INTRODUCTION

The incidence and mortality of cancer have been increasing; it is estimated that there are 50.9 million people living with cancer according to the report given by the global cancer observatory (GLOBOCAN 2020), the most diagnosed cancer is breast cancer.¹In Peru, there are various health problems; the most important/critical are gynecological cancers, with greater emphasis on breast and cervical cancer (CC). Currently, these two entities constitute one of the main causes of mortality in Peruvian women.²

The World Health Organization (WHO) considers that adequate screening would be related to a reduction in incidence and mortality for the pathologies described.³Among the main screening tests for gynecological cancers in our environment are: Taking a Pap smear, performing a clinical breast exam, and performing a mammogram, which is important for the early diagnosis of cervical cancer and cervical cancer. which constitutes one of the main causes of mortality in the female population.²

It has been shown that adequate screening reduces the incidence and mortality of gynecological cancers. We define screening as timely care performed before the onset of symptoms or the development and progression of pathologies, for this, there are various prevention methods, such as those previously described, characterized by their high efficacy and low cost for the patient; these include the Pap smear, which evaluates the presence of normal or abnormal cells present on the surface of the cervix; the clinical breast exam, which allows evaluating some anatomical alterations of the breasts; and mammography, which consists of an imaging test performed with X-rays, which allows evaluating structural alterations of the breast tissue.⁴

In Peru, there has been high mortality from cervical cancer and breast cancer; much of this has been related to a weak screening system, which sociodemographic, sociocultural, and economic factors influence.²Therefore, an exhaustive analysis of the development of the various strategies adopted is imperative. This article seeks to determine and analyze the factors that influence the interference of screening for gynecological cancers. To measure the variable "Screening for gynecological cancers," we used the variables Pap smear (PAP) and screening for breast cancer (which contains two variables: clinical breast examination and mammography) in women aged 25-69 years, based on the Demographic and Family Health Survey (ENDES) 2019-2020.

METHODS

RESULTS

Ingraph No. 1, the databases for the years 2019 and 2020 were joined, where it was found that 19.3% of women between the ages of 25 and 69 did not have a Pap smear, likewise, no significant difference in taking Pap smears between 2019 (19.3%) and 2020 (19.2%).

Graph 1: Pap test of women aged 25 to 69 in Peru, ENDES 2019-2020. 

Regarding the screening for breast cancer for the year 2019-2020, as shown in graph N°2, it was found that 54.9% of women aged 25 to 69 years did not undergo any screening for breast cancer Likewise, in 2019, 53.6% did not undergo any screening for breast cancer and this percentage for 2020 increases to 56.5%.

Graph 2: Screening for Breast Cancer in women aged 25 to 69 in Peru, ENDES 2019-2020. 

Table No.1presents the general characteristics of our sample, where it is highlighted that in relation to sociodemographic factors, 66% are under 40 years of age, 40.6% have secondary education, 67.1% are married, 60.8% live on the coast, 80.5% live in urban areas and 77.2% have health insurance; With respect to sociocultural factors, 55.1% have the age of beginning sexual relations to have been greater than or equal to 18 years, 60.5% use some contraceptive method and 81.4% have some level of knowledge about screening for gynecological cancers; As an economic factor, we find that 59% do not belong to the poverty level. Regarding the size of the sample for the present analysis, the coefficient of variation was obtained and, as can be seen inTable 1, all are less than 15%, therefore, the sample size is adequate for our study and provides us with results. reliable.

Intable No. 2it is evident that being under 40 years of age increases the interference for taking pap smears by 1.74 (RPa: 1.74, 95% CI: 1.61-1.87); women with primary education have 1.2 more times of presenting interference for taking pap smears (RPa: 1.20, 95% CI: 1.09-1.32); being unmarried is 1.62 more likely to have interference in taking a pap smear (RPa: 1.62, 95% CI: 1.52-1.74); living in the mountains and jungle increases the interference for taking pap smears by 1.33 and 1.57, respectively (RPa: 1.33, CI95%: 1.23-1.44 and PR: 1.57, CI95%: 1.43-1.71); residing in a rural area presents a prevalence ratio of 1.19 of presenting interference for taking pap smears (PRa 1.19, 95% CI: 1.09-1.29); not having health insurance increases the prevalence of interference for taking pap smears by 1.58 (RPa 1.58, 95% CI: 1.48-1.68); not using a contraceptive method increases the interference for taking pap smears by 1.23 (RPa 1.23, 95% CI: 1.15-1.31); women who do not have any knowledge about pap smears have 1.44 more times of presenting interference for taking pap smears (RPa 1.44, 95% CI: 1.34-1.54); and belonging to the poverty level increases the interference for taking pap smears by 1.21 (RPa 1.21, 95% CI: 1.11-1.31), adjusting for the other variables. On the other hand, women with a secondary education level and who began sexual relations before the age of 18 did not have a significant association with interference in taking Pap smears, with a p-value >0.05.

Table 3in the results obtained in factors that interfere with screening for breast cancer it is evident that women with primary and secondary education have 1.58 and 1.42 more times of presenting interference for performing breast screening (RPa: 1.58, CI95%: 1.52-1.65 and RPa: 1.42, CI95%: 1.37-1.47) ; living in the mountains and jungle increase the interference to carry out breast screening in a similar way by 1.21 and 1.20 (RPa: 1.21, CI95%: 1.17-1.25 and RPa: 1.20, CI95%: 1.15-1.25); not having health insurance increases the prevalence of interference for performing breast screening by 1.06 (RPa 1.06, 95% CI: 1.03-1.09); women who do not have any knowledge about gynecological screenings have 1.04 more times to present interference for breast screening (APR 1.04, 95% CI: 1.01-1.07); and belonging to the poverty level increases the interference for breast screening by 1.06 (RPa 1.06, 95% CI: 1.03-1.10). On the other hand, being unmarried, living in a rural area and not using a contraceptive method were not significantly associated with interference in performing breast screening, with a p-value >0.05.

It was also found for the age variable in the analyzed data that in women aged 25-69 years, the proportion of women under 40 years of age not undergoing breast cancer screening is reduced by 41% with respect to the group of women who are older than 40 years.

DISCUSSION

In this research study it is shown that the prevalence of women aged 25 to 69 years interviewed in the ENDES 2019 and 2020 who are not screened for gynecological cancers is 19.3% in cervical cancer and 54.9% in breast cancer.

Regarding the analysis of the factors associated with the interference of screening for cervical cancer, we find that the sociodemographic factors that are significantly associated are: age, level of education, marital status, religion, place of residence and health insurance. In the sociocultural factors, an association was found with: the age of beginning of sexual relations, the contraceptive method and the level of knowledge. Being also significant at the level of wealth in economic factors.

On the other hand, the following sociocultural factors that are significantly associated with the interference of screening for breast cancer: the level of education, the region and the place of residence. Among the sociocultural factors, it was found associated with the variables: contraceptive method and level of knowledge. Wealth level also showed a significant association.

In the last "Health Directive for the prevention of cervical cancer through early detection and treatment of pre-malignant lesions including carcinoma in situ" of 2019, it standardized that screening for cervical cancer (PAP, VIA and Molecular Test for HPV) It should be performed free of charge on all women aged 25-64 years nationwide. Of all these methods, the one that is most widely available for use by health personnel is the Pap smear. Despite the above, there is 19.3% of Peruvian women who do not undergo any screening, which makes us think about the following question: what factors are interfering with taking Pap smears in this percentage of women? After carrying out a detailed analysis, we found that all the study variables constituted a significant relationship in the interference of taking pap smears, becoming risk factors. Comparing with previously carried out studies, we found similar results.^3,4

Factors with statistically significant results such as: being under 40 years of age, low level of knowledge, living in a rural area and only having a primary education level and belonging to the non-poor classification; they have also been described in previous studies carried out in Peru.

Olaza Maguiña (2017) reports that 50% of the population that did not accept the PAP test have a primary education level and 70.4% are under 38 years of age.³In a study carried out in Mexico, it was identified that 43.5% of women who did not undergo PAP only had primary education as their level of education.⁵

Guido Bendezu Quispe (2020) found that there is a 27% higher prevalence of performing a PAP in women who had answered the question Have you heard about cervical cancer? of ENDES 2015-2017 compared to those who did not respond, showing that the level of knowledge was a determining factor for taking PAP.⁽⁴⁾These results are shared by studies carried out in South America, where the factors associated with lack of knowledge, education, marital status, beginning of sexual relations before the age of 18 and not having health insurance are reported, increase the incidence in their population.^5,6,7

Then the need for an intervention in primary prevention based on disseminating tools for the prevention and timely detection of cervical cancer would be evident. According to the analyzed data, in women 25-69 years old, the proportion of not taking a PAP in those who reside in the jungle and sierra regions is 1.56, 1.33 times respectively with respect to those who reside in the coastal region. , the information would be corroborated by various international studies where it is also evident that women who live in areas not belonging to the capital would present a lower percentage of taking PAP.⁷

Other variables described above were found, such as: use of contraceptive methods, where not using any method has a raw PR of 1.23, which would indicate that women who do not use a contraceptive method have a 23% higher probability of not having a PAP with respect to women who do use it, as reported in the study by Mamani Sánchez with the ENDES 2018 database.⁸This could be explained because women who do not use any method They do not have access to the information provided by health personnel in family planning consultations.

In recent years it has been shown that screening for breast cancer in Peru is lower than in other countries. In the study carried out, it was found that the incidence of women who did not perform any preventive screening for breast cancer was 53.6% and 56.5%. % in the last two years.

Regarding the factors associated with the interference of screening for breast cancer, the following variables were found to be statistically significant: having studied only up to primary or secondary school, belonging to the jungle or mountains, not having health insurance, not using some contraceptive method, not having some level of knowledge about gynecological screenings and belonging to the non-poor classification. The results found can be justified because in developing countries there is still a wide gap in access to cancer services, as reported in international studies. In studies carried out in Spain, it was shown that a low human development index and belonging to a low economic level have a direct association with screening.^9,10

In the analyzed data, we found the age variable as a protective factor, since in women aged 25-69 years, the proportion of women under 40 years of age not undergoing screening for breast cancer is reduced by 41% with respect to the group of women who are older than 40 years, in other countries studies show that having an advanced age has a greater coverage in carrying out screening for breast cancer.¹⁰What is described above is relevant because the average age of diagnosis for breast cancer is 62.6 years and it has been shown that screening before the age of 50 has better results in preventing this disease.

In the present study, it was found that age, marital status, place of residence and the beginning of sexual intercourse did not show an association with interference for breast cancer screening. One likely explanation is that very few women in our sample answered these questions.

Likewise, within the limitations of this study, it must be taken into account that the data was taken from the Demographic and Family Health Survey (ENDES) of the years 2019 and 2020, where no more variables can be added than those described by the survey. . The type of cross-sectional study, which allows determining association but not causality between the variables of interest.

The Demographic and Family Health Survey is a population-based survey that has quality control procedures and is designed to study health issues under the format of demographic and health surveys, constituting the main strength of the study. Currently, it is the only official source of population information that collects data on cancer prevention measures for Peruvian women.

CONCLUSIONS

The factors significantly associated with the interference of screening for gynecological cancers in women aged 25-69 in Peru, interviewed in the ENDES 2019-2020, for taking PAP are: age, level of education, marital status, region, Place of residence, health insurance, start of sexual relations, contraceptive method, level of knowledge and economic level.

In Breast Cancer Screening, the associated factors are: level of education, region, health insurance, level of knowledge and economic level. Due to the fact that statistically significant factors were found with the interference of screening for gynecological cancers, it is recommended that future studies delve into the variables raised, in order to locate the population that is vulnerable to not undergoing screening for gynecological cancers.