Journal of Nepal Health Research Council

Knowledge and Attitude Towards Human Papilloma Virus and Human Papilloma Virus Vaccine

Background: Human papilloma virus is the leading cause of cervical cancer with Human papilloma virus 16 and 18 being the commonest variants. The primary prevention by vaccination against HPV is finally gaining its momentum. This study aimed to evaluate the knowledge and attitude towards Human papilloma virus and Human papilloma virus vaccine and highlighted on the setback of their inadequate knowledge.Methods: This was a community based cross sectional study done among 120 women who attended cervical cancer screening camp at satellite clinic of Paropakar Maternity and Women`s Hospital at Bhaisepati of Kathmandu district. The interview was done one on one with a preformed questionnaire. Data was primarily entered in an individual form and analysis was done using SPSS version 23 program and was depicted in tables, diagrams and chart.Results: The mean age of the women was 41.8±9.9 with majority belonging to age group 41-50 years (47.16%), 88 (74%) women were multiparous,59 (49%) were uneducated and 50 (33%) were previously screened for cervical cancer. Among 27 (22%) of the women who had heard about HPV and knew that it causes cervical cancer, most of them have heard from social media while 110(91.6%) did not know about its vaccine and its availability while 100% of the participants had positive attitude towards receiving the information and keen on vaccinating their daughters.Conclusions: Knowledge and awareness of Human Papilloma Virus and its vaccine still remains low among the women in our society. However, there was high acceptance of HPV vaccine, indicating potentially high uptake rates in these communities. Keywords: Attitude; human papilloma virus; knowledge; vaccine.

Burden of Reproductive Organ Cancer of Females in the Population-based Cancer Registry in Nepal

Background: There are sporadic facility-based reports but an information gap in the cancer burden in the community is apparent. To address this, the Nepal Health Research Council (NHRC) started a Population-based Cancer Registry (PBCR) in 2018 in the country. Thus, this study aims to identify the cancer burden in the female population, especially in the reproductive organs.  Methods: A quantitative database analysis of the Population-based Cancer Registry for year 2018 and 2019 was performed. Data entered in the TSV (Tab-separated values) files were imported to MS Excel and SPSS data Window and variables regrouped before analysis. The national census, WHO standardized population, and registry data were used for the descriptive analysis of the registry variables. Ethical approval was taken from the Ethical Review Board of NHRC. Result: Out of 6854 cancer registries, the female population was 3590 with a male-to-female ratio of 10:11. This registry covers 10.75% of the country’s population. The crude and age-standardized cancer incidence rates were 1.24% and 66.2 per 100,000 for the female population respectively. Reproductive organs (21%) and breast (19.7%) cancers are the most common in females, and out of reproductive organs cervical (58%) and ovarian (25%) cancers are the commonest. Surgery was the main treatment modality (32.7%) with or without chemotherapy and radiotherapy.Conclusions: The burden of cancer is higher in females because of breast cancer. Reproductive organ cancers and breast cancers share an equal burden of around 20% each. The most common female genital cancer is of uterine cervix followed by the ovary. Keywords: Breast; burden of cancer; cancer registry; cervix; ovary.

Awareness and Attitude Regarding Cervical Cancer Screening among Reproductive Age Women

Background: Cervical cancer is preventable so awareness can be as effective as any other method to prevent it.The study aims to assess awareness and attitude regarding cervical cancer screening among reproductive age women in a tertiary level hospital, Kathmandu, Nepal. Methods: A descriptive cross sectional study was carried out among 170 reproductive age women attending Nepal Medical College Teaching Hospital using purposive sampling technique. A semi structured interview schedule was used to collect data via face to face interview. Data was summarized using frequency, percentage, mean and standard deviation. Multiple logistic regression was used to determine the factors associated with awareness and attitude. Results: Among 170 reproductive age women, mean age was 31.49 ± 8.70 years. Majority 151 (88.8%) of the women had heard of cervical cancer while 119 (70%) of them had heard about cervical cancer screening. Among them, only 17 (11.3%) had adequate awareness regarding cervical cancer screening. Seventy five (46.6%) of the women had positive attitude towards cervical cancer screening. Employment status [95% CI (0.01-0.38), AOR=0.06, p=0.003] was associated with awareness whereas, ethnicity, employment status and marital status were associated with attitude. Conclusions: Most of the women were unaware about the cervical cancer screening but nearly half of the respondents had positive attitude. Therefore it is very crucial to provide health education and awareness through supervised client education. Focused group discussion as an effective approach of awareness program can be conducted in order to include specific group such as unemployed and unmarried women. Keywords: Attitude; awareness; cervical cancer; reproductive age women; screening

Evaluation of Visual Inspection of Cervix with Acetic Acid and Liquid Based in Cervical Cancer Screening with Cervical Biopsy

Background: Cervical cancer is the second most common cancer among women in developing countries. Cervical cancer generally develops slowly over a period of 10-15 years. Incidence and mortality related to cervical cancer both have declining in developed countries because of effective screening programs through Papanicolaou smear. Therefore, cervical cancer can be prevented through implementation of different methods of screening programs like visual inspection of cervix with application of acetic acid visual inspection with acetic acid, liquid based cytology and human papilloma virus deoxyribonucleic acid. The purpose of this study is to compare the efficacy of  visual inspection with Acetic Acid with liquid based cytology in cervical cancer screening taking cervical biopsy as a gold standard.
 Methods: The study was conducted at Paropakar Maternity and Women’s Hospital, Kathmandu. One hundred forty four patients underwent visual inspection with acetic acid and liquid based cytology test followed by biopsy for confirmation of the lesion, when required. Data were obtained and statistically analyzed.
 Results: Out of 144 screened patients, 62 (43.05%) were positive in visual inspection with acetic acid test. Eighteen (12.5%) cases were positive in liquid based cytology. Thirteen women were positive with both tests. Thirty-nine cases underwent histopathological examination including 13 cases who were positive in both tests. The sensitivity, specificity, positive predictive value and negative predictive value for visual inspection with acetic acid was 81.25%, 65.22%, 61.90% and 83.33%, whereas for liquid based cytology it was 100%, 91.30%, 88.89% and 94.87% respectively.
 Conclusions: Liquid based cytology was more efficacious to diagnose atypical cells with higher sensitivity and specificity in comparison to that of  visual Inspection with Acetic Acid test.
 Keywords: Cervical cancer; liquid based cytology; visual inspection with acetic acid

Detection of Cervical Precancer Using Visual Inspection Method with Acetic Acid

Background: Cervical cancer screening is the priority activity of the government. Visual inspection with Acetic acid (VIA), Pap smear Liquid-based cytology, and HPV DNA testing are different methods of screening. VIA-based screening is the cost-effective method of screening in a resource-constrained setting like in our country as this doesn’t require cyto-histological testing, can be performed by trained paramedics too, and is as accurate as a cytological test.The aim is to explore pre-cancer cervical lesions by screening women in the community by visual inspection using acetic-acid.Methods: Community-based cross-sectional study done at a health camp setting for three months from March to June 2023. The married non-pregnant women of 30-60 years were screened. Descriptive tests as well as sub-group analysis performed by Chi-Square tests.Results: From ten community health camps, 1255 cases were screened and screen positivity was 14.3%. Positive results were proportionately distributed to all parity by 13-19%. Half of the positive results (47.2%) were in the 34-40 age group. There were no significant differences in screen positivity by parity or vaginal discharge. Menopausal women had 7.7% screen positivity.Conclusions: The prevalence of VIA positivity in the community was found double the previous facility-based prevalence; and there was no significant difference by parity, menopausal status, and vaginal discharge. The positivity was more in 30-45 years of age.Keywords: Cervical pre-cancer; screening; VIA.

Diagnostic Accuracy of Risk of Malignancy Indices in Ovarian Tumor

Background: Screening test for ovarian cancer has not been developed yet but several tools exist to predict it. The aim is to find out the relative accuracy of commonly practiced versions of Risk of Malignancy Indices to predict ovarian malignancy pre-operatively.Methods: Intention to treat cross sectional study at Paropakar Maternity and Women’s Hospital in Kathmandu during last six months of year 2018. Cases with ovarian mass were taken pre-operatively with serum tumor markers, ultrasound and tumor Doppler study report. Pregnancy and diagnosed malignancy were excluded. Histopathology report traced post-operatively. All five versions of Risk of Malignancy Indices were analyzed by their predictive efficiency and different cut-off value of CA-125.Results: 116 cases of ovarian tumor from 14 to 76 years (mean=35.2±11.7) were studied. There were 8.6% (n=10) malignant pathology; and isolated high vascular flow and solid component may predict malignancy (p=0.000). Up to 12 multiples of normal CA-125 value could not demonstrate clear predictive value for malignancy (p=0.061). By sensitivity, specificity, diagnostic accuracy and predictive values were similar for Risk of Malignancy Indices-1 and RMI-5 as well as Risk of Malignancy Indices-2 and Risk of Malignancy Indices-3. Cut-off of 250 is efficient by >90% and best at 300. Sensitivity of all Risk of Malignancy Indices versions were similar at cut-off level of 200, 250 and 300.Conclusions: Isolated value of CA-125 and size of tumor are not useful. All Risk of Malignancy Indices versions are reasonably good. Risk of Malignancy Indices value of 250 or more is the best predictive cut-off. Risk of Malignancy Indices-1 and Risk of Malignancy Indices-5 as well as Risk of Malignancy Indices-2 and Risk of Malignancy Indices-3 have similar predictive accuracy. Doppler study is not mandatory.Keywords: Cut-off value; diagnostic accuracy; ovarian cancer; RMI

Ovarian Carcinoma in a Young Pregnant Woman

Ovarian cancer during pregnancy is a rare event. Little is known about the treatment of this condition due to the lack of randomized trials and cohort studies. A case of 28 years female, from Kathmandu, visited Out-Patients Department with complaint of amenorrhea for 8 weeks associated with nausea and occasional pain abdomen. Dating scan was done which showed a single live intrauterine pregnancy corresponding to 8 weeks 4 days of gestation with incidental finding of adnexal cysts in both adnexa, measuring 3.6 x 3.6 cm on right and on left 3.2 x 3.6 cm. The cysts did not show any septations. At 38 weeks, she underwent caesarean section and delivered a healthy baby girl. Intra-operatively, bilateral ovarian cysts were identified, both 2x2 cm simple-looking cysts. Enucleation of bilateral ovarian cysts was done. The specimen was sent for histopathology which showed serous carcinoma of low grade in bilateral ovaries. Staging surgery was then carried out after 6 weeks. Histopathology report showed serous carcinoma of low grade in both ovaries. We present here the case of ovarian cancer during pregnancy.Keywords: Ovarian cancer; pregnancy

Case of Late Recurrence in Early Stage Epithelial Ovarian Cancer

Epithelial ovarian canceris usually diagnosed in late stage with high recurrence rate and fatality. Long term survival in late recurrence is not very common. We present a case of 66 year woman who had come in early stage of epithelial ovarian cancer. She survived despite having recurrence after 13 years following staging laparotomy with TAH with BSO with infracolic omentectomy and six cycles of adjuvant chemotherapy in 2007. She underwent secondary cytoreduction twice, first in 2013 and second in 2020 after she developed large pelvic mass. First secondary cytoreduction histopathology was inclusion cyst and second time it serous adencarcinoma grade III consistent with the histopathology of 2007. Both times she received chemotherapy after secondary cytoreduction including neoadjuvant chemotherapy (NACT) in 2020. She is doing well on follow up and is on oral etoposide.Keywords: Chemotherapy; epithelial ovarian cancer; late recurrence; secondary cytoreduction

Knowledge, Practice and Factors associated with Utilization of Cervical Cancer Screening Services

Background: Cervical cancer is treatable with regular screening and follow-up practices. The utilization of cervical cancer utilization services is found to be unsatisfactory in the context of Nepal. The objective of this study was to assess the factors that influence knowledge, practice, and utilization of cervical cancer screening among women in the Dhulikhel Municipality, Nepal.Methods: A cross-sectional study was conducted on 156 married women residing in Dhulikhel Municipality. The study participants were selected using the convenience sampling method. A standard questionnaire was used to collect the information. This study examined socio-demograhic data, knowledge, practice, and factors associated with cervical cancer screening. Descriptive and inferential statistics were used to analyze the data.Results: Only one-fifth (17.9%) of the participants had received a cervical cancer screening. Most participants possessed a sufficient level, 134 out of 85.9%, of information about cervical cancer and cervical cancer screening. Annual healthcare visits (p=0.00), participant knowledge (p=0.014), and perceived barriers (p=0.001) were statistically significant factors in the uptake of cervical cancer screening. Out of those who felt they were highly susceptible, just one-fourth, or 25%, had undergone cervical cancer screening services.Conclusions: The number of medical visits, participants' knowledge, and perceived barriers had a significant impact on the uptake of cervical cancer screening. However, there was not found any relationship between the use of cervical cancer screening and perceived susceptibility and other socio-demographic factors.Keywords: Cervical cancer; cervical cancer screening; perceived barriers; perceived susceptibility.

Adopting Logic Model to Predict Ovarian Cancer

Background: The Logic model was primarily used in educational programs and then to evaluate tuberculosis control, cervical cancer prevention programs, and cardiovascular disease in health. Unlike cervical cancer, there is a gap in screening for ovarian cancer. However, clinical services exist. Thus, the Logic model has been used to evaluate the service standards for the secondary prevention of ovarian cancer.Methods: This is the multi-centric service evaluation research adopted from the Logic Model. There are four domains namely utility, feasibility, propriety, and accuracy standards in the Logic model that includes 53 question items altogether for each participant. For each item, the participants responded on a Likert scale to assess their satisfaction with the service provided to the patients. There are 5-point satisfaction levels from strongly disagree to agree strongly. The internal consistency of items was calculated and the factor analysis was performed. Software used were Microsoft Excel, SPSS, SPSS Amos, and R. Results: The agreement level of all specialist participants was satisfactory for the current prediction and management approach to ovarian cancer with a median value of 73.5% towards positive sentiment. Cronbach’s alfa was at an acceptable level of more than 0.8 for utility, feasibility, and accuracy domains. The propriety domain had poor yield. Chi-squared test-based model fit is good (Baseline and Factor Models <0.001) and Barlott’s test of sphericity is likely to work (X2=5460.242, df=1378, and p<0.001). Other confirmatory factors were not at an acceptable level.Conclusions: The logic model may work to predict ovarian cancer with an acceptable level of reliability, however for the perfect fit it requires a larger sample size.Keywords: Factor analysis; logic model; ovarian cancer; satisfaction.

Laparoscopic Management of Dermoid Cyst of Ovary is a Safe Procedure

Background: Dermoid cyst, a common benign neoplasm of ovary in women, needs treatment because of the risk of torsion, rupture, and malignant change. Laparoscopic surgery nowadays is the preferred treatment modality, but the only issue is its safety in case of rupture and spillage of its contents with the risk of chemical peritonitis and malignant dissemination. Aim of the study was to find out the safety of laparoscopic surgery for dermoid cyst of ovary.Methods: It was a retrospective study done from January 2017 to December 2019. All the women with diagnosis of dermoid cyst of ovary managed laparoscopically either salpingoophorectomy or cystectomy were taken into study. Analysis of size of the cyst operated, the time taken, spillage rate, duration of hospital stay, and post-operative complications especially chemical peritonitis was done.Results: There were 61 women who had undergone laparoscopic surgery. Laparoscopic cystectomy was done in 68.9% (n=42), laparoscopic salpingoophorectomy in 29.5% (n=18). Mean age of the patient was 31.74±8.38 years. Mean size was 6.21±1.99 cm. Rupture and spillage were observed in 21.3% (n=13) that were > 5cm in diameter (X2= 3.62, p=0.05). Larger the size of the cyst, more the surgical time was noted (X2=6.26, p=0.04). Significant difference in mean operating time in case of cyst rupture and spillage (p=0.004) was observed. Mean hospital stay was 53.5±1.3 hours. No case of chemical peritonitis was observed with spillage. All cases had histopathology of mature cystic teratoma.Conclusions: Laparoscopic surgery is safe for dermoid cyst of ovary even with rupture and spillage of its contents.Keywords: Dermoid cyst; laparoscopy; spillage

Determinants of Uptake of Cervical Cancer Screening among Women Attending Tertiary Level Hospital

Background: Cervical cancer, being the fourth commonest cancer in women worldwide, is also the most frequent cause of cancer deaths among women in developing and underdeveloped countries. Screening is the gold standard to control the disease yet, its uptake is still very low among Nepalese women. Thus, the objective of this study was to find out the determinants of uptake of cervical cancer screening among women.Methods: Data were collected from a total of 220 women visiting gynecology outpatient department of Tribhuvan University Teaching Hospital, Kathmandu by using non-probability purposive sampling technique. Descriptive statistics and binary logistic regression analysis were applied.Results: The study findings revealed that the prevalence of uptake of cervical cancer screening was about one third (38.6%). Educational qualification had a significant association with the uptake of cervical cancer screening (p=0.017). Women’s age (COR=0.267; 95%CI=0.150-0.475), knowledge on availability of health services (COR=5.310; 95% CI=2.947-9.567), awareness on cost of screening services (COR=26.329; 95% CI=12.704-54.566), and knowledge level (COR=2.677; 95%CI= 1.385-5.173) had a significant association with the uptake of cervical cancer screening in bivariate analysis. Age (AOR=0.148; 95%CI=0.058-0.375) and awareness on cost of screening services (AOR=61.048, 95%CI=19.194-194.175) were found as major determinants of uptake of cervical cancer screening. Conclusions: The findings of this study conclude that the prevalence of uptake of cervical cancer screening was below half. Determinants of uptake of cervical cancer screening were age and awareness on the cost of screening services. So, awareness campaigns about cervical cancer screening are very necessary to increase its uptake and to reduce the morbidity and mortality associated with it.Keywords: Cervical cancer screening; determinants; uptake