Issue of Cervical Cancer in Developing Countries

Introduction

Cervical cancer is the fourth most frequently occurring cancer in women and the eighth-most frequent cancer worldwide (World Cancer Research Fund International, 2019). According to the World Health Organization, (2019), about 570,000 new cases of cervical cancer were reported in 2018 representing 6.6% of all cancers related to female. The American Cancer Society (ACS) has stated that 12,170 new cases of cervical cancer were diagnosed in the United States in 2012 but greater than 500,000 new cases were diagnosed each year; an annual incidence of 4.5 cases per 100,000 in Western Asia to 34.5 per 100,000 in Eastern Africa (Boardman, 2019). Cancer council, 2019 demonstrated that Cervical death rate in Australia has decreased by half since the beginning of the National Cervical Screening Program, 1991. It has also presented that approximately 90% of all cervical cancer deaths occurred in low-income and middle-income countries (WHO, 2019). Therefore, cervical cancer has been the second most common cancer-related deaths in developing countries when in developed countries, cervical cancer is not even among the top 10 causes of death (Boardman, 2019). The developed countries have experienced dramatic reductions in the occurrence and mortality from cervical cancer that accounts for only 3.6% (Rahman et al., 2013).

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Cervical cancer is associated with 15 high-risk Human Papilloma Virus (HPV) types, while, it is caused by HPV 16 and 18 (Rahman et al., 2013). Approximately 99% of cervical cancers are caused by the Human Papilloma Virus (HPV).  Although HPV can be transmitted by nonsexual route majority is sexually transmitted.  The major risk factors are: having many sexual partners or being sexually active at an early age have a higher risk of HPV infection. Likewise, smoking, weak immune system, long-term usages of contraceptive pills, other sexually transmitted diseases (STD) and socio-economic status increases the risk of developing cervical cancer (Nordqvist, C., 2019). The HPV infection is highly present in sexually active women and almost 90% of infections get clear within months to few years, although cytology reports in 2 years after infection may present low grade squamous intraepithelial lesion (Broadman, 2019). Only 5 % of HPV infections develop into cervical intraepithelial neoplasia (CIN) grade 2 or 3 lesions within 3 years of infection and only 20% CIN grade 3 progress to invasive cervical cancer within 30 years (Boardman, 2019). Cervix cancer can be prevented by HPV vaccination and Papanicolaou (Pap) screening programs. The treatment varies according to the stages; early invasive requires surgery and in more advanced cases, radiation combined with chemotherapy is preferred (Boardman, 2019).

Research gap

Many studies have reported a high burden of cervical cancer among developing countries. In low or middle-income countries, greater than eight out of ten women are diagnosed with cervical cancer and nine among ten die from cervical cancer (Ginsburg et al., 2017) whereas, cervical cancer is uncommon in developed countries like United States (Boardman, 2019). There has been always a gap between developed and developing countries with regards to disease awareness and prevention. The disproportionate burden in developing and developed countries is mainly due to of lack of life-saving interventions such as HPV vaccination and cervical cancer screening (Ifemelumma et al., 2019) along with treatment of pre-cancerous lesions (Ginsburg et al., 2017; Rahman et al., 2013). Morbidity and mortality can be reduced by early detection and treatment. Many studies presented that regular screening program can reduce the cases by 80% as in developed countries (Rahman &Kar, 2015). The awareness among the women about the screening is vital. In developing countries, the doctor-patient ratio is low and nursing staffs are the major workforce for providing information among the general public (Rahman &Kar, 2015).  The nurses with a low level of knowledge in regards to cervix cancer and screening program are less likely to uptake and access Pap smear services to the patients.

A study in India showed that nurses did not have adequate knowledge, awareness about the screening program, while 85% had never taken pap tests from patient and 90% had never referred for Pap smear test (Shekhar, Sharma, Thakur, & Raina, 2013). Since, nurses are the frontline personnel in educating women in the prevention of diseases and health promotion influencing women to uptake cervical cancer screening (Thippeneeranna, Mohan, Singh, & Singh, 2013); nurses require having current and accurate information in cervical cancer and Pap smear test. Many studies among the nursing staffs have shown some awareness about cervical cancer and screening programs; however, screening uptake rates are still far from a satisfactory level in most developing countries (Shekhar, Sharma, Thakur, & Raina, 2013; Rahman &Kar, 2015 and Sudharshini, Anantharaman, & Chitraa, 2012). The health care workers in Ethiopia reported barriers of practicing test as 52% were lack of training and 53% lack of resources (Goedken et al., 2015) and finding it unnecessary (Ozdemir & Bilgili, 2010; Andsoy & Gul, 2014).

The majority of studies on cervical cancer and Pap tests’ awareness and practices are conducted among the women of different geographical areas in developing countries while very limited studies are obtained among nursing staffs. As nurses are the key individual to come in contact while visiting any health care facilities; it is absolutely necessary for them to be aware of the disease conditions and its preventive measures. As it is mentioned, the level of awareness and practice of screening is low among the nursing staffs that are responsible for making their clients’ clear and confident about the test. This study has been conducted to fill a knowledge gap among the nurses in developing countries since no such study has been done. The aim of the study is to review the awareness and practice about Pap smear test in the detection of cervical cancer among the nursing staffs in developing countries. Further, the study might provide data for researchers, educators, and policymakers for further planning and intervention for the cervical cancer screening test.

Literature review

A descriptive cross-sectional study was conducted on cervical screening: knowledge attitude and practice in tertiary care teaching and referral institute of rural India among the nursing staff (Shekhar, Sharma, Thakur, & Raina, 2013). A pretested questionnaire was distributed among 262 nurses in the teaching institute. Among them, 77% were aware that Pap smear is used to detect cervical cancer, but less than half knew it can also detect precancerous lesions (Shekhar, Sharma, Thakur, & Raina, 2013).  On the basis of scoring, only 26.7% of the participants had adequate knowledge about cervical cancer and its screening and only 7% of them had undergone the Pap test (Shekhar, Sharma, Thakur, & Raina, 2013). There was a significant association between higher parity and nurses over 30 years with self-screening.  Furthermore, a majority (85%) of the staff nurse had never practiced a Pap smear test on a patient and about 90% of the nurses had never referred for Pap smear test (Shekhar, Sharma, Thakur, & Raina, 2013).  Most nurses had a perception that the doctor is responsible for performing the Pap screening test (Shekhar, Sharma, Thakur, & Raina, 2013).

A study was conducted to identify the awareness of cervical cancer screening among nursing staff in a tertiary institution of rural India (Singh, Seth, Rani, & Srivastava, 2012). Total 205 staff nurses working in Rural Institute of Medical Sciences and Research, Saifai, Etawah were interviewed with a pretested self-administered questionnaire containing some recall questions about demographics, diseases conditions, and screening (Singh, Seth, Rani, & Srivastava, 2012). Seventy-four percent knew that cervical cancer can be detected by Pap smear test; however, only 59% were aware that both precancerous and cancerous cervix lesion can be detected by Pap test (Singh, Seth, Rani, & Srivastava, 2012). Among all the nurses, only 11% had self screened while, almost half (47%) of the nurses had never practiced Pap smear and 63% of them had never referred their patient for the cervical screening test (Singh, Seth, Rani, & Srivastava, 2012). Most respondents (79%) believed that Pap smear and speculum examinations are doctors’ procedure (Singh, Seth, Rani, & Srivastava, 2012).

A study was conducted in Sikkim, India to assess the knowledge of cervix cancer and practice of screening test among the nurses in April 2012 to February 2013 (Rahman &Kar, 201). This study reported that the majority (90.4%) of participants were aware of cervical cancer whereas, 25% were unaware of the commonest site. Among 320 nurses who were aware of cervix cancer, 79.1% had heard of the cervical screening test (Rahman &Kar, 201). One-third of the nurses had knowledge that screening starts at 21 years or 3 years after first sexual intercourse (Rahman &Kar, 201). Cervical cancer and screening awareness were significantly more among the senior staffs with older age (P<0.007) and married nurses were more aware of Pap smear test; respondents from Christian and Buddhist religion were more likely to be aware of cervix screening in comparison to Hindu religion (Rahman &Kar, 201). Only 11.9% of the total sample had ever taken the screening test (Rahman &Kar, 201). The most common reason for avoiding tests was; not being at risk, the pelvic examination being uncomfortable and fear of screening result (Rahman &Kar, 2015).

A cross-sectional interview-based study was conducted on nurses regarding knowledge levels on risk factors, symptoms, prevention, and screening of cervix cancer and their behaviors in tertiary health institutes of Ahmedabad, India (Shah, Vyas, Singh & Shrivastava). Of 100 respondents, 69% were aware of cervical carcinoma; 92.4% answered vaginal discharge, 86.9% and 66.6% stated as abnormal menstruation and pain as symptoms of cervix cancer and only 11.5% had knowledge of multiple sex partners as one of the risk factors (Shah, Vyas, Singh & Shrivastava). Out of 69% having some knowledge on cervical cancer, 88.4% had knowledge regarding Pap test when only 8% among the knowledgeable nurses on screening had undergone through Pap smear test (Shah, Vyas, Singh & Shrivastava).

A research study was carried out to assess knowledge, attitude and practice about Pap smear tests among 224 nursing staffs in Regional Institute of Medical Sciences, North-Eastern India (Thippeneeranna, Mohan, Singh, & Singh, 2013). Most of the participants (98.6%) had heard about cervical cancer yet, 18.3% were lacking adequate awareness regarding risk factors (Thippeneeranna, Mohan, Singh, & Singh, 2013). Knowledge of Pap smear screening was among 88.8% of the nurses (Thippeneeranna, Mohan, Singh, & Singh, 2013). Out of 88.8%, only 11.6% had ever undergone Pap smear at least once in their lifetime (Thippeneeranna, Mohan, Singh, & Singh, 2013). The common reasons for not participating in screening programs were: lack of any symptoms (58.4%), inadequate counselling (42.8%), no recommendation (29.9%) and fear of vaginal examination (20.5%) (Thippeneeranna, Mohan, Singh, & Singh, 2013).

A cross-sectional survey was conducted to determine the awareness among the nursing staffs about cervical cancer and Pap smear working in a tertiary care institute in central India excluding nurses working in Obstetrics and Gynecology departments (Jain, Bagde, & Bagde, 2016). Total 157 samples were taken for study; around 86% had some knowledge about cervix cancer and 69% were aware of the precancerous lesion (Jain, Bagde, & Bagde, 2016). Nearly 43% were unaware of any risk factors and 27.6% were unknown of any symptoms about cervical cancer (Jain, Bagde, & Bagde, 2016). Most of the nurses (86.2%) had known about the Pap smear screening, but only 58.6% were known that the Pap smear test facilities were available in their own hospital (Jain, Bagde, & Bagde, 2016).

An interview-based cross-sectional study regarding knowledge and awareness of cervix carcinoma and its screening test was conducted in tertiary care teaching institute in South India among 200 nurses from June 2013 to July 2013 (Dhodapkar, Chauhan, & Thampy, 2014). The report presented that 85% of the nurses were aware of the cervical cancer term and 45% knew it is the common gynecological cancer in India (Dhodapkar, Chauhan, & Thampy, 2014). Howbeit, only 30.6% had knowledge about being the leading cause of death among women cancer (Dhodapkar, Chauhan, & Thampy, 2014). An average of 19.5% of participants reported young age at first intercourse, cigarette smoking, high parity, multiple partners and low socioeconomic status as risk factors (Dhodapkar, Chauhan, & Thampy, 2014). Among 119 nurses that were aware of Pap smear as a screening test, only, 4% had ever done Pap smear examination (Dhodapkar, Chauhan, & Thampy, 2014).

A research study on knowledge and awareness among the interns and nurses about cervical carcinoma was done in Tertiary Care Hospital in Karachi, Pakistan (Ali et al., 2010). Among 400 samples, 1.8% was not aware of cervical cancer as a disease; only 23.3% of participants knew cervix cancer is a most common cause of women cancers and about a quarter knew as it ranks second in mortality (Ali et al., 2010). Seventy-eight percentages knew infection as a common cause, among them 62% said virus as the cause and 61% of respondents recognized the virus as Human Papilloma Virus (HPV) (Ali et al., 2010). Most of the respondents said it is sexually transmitted disease while, only 26% of the total sample were aware of one or more risk factors and 37% knew that Pap smear is the screening test for cervical cancer (Ali et al., 2010).

A study was done regarding cervical cancer prevention knowledge and attitudes in hospitals of East Azerbaijan Province of Iran among the female university students and hospital staffs (Asgarlou, et al., 2016). A sample of 600 students and 400 hospital staffs were selected by stratified random sampling technique (Asgarlou, et al., 2016). The results showed that 29.1% responded that they were not aware of cervical cancer; only 10.3% perceived their knowledge was high, 52.9% as an intermediate and 34.9% as low level of knowledge (Asgarlou, et al., 2016). Nevertheless, 93% of respondents knew cervix cancer as a severe health issue, knowledge was statistically significant with education (P<.001) and occupation (P<.001) (Asgarlou, et al., 2016).

A descriptive cross-sectional study was conducted to assess the knowledge, attitude, and practices (KAP) regarding cervical cancer and its screening among the healthcare practitioners and find out the existing differences between rural and urban Democratic People’s Republic of Korea (Tran, et al., 2011). A purposive sample of 200 female health care practitioners from 128 health care centers in 6 provinces was interviewed with a standardized questionnaire (Tran, et al., 2011). The majority (98%) of participants were aware of cervical cancer but, national cervical cancer policy awareness was lesser in rural (44%) than urban (62%) participants (Tran, et al., 2011). More urban (89%) than rural (71%) participants were aware of cervix cytology and about 30% of participants were knowledgeable about associations of cervical cancer and Human Papilloma Virus (HPV) (Tran, et al., 2011). Only minor (4%) rural and 21% urban healthcare practitioners (HCPs) had provided cytology while, only 13% of health care practitioners had ever undergone cervical cytology smear (Tran, et al., 2011).

A study was conducted among the female health care workers (219) being selected from 6 districts of Sri Lanka to identify the knowledge and practice of breast and cervical cancer screening practices (Nilaweera, Perera, Paranagama, & Anushyanthan, 2012). The study demonstrated that 76.3% of respondents had knowledge about Pap test detecting precancerous lesions in cervical cancer (Nilaweera, Perera, Paranagama, & Anushyanthan, 2012). Among 169 married health care workers, 73.4% never had Pap screening test and only 17.2% had screening test in the last 5 years (Nilaweera, Perera, Paranagama, & Anushyanthan, 2012). The commonest reason for avoiding Pap smear test was not being necessary (47%) followed by having no symptoms ( 23.2%), fear/dislike (17.3%) and 3% each for not knowing about the test and unknown about the availability of services (Nilaweera, Perera, Paranagama, & Anushyanthan, 2012).

A research study on cervical cancer and screening practices’ knowledge was carried out at the regional hospital in Tanzania among 137 nursing staffs (Darj, & Urasa, 2011). Less than half of the nurses had adequate knowledge about cervical cancer and significant association was reported between knowledge levels of cervical cancer causes and HPV transmission and age (Darj, & Urasa, 2011). Young nurses had more adequate knowledge; registered nurses were more knowledgeable in comparison to enrolled nurses (Darj, & Urasa, 2011). Most nurses (84.6%) had never got Pap test, the most common reasons were: unknown about where to go for the test (54.7%), no reason for the test (13.1%), fear of procedure (9.5%) and afraid of negative results (7.3%) respectively. Out of 21 who got a Pap test; 13 had decided on their own while 8 had been recommended by the physicians (Darj, & Urasa, 2011).

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A study was designed to determine the knowledge and awareness of cervical cancer prevention among the health care workers in six hospitals of Yaounde Cameroon (McCarey et al., 2011). Of total 401 respondents, most (86%) did know about the cervix cancer as a major health issue and 90%  perceived that cervical cancer can be prevented by screening programs (McCarey et al., 2011). Similarly, 84% believed that screening may be performed by Pap smear test; 54% believed that screening uptake is poor among Cameroon population since it is expensive (35%) (McCarey et al., 2011).

A study to examine the level of knowledge, perception, and attitude towards cervical cancer screening of female staff and students was executed in Nigeria Delta University, Nigeria (Owoeye & Ibrahim, 2013). Among 360 participants, 72% were found to be aware of cervical cancer, while only 50.6% were found being aware of the screening test (Owoeye & Ibrahim, 2013). The most mentioned screening test was Pap smear test with 41.2% responses, however, 24.8% wrongly believed blood test as cervix cancer screening (Owoeye & Ibrahim, 2013).

A study was executed to investigate the KAP of nurses towards cervical cancer screening in Lagos University Teaching Hospital (LUTH) (Awodele et al., 2011). The report presented almost all the nurses were aware of cervix cancer (99%) and 92% aware of Human Papilloma Virus as a causative agent (Awodele et al., 2011). Furthermore, respondents were quite well known about Pap smear (91%) as screening technique with good attitudes (89%), but most of the respondents had never had done Pap smear (Awodele et al., 2011).

A cross-sectional study was conducted to assess the perception and utilization of cervical screening among nurses in Federal Teaching Hospital, Abakaliki, Nigeria (Ifemelumma et al., 2019). This study depicted a good knowledge of cervical cancer as all (388) knew about preventable cervical cancer as a public health concern (Ifemelumma et al., 2019). Utilization of cervical screening test was found low as only 20.6% had undertaken Pap smear test while, the most common reason for not screening was that they never had thought of taking the test (28.4%) (Ifemelumma et al., 2019).

A research was carried out in University College Hospital, Ibadan, Nigeria among female nurses to determine their perception and utilization of cervical screening services (AO, & ET, 2018). The mean knowledge score among the 503 respondent was 22.8 $\pm$

4.1 (AO, & ET, 2018). Eighty-eight percent knew cervical cancer as preventive and 82% believed screening to carry out as soon as sexual intercourse begins (AO, & ET, 2018). Only 32.6% nurses had undergone cervical screening service and lack of time (50.8%) and fear of result (13.9) were the reasons to avoid Pap test (AO, & ET, 2018).

A cross-sectional, observational survey was conducted in Haiti in Western Hemisphere to assess KAP on cervical cancer screening and prevention among 27 health workers (Zahedi, Sizemore, Malcolm, Grossniklaus,& Nwosu, 2014). 100% correctly stated cervical cancer as the most common cause of death in women and 52.2 % stated it can be preventable. Twenty-two (22/27) stated that pre-cancerous stage can be identified; almost all (25/27) participants recognized the purpose of screening is to identify precancerous changes (Zahedi, Sizemore, Malcolm, Grossniklaus,& Nwosu, 2014). One-fourth of the participants reported as they had performed screening of any kind, only 16.7% had ever performed Pap smear and only one had performed >10 times in their career (Zahedi, Sizemore, Malcolm, Grossniklaus,& Nwosu, 2014).

A study was carried to examine the KAP about cervical cancer and screening in Chennai Corporation among 107 female health care practitioners (Sudharshini, Anantharaman, & Chitraa, 2012). About 100% were aware of cervix cancer and 95.3% aware of screening techniques either Pap smear or visual inspection while, only 18.4% had got cervical screening test (Sudharshini, Anantharaman, & Chitraa, 2012).

A study was conducted to investigate Jordanian female health workers’ awareness, practice and attitude on cervical screening (Obeidat, Amarin, & Alzaghal, 2011). Out of 187, 80% respondents had awareness score ±SD of 7.91±2.8; had never taken Pap smear test and nearly half of them were unaware of available screening, however, 19.1% were been tested with awareness score± SD of 9.23 ± 3.03 (Obeidat, Amarin, & Alzaghal, 2011).

A research was carried out between February and March 2012 to assess KAP of cervix cancer and its prevention among health care providers in three government hospital in Addis Ababa, Ethiopia (Goedken et al., 2015). Overall knowledge was high although, knowledge of etiology and risk factors was low (Goedken et al., 2015). Health care workers had no experience to perform screening tests; <40% had delivered any type of screening services. Lack of training (52%) and resources (53%) were reported as a barrier in performing screening services (Goedken et al., 2015).

A study was done to determine the KAP status of nurses on the early diagnosis of breast and cervical cancer in an educational hospital in Ankara (Ozdemir & Bilgili, 2010). Of 550 nurses, only 46.9% of nurses had adequate knowledge on early diagnosis of cervical cancer and 23.7% carried out Pap smear test (Ozdemir & Bilgili, 2010). The common reasons to avoid screening tests were negligence, fear of cancer and finding unnecessary (Ozdemir & Bilgili, 2010).

An institution-based cross-sectional study was carried out regarding cervical cancer screening’s knowledge and practice among female health practitioners in Southern Ethiopia (Dulla, Daka, & Wakgari, 2017).  Out of a total of 367 practitioners, 89.6% had enough knowledge of cervix cancer (Dulla, Daka, & Wakgari, 2017). Over two-thirds of the respondent (77.1%) were aware of the procedure to detect precancerous changes while, only 11.4% of respondents had undergone cervical cancer screening (Dulla, Daka, & Wakgari, 2017).

A descriptive study was performed to evaluate the KAP of medical workers at Naresuan University Hospital, Thailand (Oranratanaphan, Amatyakul, Iramaneerat, & Srithipayawan).  The knowledge about Pap smear, early detection, and treatment was adequate (90.9% and 81.6% respectively) but, awareness on risk factors was poor (Oranratanaphan, Amatyakul, Iramaneerat, & Srithipayawan).  The fear of vaginal examination, embarrassment, lack of symptoms and remaining busy were the most frequent reasons to avoid Pap screening test (Oranratanaphan, Amatyakul, Iramaneerat, & Srithipayawan). 

Conclusion:

Cervical cancer is the major cause of mortality and morbidity among women worldwide. Early screening for the detection of cervical cancer is a key intervention to reduce this public health issue. Many studies have reported that even though nursing staff has adequate knowledge on a screening test but, the utilization of Pap smear is low among them. Since nurses have a significant contribution to improve cervical cancer awareness and screening practice among women, the reasons for the poor practice of Pap smear test requires to be investigated among nurses in developing countries.

References:

• Alzahrani, H. H. (2018). Knowledge, Attitudes, and Practices in Relation to Cervical Cancer Screening among Female Employees at King Abdulaziz University. International Journal of Nursing Didactics, 08(03), 01-10. doi:10.15520/ijnd.2018.vol8.iss03.2050.01-10
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• Asgarlou, Z., Tehrani, S., Asghari, E., Arzanlou, M., Naghavi-Behzad, M., Piri, R., … Moosavi, A. (2016). Cervical Cancer Prevention Knowledge and Attitudes among Female University Students and Hospital Staff in Iran. Asian Pacific journal of cancer prevention : APJCP, 17(11), 4921–4927. doi:10.22034/APJCP.2016.17.11.4921
• Awodele, O., Adeyomoye, A. A., Awodele, D. F., Kwashi, V., Awodele, I. O., & Dolapo, D. C. (2011). A Study on Cervical Cancer Screening Amongst Nurses in Lagos University Teaching Hospital, Lagos, Nigeria. Journal of Cancer Education, 26(3), 497-504. doi:10.1007/s13187-010-0187-6
• Boardman, C. H. (2019, February 12). Cervical Cancer: Practice Essentials, Background, Pathophysiology. Retrieved from https://emedicine.medscape.com/article/253513-overview
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• Chen, S., Tsai, S., Hsieh, M., Lee, L., & Tzeng, Y. (2016). Factors Predicting Nurse Intent and Status Regarding Pap Smear Examination in Taiwan: a Cross-sectional Survey. Asian Pacific Journal of Cancer Prevention, 17(1), 165-170. doi:10.7314/apjcp.2016.17.1.165
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• Dulla, D., Daka, D., & Wakgari, N. (2017). Knowledge about cervical cancer screening and its practice among female health care workers in southern Ethiopia: a cross-sectional study. International Journal of Women’s Health, Volume 9, 365-372. doi:10.2147/ijwh.s132202
• Ginsburg, O., Bray, F., Coleman, M. P., Vanderpuye, V., Eniu, A., Kotha, S. R., … Conteh, L. (2017). The global burden of women’s cancers: a grand challenge in global health. The Lancet, 389(10071), 847-860. doi:10.1016/s0140-6736(16)31392-7
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• Oranratanaphan, S., Amatyakul, P., Iramaneerat, K., & Srithipayawan, S . ( 2010). Knowledge, attitudes and practices about the Pap smear among medical workers in Naresuan University Hospital, Thailand. Asian Pacific Journal of Cancer Prevention : APJCP, 11(6):1727-1730]. https://europepmc.org/abstract/med/21338223
• Owoeye, I., & Ibrahim ., I. (2013). Knowledge and attitude towards cervical cancer screening among female students and staff in a tertiary institution in the Niger Delta. International Journal of Medicine and Biomedical Research, 2(1), 48-56. doi:10.14194/ijmbr.219
• Ozdemir, O., & Bilgili, N. (2010). Knowledge and Practices of Nurses Working in an Education Hospital on Early Diagnosis of Breast and Cervix Cancers. TAF Preventive Medicine Bulletin, 9(6), 605. doi:10.5455/pmb.20100427030359
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References:

• Shah, V., Vayas, S., Singh, A., & Shrivastava, M. (2012). Awareness and Knowledge of cervical cancer and its preventionamong  the nursing staff of a tertiary health institute in Ahmedabad, Gujarat, India. National Institute of Health. https://dx.doi.org/10.3332%2Fecancer.2012.270
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