In Mexico, Hysterectomy Is Often Used as Treatment for Cervical Abnormalities
In Mexico, most physicians know that human papillomavirus (HPV) is the principal cause of cervical cancer and that screening should begin after first intercourse. However, according to data from 1,206 obstetrician-gynecologists and general practitioners, many mistakenly use hysterectomy to treat low-grade abnormal cell growth on the cervix.1 Although obstetrician-gynecologists tend to be better informed than general practitioners, more than 60% of both groups incorrectly believe that cancer-causing strains of HPV also cause genital warts. Nearly all physicians support educating women about HPV's link to cervical cancer, but the majority agree that this information could cause problems within partnerships.
Data were collected in 2002 at a random sample of 288 public and private health care facilities located in urban areas. At each site, four physicians were nonrandomly selected to complete a self-administered questionnaire; respondents provided information about their background characteristics, knowledge and practices related to cervical cancer screening and treatment, knowledge of HPV and attitudes toward counseling. Researchers conducted chi-square tests to identify significant differences between obstetrician-gynecologists and general practitioners.
Seventy-five percent of respondents were nonspecialists. Overall, 69% were male, 42% were aged 45 or older, and 65% were from the central region. Forty-eight percent earned a bimonthly salary of US$337–865, and 86% were Catholic. Almost all (93%) had been trained at a public university; 40% worked in the private sector only, 33% in the public sector only and 27% in both. Most (86%) had performed a Pap smear in the last two weeks.
Overall, 83% of respondents had read or been informed about Mexico's official norms (Ministry of Health clinical practice guidelines) for the diagnosis and treatment of cervical cancer. Although these norms do not specify when women should get their first Pap smear, 77% of respondents thought screening should commence after first intercourse, regardless of age. However, 9% cited first childbirth, thus overlooking HPV risk between first sex and motherhood. The majority (73%) correctly stated that women should wait one year after a normal Pap test to repeat the process, but 16% incorrectly indicated a waiting period of six months.
Bivariate analyses revealed that obstetrician-gynecologists identified first sex as a starting point for screening in significantly higher proportions than did nonspecialists (81% vs. 76%). Contrary to official recommendations, 37% of obstetrician-gynecologists and 25% of general practitioners considered hysterectomy an appropriate treatment for mild or moderate cervical dysplasia—a statistically significant difference. The proportions who correctly cited electrosurgery, laser therapy and cryotherapy as recommended treatments were also higher among obstetrician-gynecologists than among general practitioners (55–73% vs. 32–52%). Use of hysterectomy in the past year to treat mild or moderate dysplasia was reported significantly more frequently by specialists than by nonspecialists (43% vs. 18%), as was use of the recommended procedures (23–52% vs. 11–15%). In addition, significantly higher proportions of physicians working in the private sector than of those working in other settings identified hysterectomy as a treatment option (34% vs. 21–27%) and had used the procedure in the past year (30% vs. 13–27%).
Overall, 80% of respondents correctly identified HPV as the principal cause of cervical cancer; 96% were aware of the link between this cancer and HPV; and 84% had heard about cancer-causing strains of the virus. Still, 61% incorrectly stated that these strains also cause genital warts. Almost all respondents believed that women should be informed that HPV causes cervical cancer. However, roughly one-third felt that providing this information could create unnecessary anxiety and confusion, and two-thirds thought it could cause problems within partnerships. About one-quarter believed the information would discourage women from seeking a Pap test.
A significantly lower proportion of obstetrician-gynecologists than of general practitioners incorrectly identified a family history of cervical cancer as the primary cause of this illness (7% vs. 17%). Moreover, a significantly higher proportion of obstetrician-gynecologists than of general practitioners had heard about cancer-causing strains of HPV (96% vs. 80%), and a significantly lower proportion said they did not know whether these strains also cause genital warts (10% vs. 24%). A significantly higher proportion of obstetrician-gynecologists than of general practitioners felt that informing women of the link between HPV and cervical cancer would cause unnecessary anxiety (37% vs. 28%). Concerns about the effects of counseling were generally more common among respondents in the north than among those in the central and southern regions.
The researchers acknowledge that respondents were not randomly selected within each facility and that results may not be generalizable to rural areas. They conclude that appropriate dysplasia management is a priority area for provider education and that given physicians' widespread agreement that women should be educated about the link between HPV and cervical cancer, providers need to be armed with accurate information to share with women and their partners, as well as an awareness of and sensitivity to the implications this information carries.—R. MacLean
1. Aldrich T et al., Mexican physicians' knowledge and attitudes about the human papillomavirus and cervical cancer: a national survey, Sexually Transmitted Infections, 2005, 81(2):135–141