Prevalence and risk factors of cervical lesion among married women with low socioeconomic status in China (Preprint)

Abstract

Cervical cancer (CCA) is the fourth most common cancer and the fourth primary cause of cancer-related deaths in women, with an estimated 604,000 new cases and 342,000 deaths worldwide in 2020. The global incidence of CCA is 6.5% in women. In China, CCA ranks sixth among female cancers, with an incidence rate of 11.0 per 100,000 people, accounting for 18.2% of global cervical cancer cases and 5.2% of Chinese cancer cases. Early-stage CCA is often asymptomatic, and the reversible stage of precancerous lesions is relatively long. Early-stage CCA is often asymptomatic, and the reversible stage of precancerous lesions is relatively long. Lesions have a 5–10-year period between the development of cervicitis and that of CCA and are known, at that stage, as precancerous lesions (i.e., cervical intraepithelial neoplasia (CIN), staged as progressive CIN Ⅰ, II, and III). Most countries have developed CCA screening programs. The World Health Organization’s (WHO) global strategy for the elimination of CCA by 2030 aims to reduce the prevalence of CCA to 4 per 100,000 people within the 21st century . High-risk human papillomavirus (HPV) proves a major cause of cervical intraepithelial neoplasia, which can develop into CCA if left untreated . Most HPV infections cause low-grade squamous epithelial lesions; they spontaneously regress in more than 90% of cases, though they eventually progress to high-grade lesions in approximately 10% of cases and even less frequently evolve into invasive CCA. Studies have shown that women with CIN III have a twofold increased risk of developing cervical cancer in the long term, even after completing treatment and following up with regular screenings . Therefore, the prevention of CCA is necessary. HPV vaccination and regular CCA screening are effective for preventing CCA. The WHO recommends screening women with the ages of 30 to 49 for CCA; however, in low-and middle-income countries with a high disease burden, two in three women in this age group are not screened for CCA. In China, the screening rate for CCA is very low in women aged 35–64 years. These women have a high incidence of cervical lesions, including CCA; therefore, screening for CCA is necessary. The detection and correction of risk factors in this age group will aid in the prevention of CCA. The risk factors of cervical lesions in rural women have received much attention at home and abroad, but there are significant differences in the results of studies of varying regions and socioeconomic statuses. In most studies in worldwide, rural women have lower levels of education, and urban women have lower income, leading to decreased awareness pertaining to lower CCA awareness and screening rates, as well as decreased less awareness regarding of risky sexual behavior, including not using such as using contraception, which can accelerate to the development of cervical lesions. However, there are few systematic studies on women of low socioeconomic status worldwide, and the incidence and risk factors of cervical lesions vary significantly with regions and social and cultural backgrounds. To help such vulnerable groups, China offered free CCA screening to rural women in 2009 and expanded screening to rural and urban subsistence (i.e., urban women with non-agricultural household registration whose per capita household income is below the local minimum standard of living) women in 2020. In a study by Zhao et al, a data analysis conducted by the National Cervical Cancer Screening Program in 2021 in rural China showed that the early detection rate increased from 89.60% (11,883) in 2012 to 92.80% (26,962) in 2018 (p<0.001). Jinan is the capital city of Shandong Province in China, with a permanent population of 8.91 million and about 500,000 rural women and urban subsistence women in need of CCA screening. Therefore, there is an urgent need to understand the risk factors associated with cervical lesions in women with low socioeconomic status. This study comprised rural and urban subsistence women in Jinan, China, whose socioeconomic status is low. All rural and urban subsistence women were accepted for CCA screening. All participants were offered ThinPrep cytology tests (TCT)and HPV tests to evaluate the prevalence of cervical lesions, estimate risk factors of cervical lesions, make practical suggestions on risk factors, and provide evidence for nationwide prevention strategies for CCA programs.

This study aimed to investigate the prevalence of cervical lesions in married women with low socioeconomic status, and the related risk factors to provide evidence for the development of cervical cancer prevention strategies.

We obtained data from the Cervical Cancer Screening Program database of Jinan, Shandong Province in 2020. Descriptive analysis was employed to estimate the prevalence of cervical lesions. Univariate analysis and binary logistic regression were used to investigate the association between the related variables and cervical intraepithelial neoplasia (CIN).

Among 142677 women aged 35-64 years, 787 (0.55%) cervical lesions were detected, of which 503 were CIN Ⅰ, 254 were CIN Ⅱ/Ⅲ, and 30 were invasive cervical cancer. Being in the age group of 35-44 years (Odds Ratio OR=1.33, 95% CI: 1.03–1.72), high or technical secondary school level education (OR= 1.47, 95%CI:1.13-1.90)， living at higher level regions of economic development (OR=1.40, 95%CI:1.16-1.68), and abnormal leukorrhea (OR=1.61, 95% CI:1.07-2.41) were associated with increased risk of cervical lesions. Menopause was found to be protective (OR=0.78, 95% CI: 0.65–0.94).

Married women with lower socioeconomic status had a lower prevalence of cervical lesions but had a higher prevalence of cervical cancer. Women aged 35-44 years, those with high or technical secondary school level education, those living at higher level regions of economic development, those with abnormal leucorrhea, and those being pre-menopause are at higher risk for cervical lesions. Cervical cancer screening and prevention for these women should be strengthened.

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