We found that a lack of gynecological follow-up and cytological screening was associated with the diagnosis of advanced cervical cancer. Most advanced cancers are detected after symptoms, particularly vaginal bleeding, as reported in other studies . It should be noted that the cervix was clinically abnormal in over 75% of cases in Group A, confirming the importance of screening and systematic clinical examinations to diagnose asymptomatic cancers at an early stage . In addition, we observed a higher proportion of adenocarcinomas in cases diagnosed at advanced stages.
We found no association between most sociodemographic variables, such as age, ethnicity, and social disadvantage, and advanced-stage diagnosis. Contrary to our hypothesis that socially and economically disadvantaged women have poorer access to care, this was not the case in our population with regard to cytological screening. This is in contrast to results from the United States , which may be related to differences in healthcare across countries. In a survey by the French health authority ) the factors associated with lack of cervical cancer screening were age over 50, disability status, alcohol or opioid abuse, chronic diseases such as obesity, diabetes, HIV infection, hepatitis, and mental illness, and life in disadvantaged geographical areas. Our study did not have the power to examine these factors. Parity was significantly associated with late diagnosis. The literature suggests that there are pathophysiological reasons for this association , because the hormonal changes during pregnancy alter the epithelial junction, the transformation zone most susceptible to HPV infection. In addition, this transition is maintained longer in the exocervix in multiparous women. We found no between-group differences in smoking and HIV status, which are known risk factors for cervical cancer.
Strengths and weaknesses
Most patients received full care at our center from the first visit, through diagnostic and staging procedures, therapy and comprehensive follow-up. This reduces the risk of recruitment bias in some specialized pelvic cancer centers to which patients are referred after diagnosis and evaluation. Our recruitment was through both gynecologic clinics and emergency departments, so closer to a population-based study. In addition, the number of patients was relatively large for a single-centre study.
The main weaknesses of our study lie in its retrospective nature, including possible selection bias and missing data. These were numerous for specific socio-demographic variables, and social disadvantage was not assessed using a systematic scale such as the EPICES score [15, 16], since not all variables were routinely collected. The validity was also limited, so we could not perform a multivariate analysis.
Interpretation in relation to the literature
In previous studies [17,18,19,20,21], mainly from Africa, where health infrastructures for screening and prevention differ, the factors associated with a diagnosis of advanced cervical cancer, as in our study, were high parity, also low level of education, long distance from the health center and young, age at first intercourse, variables not available in our study, and living with HIV. The number of women living with HIV in our population was not enough to draw a conclusion, but it should be noted that we offer annual gynecological visits with cervical screening for these patients at our center.
In France, cervical cytology coverage was estimated at 61.9% in 2016. . It was recommended every 3 years for women between the ages of 25 and 65. Despite information campaigns on screening and the relative accessibility of gynecological aftercare by general practitioners, midwives or gynecologists in practices or in hospitals, a large proportion of patients do not make use of such care.
In our center there is a structured network with close collaboration that allows doctors and midwives to refer patients to our cervical disease clinic through a dedicated channel, with access to colposcopy for low-grade lesions within 1 month and for high-grade lesions within 2 weeks after the cytological results. None of the patients who were diagnosed at an advanced stage were referred from the Cervical Diseases Channel. This indicates that the high-grade lesions diagnosed at the center were adequately treated with LEEP and ablative therapy and properly followed up, preventing progression to advanced stages. It is therefore important to increase the training of general practitioners, midwives and healthcare providers in general.
However, with a sensitivity of only 58%, the performance of cytological screening is not perfect. . Because the HPV subtype is strongly associated with cervical changes and cancer, and the reproducibility of HPV testing is better than cytology, the latest guidelines recommend HPV testing as the first line of screening for all women between the ages of 30 and 64 with cytology Screening maintained in women aged 24 to 29 years . While the incidence of cervical squamous cell carcinoma has decreased in countries with cytological screening, the proportion of cervical adenocarcinoma has increased which is less amenable to prevention through cervical screening through cytology .