Outcomes of screening to prevent cancer: analysis of cumulative incidence of cervical abnormality and modelling of cases and deaths preventedBMJ 2003; 326 doi: https://doi.org/10.1136/bmj.326.7395.901 (Published 26 April 2003) Cite this as: BMJ 2003;326:901
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A study on the knowledge of women in Blantyre, Malawi about cervical cancer and the cervical smear test(1997).
Cervical cancer is the cause of increased morbidity and mortality
rates in Malawi among women. Lack of cervical cancer screening programmes
and activities to raise the awareness of women pertaining to cervical
cancer are contributing factors to this problem.
Literature and research elsewhere has revealed that, lack of
programmes or services that increase awareness and knowledge of women
about the disease has been linked with high morbidity and mortality rates.
This descriptive study was conducted to assess the knowledge and
awareness of women in Blantyre Malawi, pertaining to cervical cancer and
the smear test. qualitative and quantitative approaches of research were
employed. One hundred women who were attending ante-natal family planning
and the under five’s clinics at Queen Elizabeth Central Hospital in July
and August 1998, were interviewed using a structured interview schedule
which had been pilot tested. The respondents were selected to participate
in this study using a non-probability type of sampling technique. Verbal
consent was sought from the respondents before collecting the data.
Professional collaborative evidence was also solicited from one of
the hospital doctor’s and three nurse’s using an interview guide. In
addition, data from the family planning clinic documents concerning
cervical cancer and the smear test were also examined.
The results of the study revealed that the knowledge and awareness
level of women pertaining to cervical cancer and the smear test was low,
but the knowledge and awareness level about cancer was high. The majority
of the women (89%) had not heard anything about cervical cancer.
The remaining 11% although aware of cervical cancer had not heard
about the cervical smear test. Five of these women had gained their
knowledge about cervical cancer from the radio. Although no respondents
had a cervical smear test, the majority were willing to do so given the
Thirty three percent of the respondents agreed to pay for the test if
given the choice. The others (65.9%) would not pay for the test because
they could not afford to. The amount of money the respondents were
prepared to pay was about MK46 (which is equivalent to 99 pence).
There is need to raise Malawian women’s awareness and knowledge on
cervical cancer and the smear test. Health personnel are the main sources
of the information about the disease, prevention and treatment.
Therefore, they should be in the forefront to disseminate health
information about cervical cancer and the smear test. The mass health
education activities which have been initiated by the National Cancer
Association of Malawi, should be strengthened. Coverage should be wide
spread, so that women in the remote or rural areas get the information.
The researcher recommended that the government introduce affordable and
accessible cervical cancer smear services. The services are now in place.
Project Hope and John Hopkins have initiated cervical smear services in
Competing interests: No competing interests
Dr. Raffle and colleagues provide interesting new data on the
outcome of cervical screening. It is particularly useful to be able to
tell women that over 20 years of five-yearly screening, approximately 16%
will have an abnormal smear, 8% will have a biopsy and 4% will be treated
for high-grade disease. The authors also estimate the number of cancers
and deaths that might be prevented over 30 years in such a cohort. It is
unclear exactly how they obtained their estimates, but numbers are
surprisingly low. When estimating the number of premature deaths avoided
in screened women, they apply the factor 60% obtained from a population in
which approximately 1 in 5 eligible women are not screened regularly. In
screened women the figure should be closer to 75%, which is more in
keeping with the results from case-control studies[2,3].
Fitting an age-cohort model to mortality data from England and Wales
for 1950 to 1987 and extrapolating to 2011, we estimate the cumulative
number of deaths in an unscreened cohort to be approximately 50% greater
than the authors. Assuming that 75% of the deaths after 1996 would be
prevented in a screened cohort, the number of premature deaths avoided is
2.4 times greater than in the paper. Over the next 30 years, the effect of
screening in women born in the early 1960s will be much greater -
approximately 2% of those screened will be prevented from getting cervical
Describing the benefits of screening in terms of the number needed to
be screened in order to prevent one death, equates screening with
treatment. Screening is not treatment. It is perhaps better to think of it
as insurance. The issue is not how many need to be insured in order for
one person to avoid bankruptcy. It is not even simply a question of
whether the cost of insurance premium is more or less than the expected
pay out (it will always be more). Insurance is put in place in order to
avoid catastrophic consequences of an unlikely event. Women need to be
aware of the common negative consequences of regular screening, but they
should perhaps think of it as a costly and imperfect insurance policy that
may save them from the horrors of invasive cervical cancer.
1. Raffle AE, Alden B, Quinn M, Babb PJ, Brett MT. Outcomes of
screening to prevent cancer: analysis of cumulative incidence of cervical
abnormality and modelling of cases and deaths prevented. BMJ.
2. IARC Working Group on evaluation of cervical cancer screening
programmes. Screening for squamous cervical cancer: duration of low risk
after negative results of cervical cytology and its implication for
screening policies. BMJ. 1986;293:659-64.
3. Sasieni PD, Cuzick J, Lynch-Farmery E. Estimating the efficacy of
screening by auditing smear histories of women with and without cervical
cancer. The National Co-ordinating Network for Cervical Screening Working
Group. Br J Cancer. 1996;73:1001-5.
Funded by Cancer Research UK. Additional funding from the NHS Cervical Screening Programme
Competing interests: No competing interests