Cervical Cancer Screening in an Early Diagnosis and Screening Center in Mersin , Turkey

Cancer is a major public health problem both in Turkey and worldwide due to its disease burden, fatality and tendency for increased incidence (Sahin et al., 2013). Of all cancer types cervical cancer is the fourth most common cancer in women, and the seventh overall, with an estimated 528,000 new cases worldwide in 2012 (Ferlay et al., 2013). The global burden of cervical cancer is disproportionately high among the developing countries where 85% of the estimated new cases occur (Ali et al., 2012). On the contrary developed countries have been successful in controlling the incidence of cervix cancer largely due to the widespread and systematic use of the Papanicolaou (Pap) smear test which is an effective, easily applicable, low-cost, harmless and high-sensitive method of early diagnosis, reducing treatment burden, morbidity and mortality (Elovainio et al., 1997). Cervical cancer has a long preclinical detection phase consisting of slowly progressing precancerous lesions such as


Introduction
Cancer is a major public health problem both in Turkey and worldwide due to its disease burden, fatality and tendency for increased incidence (Sahin et al., 2013).Of all cancer types cervical cancer is the fourth most common cancer in women, and the seventh overall, with an estimated 528,000 new cases worldwide in 2012 (Ferlay et al., 2013).The global burden of cervical cancer is disproportionately high among the developing countries where 85% of the estimated new cases occur (Ali et al., 2012).
On the contrary developed countries have been successful in controlling the incidence of cervix cancer largely due to the widespread and systematic use of the Papanicolaou (Pap) smear test which is an effective, easily applicable, low-cost, harmless and high-sensitive method of early diagnosis, reducing treatment burden, morbidity and mortality (Elovainio et al., 1997).Cervical cancer has a long preclinical detection phase consisting of slowly progressing precancerous lesions such as

Cervical Cancer Screening in an Early Diagnosis and Screening Center in Mersin, Turkey
Tufan Nayir 1 , Ramazan Azim Okyay 2 *, Ersin Nazlican 3 , Hakki Yesilyurt 4 , Muhsin Akbaba 3 , Berrin Ilhan 1 , Aytekin Kemik 1 CIN 2 and 3 and adenocarcinoma in situ, caused by persistent infection with one of the oncogenic types of HPV, particularly HPV 16 and 18.The precursor lesions may progress to invasive cervical cancer over a period of 1 to 4 decades.Therefore, screening programs such as Pap smear screenings play an important role in cervical cancer prevention (Sankaranarayanan, 2014).Pathological changes in epithelial tissues can be diagnosed with the Pap smear test even when there is no indication (Ozdemir and Bilgili, 2010).The valueof the cervical cancer screening in reducing the risk of cervical cancer and mortality has been firmly established, and it is estimated that regular screening reduces the risk of cancer up to 80% (Stewart and Kleihues, 2003;Ozgül, 2010).
Being the eighth most common cancer type in terms of both incidence and cause of death, cervix cancer is a remarkable health problem in Turkey which is a country with a young population (Kaya, 2009;Ozgul, 2010).In Turkey, cancer screening activities are mainly being conducted by two health institutions of the Turkish Ministry of Health; by "Early Diagnosis and Screening Centers for Cancer" (abbreviated as KETEM in Turkish) and by "Mother and Child Care and Family Planning Centers" in the context of the Reproductive Health Program and by means of the polyclinic and clinic activities at the hospitals (Demirhindi et al., 2012).
The purpose of this study is to present the results of a screening survey for cervical cancer targeting women population living in an urban area in the province of Mersin, located at the Mediterranean region of Turkey.The survey also aims to raise population awareness and level of knowledge about cancers besides early diagnosis and cancer prevention.

Materials and Methods
This community-based descriptive study included women living at Akdeniz county of Mersin province.Akdeniz county is an urban district of Mersin province with a population of 53.277 women between 35-65 ages which is the accepted target population for cervical screening according to national standards for cervical cancer screening (Turkish Ministry of Health, 2009).
A total of 1032 screened women between 30 and 65 ages within the routine screening programme conducted by the Early Diagnosis, Screening and Education Center for Cancer of the Mersin Province (KETEM) constituted the study population.
The study was carried out between January and June 2013.The women in the study group were educated about all types of cancer, but in particular about cervical cancer by the researchers.The local population was also informed about the subject by the help of printed handouts and posters.The names and addresses of women in the study group were listed and home visits were performed to inform them about the study and invite them at the proper time of their menstrual cycle in groups of ten to the KETEM where a room was specifically equipped for cervical smear.
The women who arrived at the KETEM to participate in the study signed an informed consent form after being re-informed and clarified for any question.A questionnaire about personal information, history of reproductive health and physical examination was filled for every woman followed by cervical smear sampling by brushing method at the transformation zone of the cervix according to medical literature (Fiscella and Franks, 1999).The samples obtained and carefully fixed with ethanol were transferred to the cytology laboratory before the end of the official working hours.The maximum attention was paid during the process taking into account that cervix carcinomas were greatly missed due to defects in sampling and evaluation procedures associated with 30% of the new cases of cervical cancer each year (ACOG, 2009).
The women who did not care about the rules sited below and previously declared at home visits, which were also depicted at the handouts, were not sampled and re-invited for the procedure: 1) A sexual abstinence of at least 48 hours before sampling, 2) No vaginal douching since 24 hours before sampling, 3) No use of any vaginal medication (cream, tablets or any form) since 48 hours before sampling, 4) No menstrual bleeding.
Cytology laboratory reported the examination results according to the Bethesda III classification system (2001).In Bethesda classification smears' cytology abnormalities were classifid under 3 categories: atypical squamous cells (ASC); low-grade squamous intraepithelial lesions (LSIL); and high-grade squamous intraepithelial lesions (HSIL).The ASC category was subdivided into 2 categories: the unknown signifiance category (ASC-US); and the one, which high-grade lesions cannot be excluded (ASC-H) (Apgar et al., 2003).
The data were analyzed by SPSS 11.5 statistical package program.

Results
The number of women agreed to participate in the  study was 1032.The mean age of the participants was 43.8±8.6 (min.30, max.65) years.The main education level was primary school (54.9%), and the majority of participating women were principally unpaid domestic workers (91.8%).The characteristics of participants are presented in Table 1.
The most common gynecological symptom in participants was abnormal vaginal discharge with 30.1%.The percentage of the participants who had previously undergone smear was 40.6%.History and clinical presentation of participants included in the study is presented in Table 2.
Epithelial cell changes were found to be in 26 (2.5%) participants with ASC-US in 18 (1.7%),ASC-H in 2 (0.2%), LSIL in 5 (0.5%) and HSIL in 1 (0.1%).The most observed clinical presentation together with epithelial changes was abnormal vaginal discharge.In 25 (96.1%)participants with epithelial changes abnormal vaginal discharge was present.Another remarkable finding is that the 24(92.3%) of the participants with epithelial changes had primary school or lower education levels.Comparison of epithelial cell changes found in our study with other similar studies is presented in Table 3.

Discussion
Cervical cancer is the most widely screened cancer in the world both in high-and middle-income countries.Population-based cervical cytology screening programs offering Papanicolaou testing every 3 to 4 years have reduced cervical cancer incidence and mortality by up to 80% in developed countries of Europe, North America, Japan, Australia, and New Zealand in the past 5 decades (Stewart and Kleihues, 2003).This has emphasized the key role of effective screening program to detect precancerous lesions that could develop into invasive cancer (IdestrOm et al., 2002;Saraiya, 2003) as in the example of a cervical cancer screening program in Taiwan that achieved a 47.8% of decrease in the incidence of invasive cervix cancer between 1995 and 2006 (Chen et al., 2009).
The mean age of the participants was 43.8.It is thought that the average age of the women population included in the study was appropriate considering the fact that the most common age to develop cervical cancer is between 40 and 50 years, and its precursor lesions usually occur 5-10 years prior (Banik et al., 2011).The most observed clinical presentation together with epithelial changes was abnormal vaginal discharge.It is well known that HPV infection, intraepithelial lesions and abnormal vaginal discharge is closely associated (Ojiyi et al., 2013;Vaidya, 2003).As it points out unhealthy cervix, abnormal vaginal discharge sholud not be overlooked (Singh et al., 1992).
In this study, 40.6% of participants had previously undergone the Pap smear test while in other studies conducted in Turkey have reported a rate of 10% and 20% (Demirhindi et al., 2012;Sevil et al., 2013;Karabulutlu, 2013).This might result from the methodological differences between studies.On the other hand in developed countries this rate is near 90% (Solomon et al., 2007).Conclusively, it seems that the awareness and performance of Turkish women is weaker.
Epithelial cell changes were found to be in 2.5% of the participants with ASC-US in 1.7%, ASC-H in 0.2%, LSIL in 0.5% and HSIL in 0.1% in this study.Sengul et. al (2014) found an overall prevalence of the cytological abnormality 1.83%, with ASCUS in 1.18%, LSIL in 0.39%, HSIL in 0.16%, atypical glandular cells of undetermined significance (AGUS) in 0.07% and squamous cell carcinoma in 0.02% in an hospital setting.Mehmetoğlu et al. (2010) reported epithelial cell anomalies in 1.2% of the cases among them 0.6% was LSIL and 0.6% was HSIL in a study performed in 332 married women attending a Family Medicine Clinic in Bursa Province of Turkey in 2010.Turkish Cervical Cancer and Cervical Cytology Group ( 2009) performed an important study with the participation of 33 healthcare centers including 140334 women for the evaluation of the prevalence of cervical cytological abnormalities in Turkey.Their overall prevalence of cytological abnormality was 1.8% and prevalence of ASCUS, LSIL, HSIL, and atypical glandular cells (AGC) was 1.07%, 0.30%, 0.17% and 0.08%, respectively.Another study performed in Turkey by Eroğlu et al. (2008) among applicants to Konya provincial KETEM (Early diagnosis, screening and education center for cancer) for cervical smear reported cytology results as ASC-US in 0.5%, LSIL in 0.02% and HSIL in 0.02%.Oner et al. ( 2004) examined 17 years old and older married women in Doğankent, a semirural area of Adana province, in the Mediterranean region of Turkey and reported epithelial cell changes 1.8% with ASC-US in 1.1%, LSIL in 0.4% and HSIL in 0.4%.Comparison of epithelial cell changes with other similar studies carried out in Turkey is highlighted in Table 3.Although there are differences in the findings obtained in these studies, the diversity is likely due to differences in the methodology of the studies.While some of the above-mentioned studies were designed as community-based researches such as ours, in the other studies, participants were chosen among women admitted to the health care providers.In addition, the age groups included in these studies vary.Nevertheless, when compared with studies conducted in the western communities the rates are quite lower in Turkey (Kulig et al., 2006;Duggan et al., 2006).
The 26 participants with abnormal epithelial changes were referred to gynecology outpatient clinics for advanced diagnosis and treatment, where gynecologists who examined the patients performed colposcopies to take cervical biopsies.In one of them, squamous cell carcinoma was detected and total abdominal hysterectomy and bilateral salpingo-oophorectomy operation was performed.
In conclusion, the incidence, mortality, and morbidity of cervical cancer have been reduced by means of early detection of the cervical abnormalities particularly in the developed countries having the regular cervical cancer screening programmes.Cervical cancer screening remains an evolving field with new HPV DNA tests, and development of new technologies.However, Pap smear test is effective, easily applicable, low-cost, harmless and high-sensitive method of early diagnosis, reducing treatment burden, morbidity and mortality, and have been embraced as the effective population screening method extensively.Taking into account the presence of women who had never undergone Pap test; it should be offered at primary level of health care in the form of a community-based service.The community should be enlightened about Pap smear test, including its aim, the required frequency of application, by diffuse educational activities, media programs.The aim should be the establishment of a well organized, continuous and community-based cervical cancer screening program; with final conclusion of reduced morbidity and mortality.

Table 3 . Comparison of Epithelial Cell Changes with Other Similar Studies
* Turkish Cervical Cancer and Cervical Cytology Research Group