Pap smear test results are normal, the respondent is better off coming for an examination 1-2 years later and if the Pap smear test results are not given treatment by a doctor and for an examination 6 months later.

Data Analysis

The data on respondents' characteristics including gender, age, last education, occupation, income, and ethnicity are displayed to show the frequency distribution. Pap smear results were tabulated using univariate analysis in the form of normal and abnormal pap smear percentages

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RESULTS AND DISCUSSION Characteristics Respondent.

Table 1 shows that the majority were 36-45 years old (34%), the majority of respondents' income was above Rp2,499,000 (60%), the majority of respondents have a college education level (58%). The majority of respondents were Muslim (64.7%) and Bataknese (52.7%).

TABLE 1. Characteristics Respondent (n=150)

Characteristics F %

Age

17-25 years 32 21.3

26-35 years 17 11.3

36-45 years 51 34

>45 years 50 33.4

Income

<Rp2.499.000 60 40

>Rp2.499.000 90 60

Educational level

Primary school 5 3.3

Junior-Senior school 58 38.7

Collage 87 58

Religion

Muslim 97 64.7

Christian 53 35.3

Tribe

Javanese 50 33.3

Batakese 79 52.7

Malay 4 2.7

Others 17 11.3

Pap-smear Results Based on Predisposing Factors.

Table 2 shows that the results of the pap-smears were based on predisposing factors with the majority of them having normal results and only 7 out of 150 respondents had abnormal results.

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TABLE 2. Pap-smear Results Based on Predisposing Factors Predisposing factors Frequency % Pap-smear

normal frequency

% Pap-smear abnormal frequency

%

Age of sexual intercourse

< 20 years 11 73.3 10 6.7 1 0.7

>20 years 139 92.7 133 88.7 6 4

Number of multiple partners

No 143 95.3 142 94.7 1 0.7

>1 7 4.7 2 1.3 5 3.3

Smoking

No 133 88.7 126 84 7 4.7

Yes <15 sticks/day 8 5.3 8 5.3 0 0

Yes >15 sticks/day 9 6 9 6 0 0

Husband smokes

No 70 46.7 68 45.3 2 1.3

Yes <15 sticks/day 61 40.7 58 38.7 3 2

Yes >15 sticks/day 19 12.7 17 11.3 2 1.3

Number of Parity

Never 30 20 30 20 0 0

1-2 55 36.7 54 36 1 0.7

3-4 43 28.7 41 27.3 2 1.3

>4 22 14.6 18 12 4 2.7

Duration of contracep- tive use

No using 80 53.3 79 52.7 1 0.7

< 5tahun 36 24 33 22 3 2

> 5 years 34 22.7 31 20.7 3 2

Use of vaginal soal

No using 70 46.7 68 45.3 2 1.3

Using 80 53.3 75 50 5 3.3

Use of sanitary nap- kins

Modern sanitary nap- kins

87 58 82 54.7 5 3.3

Traditional sanitary napkins

47 31.3 46 30.7 1 0.7

Conventional sanitary napkins

16 10.7 15 10 1 0.7

Age of menstruation

<12 years 35 23.3 33 22 2 1.3

>12 years 115 76.7 110 73.3 5 3.3

Family history of can- cer

No 140 93.3 138 92 2 1.3

Yes 10 6.7 5 3.3 5 3.3

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In research conducted by the author, it was found that the majority of respondents had the age of first having sexual intercourse, most of the respondents were at the age above 20 years. Cervical cancer is thought to be a sexually transmitted disease, where some evidence suggests an association between a history of sexual intercourse and the risk of this disease. Thus, women who have sex before the age of 18 are five times more likely to develop cervical cancer (Ferlay J, et al., 2012)

In adult women aged more than 20 years and over, the condition of the reproductive organs begins to experience the aging process, and in theory, it is explained that the risk factors that can increase the incidence of women suffering from cervical cancer are premenarchal and postmenopausal age. Generally, new mucosal cells mature after women are 20 years old and over. A woman has sex in their teens, most vulnerable when done under the age of 16 years. This is related to the maturity of the mucosal cells in the cervix at a young age the mucosal cells in the cervix are immature and that means they are still susceptible to stimulation, so they are not ready to accept external stimuli, including chemicals carried by sperm. Because they are still vulnerable, mucosal cells can change their nature to become cancerous. But when sex is done after the age of 20 years in which the mucosal cells are no longer very susceptible to change. HPV infection is influenced by the age and condition of a person's immunity, these two factors affect the false positive value. A false positive value is a positive HPV DNA test, but after performing other tests such as colposcopy, VIA, and pap-smear, it turns out that there are no abnormalities that refer to cervical cancer. Women over the age of 30 are more likely to have persistent or persistent HPV infection [7].

The majority of respondents did not have multiple partners. Circumcision was once considered a protective factor, but now it is only associated with a reduced risk factor. Case-control studies show that cervical cancer patients are more likely to have active sex with partners who have sex repeatedly. In addition, partners of men with penile cancer or partners of men whose wives died of cervical cancer will also increase the risk of cervical cancer.

This is in line with research conducted by Chinwe R, (2015) that there is a significant relationship (p<0.05) between the incidence of cervical precancerous lesions and the number of sexual partners. This is following the theory that married women increase the risk of cervical cancer due to sexual behavior. Cervical cancer can occur due to sexual activity because, during sexual intercourse, germs can enter the female reproductive organs which can cause infection which if not treated immediately can become cervical cancer after several years [8]. Women who are sexually active at the age of 20-35 years and infected by HPV will suffer from cervical cancer in 10-20 years and women who are married before the age of 20 years will be at risk of cervical cancer because the reproductive organs are not ready to have sexual intercourse at that age. early age, but women who are slow to marry are also a risk factor for cervical cancer because this group of women will continue to ovulate without pause so that stimulation of the endometrium occurs continuously so that it can make endometrial cells turn into cancer cells.

The majority of respondents have never smoked, and the majority of respondents' husbands also do not smoke.

Tobacco contains carcinogenic ingredients, either smoked as cigarettes or chewed cigarettes. Cigarette smoke produces polycyclic aromatic hydrocarbons heterocyclic amine which is highly carcinogenic and mutagen, whereas when chewed it produces nitrosamines. Materials derived from smoked tobacco are found in the cervical sap of women who smoke and can be a carcinogen for viral infections. By research conducted by Lipinwati, (2014)There is a significant relationship (p <0.05) between the incidence of cervical precancerous lesions and exposure to cigarette smoke.

Low-income groups generally have less quantity and quality of food and this affects the body's immunity. There is a strong relationship between the incidence of cervical cancer with low socioeconomic levels. Low-income groups are usually less accessible to quality health services including pap-smear examinations that should be carried out for women aged 35 years and over. Low-income women usually do not pay attention to nutritional status and immunity.

Income is very influential on the incidence of cervical cancer. Low incomes find it difficult to apply personal hygiene, sanitation, and poor health care. According to a study Setyarini, (2009), there is a relationship between cervical cancer and income, where women with low incomes are 4 times more at risk than women with high incomes.

Most of the respondents had a parity of 1-2 children even though the age of menarche or menopause did not affect the risk of cervical cancer, pregnant at a young age and the number of pregnancies or improper delivery management could increase the risk. In line with a study regarding cervical cancer risk factors, the results showed that parity status (p-value=0.000, OR 0.09) [11]. Respondents with parity status of women with the majority of abnormal pap smears were 32.5 with a history of parity 2. Parity more than > 3 had a 16.03 times risk of cervical cancer than people who had parity <3 [10]. Women with high parity are associated with eversion of cervical columnar epithelium during pregnancy which causes new dynamics of immature metaplastic epithelium that can increase the risk of cell transformation and trauma to the cervix, making it easier for HPV infection to occur [12].

Hormonal changes during pregnancy may make women more susceptible to HPV infection or cancer growth.

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The majority have never used hormonal contraception. The risk of noninvasive and invasive cervical cancer has shown an association with oral contraceptives. However, these findings are not always consistent and not all studies can justify risk estimates by controlling for the influence of sexual activity. In line with research conducted by a study, it was found that there was a significant relationship between the length of use of oral contraceptives in women aged >35 years and the incidence of cervical cancer with a p-value of 25,865 [13].

Taking birth control pills for more than 5 years containing progesterone and estrogen has a bad effect on the uterus, namely infection in the uterus, and allows a woman to suffer from uterine cancer [14]. It can be concluded that the use of contraception affects the incidence of cervical cancer. Oral contraceptives with high estrogen levels cause adhesion of Candida albicans which is the bacteria that causes flour albus. Candida albicans can cause adhesions to the vaginal epithelium and is a medium for fungal growth. Candida albicans thrives in an environment of pH 5-6.5, these changes can be asymptomatic or cause infection.

Most of the respondents do not use vaginal soap, the habit of washing the vagina with antiseptics in the form of vaginal washes and deodorants to maintain vaginal hygiene and health or other reasons can increase the risk of cervical cancer. According to the results of a study, it was found that 48% of respondents used ordinary soap with a pH level > 4. The choice of cleaning fluid must also be considered by choosing a special cleanser for the feminine area [15]. Based on the Ministry of Health, the pH level in vaginal washing soap that is allowed is a pH of 3-4. The use of cleansers with a pH level that is too high is not recommended because it will cause the genital skin to become wrinkled and kill bacteria in the vagina.

Most of the respondents used herbal sanitary napkins with menstrual age >12 years, the frequency of changing sanitary napkins as a risk of cervical cancer was more associated with maintaining the cleanliness of the genital organs. Changing sanitary napkins regularly can prevent pathogenic bacteria that trigger the disease. Sanitary pads are very important things for women when a woman is menstruating. However, unwittingly sanitary napkins are one of the causes of female diseases because of the presence of dioxin substances that can cause cancer. A study shows that there is an effect of using sanitary napkins during menstruation on the risk of cervical cancer (p-value=0.001) [16].

There are no hereditary or familial genetic factors with cervical cancer. Genetic changes in several gene classes have been associated with cervical cancer. Tumor necrosis factor (TNF) is involved in initiating cell commitment to apoptosis, and the genes TNFa-8, TNFa-572, TNFa-857, TNFa-863, and TNF G-308A have been associated with a higher incidence of cervical cancer [17]. Irregular periods can be caused by hormonal balance disorders.

CONCLUSION

The Pap smear examination was carried out by implementing a health protocol according to the direction of the COVID-19 group team and the results of the examination showed that the majority had normal pap smears

ACKNOWLEDGEMENT

The author would like to thank to Kementerian Riset dan Teknologi/Badan Riset dan Inovasi Nasional (Kemenristek/BRIN) Direktorat Jenderal Penguatan Inovasi.and who have contributed to this research.

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