Presentation of Invasive Cervical Cancer in Bangladesh

Background: Cervical cancer is a disease of significant worldwide morbidity and mortality. More than 85% of the disease occurs in developing countries. Bangladesh, like other developing countries faces a burden ofthe disease. Objective: To find out the different way of presentation of invasive cervical cancer patients. Methods: This cross-sectional study was carried out in the Gynaecologic Oncology wing of the Department of Obstehics and Gynaecology of Bangabandhu Sheikh Mujib Medical University (BSMMU) during l'tJanuary 2007 to 306 April2008. One hundred and four patients with invasive cervical cancer admitted in hospital were enrolled in the study by purposive sampling. All the information were collected in a pre-designed structured questionnaire. Data were analyzed using statistical program SpSS version: 17.0. Frequency distributions were used to present the characteristics of the patients. Chi-square test was calculated and the significant level was set at P< 0.05.Results: Maximum patients (6O.6yA were in stage II. Majority of the patients (61.5%) presented with abnormal bleeding. Exophytic growth was found in the majority of the patients (71.2%). Squamous cell carcinoma was more (92.3%) in the majority of patients and adenocarcinoma was more in younger age group. Conclusion: The status of the patients in this study reflects advanced stage of the disease at presentation and the peak incidence was observed n36-45 yeaxs age group.

enrollment in the study.The information was collected in a pre-designed structured questionnaire by an interviewer.
The questionnaire included the socio-demographic characteristics of the patients, age at diagnosis, parrty, menopausal status, presenting complaints, stage of the disease at diagnosis, type of growth, histology and degree of ditferentiation.Staging was done according to Interna- tional Federation of Gynaecology and Obstetrics (FfGO)   classification.In cases where there were lnore than one presenting symptoffis, the presentation assigned was the one thatprompted the patient to seek medical advice.Data   were rechecked, edited and analyzed using statistical program SPSS version: 17.0.Frequency distribution and cross tabulation were used to present the characteristics of the patients.Chi-square test was calculated and the significant level was set at P<0.05.

Results:
A total of 104 cases of cancer cervix were recruited from the admitted patients in the Gynaecological oncology wing of BSMMU during one year four months period, from 1" January 2007 to 30'h April 2008.Cancer cervix accounted for approximately 7.8% of all gynaecological patients and 70% of all gynaecological malignancies admitted in BSMMU in the year 2001 .
Majority of the patients suffering from cervical cancer were of mean age of 45.21 years with SD*9.75 (range 26-80 years).More than 45% were within the age range of 36-45 years [Figure -1].Forty patients (38.46%) in this study were postmenopausal and sixty-four (61 .54%)were premenopausal.About ninety-eight percent women were multiparous and only two patients (1 .9%)were primipa- rous.Seventeen (16.3%) patients were in stage I, sixty- three (60.6%)were in stage II and twenty (19.2%)were in stage III.Two patients (1.9%) could not be staged properly as they were discharged on risk bond fTable- ll.Maximum patients (32.7%) were found to be in stage IIB at first detection and the least patients(1.9%)were found in stage IV and there were no patient found in stage IA.Regarding presenting complaints, majority of the patients (61.5%) presented with abnormal.vagrnal bleed- ing.Nineteen patients (I8.3%) presented with postmeno- pausal bleeding, twelve patients (11.5%)presented with 30 vaginal discharge and post coital bleeding occurred in six patients (5 .8'%).Only one patient(<l%) had abnormal pap smear report before the diagnosis of the disease[Table -Il].Regarding the type of growth , exophytic growth was found in the majority of the patients(71.2%).The assocra- tion between type of growth (gross appearance of cervix) and stage of the cancer is shown in TableIII.Exophytic growth was more in stage II Cancer and endophytic growth was more in stage III and stage IV cancer.The morphological categ orrzation was squamous cell carci- noma in 92.3% cases and the rest was adenocarcinoma (7 .7%).The majority of patients (39.4%) presented with moderately differentiated or grade II lesion and higher proportion of squamous cell carcinoma was found among 36-45 years of age group [Table-Iv].Moderately differen- tiated tumour were predominant variety in stage II (47.6%), stage III (30%) and stage IV (100%) cancer respectively [Table -V].Well differentiated tumour was predorninant variety in stage I (58.8%) cancer and this was statistically significant (P<0.05).patients in this study was abnormal vaginal bleedir,g (61.S%).This finding is similar to other sfudy6'10 .Report with abnormal pap smear was found in only one patient.
In the study of Pretorius R et al, abnormal pap smear was the presentation in 28o/ocasesto.Comparing the two, the difference in presentation lies in the utihzation of cervical cancer screening programmes.There has been a substantial decline in the incidence of and mortality from cervical cancer in the developed countries.In all populations, there is a direct relationship between the proportion of the population screened and declining incidence of cervical cancer and deaths from cervical cancer.Population-based   screening programs have lead to 50-80% reduction in deaths from cervical cancer in various developed countriest'.In this sfudy, no patient was found in stage IA.
This is an important faet that despite of having no visible growth in cervtx, a suspicious hypertrophic cervix might be harboring cancer.Many of such cases are initially undiagnosed but after surgery the histopathological report revealed cervical cancer.Hence, it is essential that all suspicious looking cervices should be subjected to colposcopy guided biopsy before undertaking definitive treatment.The morphological categ orization of cervical cancer is also important.In this study the percentage of adenocarcinoma is 7 .7%which is compatible with that of Lahore reports (7 .9%)14.There are disparate views on the significance of differentiation with regard to prognosis.Some authors have found that prognosis was more favorable in those with better differentiated tumourslt.In this study maximum (39.4%) patients had moderately differentiated tumour indicating poorer prognosis in those patients.

Conclusion:
The status of the patients of cervical cancer in BSMMU reflects late presentation of the disease and advanced stage of disease at presentation.Given the current socio- economic status, it is unlikely that there will be an appre- ciable decline in the incidence of cervical cancer in Bangladesh in near fufure.Hence, the need is to educate the women about the symptoms of cervical cancer, cervical cancer screening and primary prevention of cervical cancer by HPV vaccination, so that the disease could be identified in a pre invasive or early stage and mortality

Table - I
Stage of cetvical cancer at first detection TL Presentation of Invasive Cerr,zical Cancer in BanTable-II Chief Complaint of the patients **ith cervical cancer (n-104) Chief complaint

Table - V
Association of stage of cancer with histologic gradeCervical cancer is rapidly becoming a major and growing public health hazard and cause of women's morbidity and mortality in our country.The age distribution of patients in this study was similar to that of the study done by Haghdel in Iran6.The peak incidence was in the fifth decade followed b,r an actual apparent decrease after 65.Another study found the rate of decline atter The prognosis of the majority of the patients in this study is therefbre likely to be poor as majority of patients are in advanced stages.Most common presenting complaint of the patients in this sflrdy was abnorrnal vaginal bleeding J VoI. 6. Issue 1. Jan 2013