We found that lack of gynecological care and cytological screening were associated with a diagnosis of cervical cancer at advanced stages. Conversely, most advanced stage cancers were discovered following symptoms, in particular bleeding, as reported in other studies10.. 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 stage3. Also, we observed a higher proportion of adenocarcinomas in cases diagnosed at advanced stages.
We found no association between most socio-demographic variables such as age, ethnic origin, and social deprivation, with diagnosis at advanced stages. Contrary to our hypothesis that socially and economically disadvantaged women would have poorer access to care, this was not the case in our population regarding cytological screening. This contrasts with findings from the United States11, which may be related to the differences in health care coverage between countries.
Parity was significantly associated with late diagnosis. The literature suggests that there me pathophysiological reasons for this association12 , because the concentration of estrogens and progesterone during pregnancy alters the epithelial junction, which is the transformation zone which is most vulnerable to HPV infection. In addition, this junction is maintained in the exocervix longer in multiparous women. We found no differences between groups regarding smoking and HIV status, which are known to be risk factors for cervical cancer.
Strengths and weaknesses
Most patients were cared for entirely in our center from the first visit, through diagnostic and staging procedures, therapy and comprehensive follow-up. This decreases the risk of recruitment bias in some dedicated pelvic cancer centers where patients are referred after diagnosis and assessment. Our recruitment was through gynecologic clinics as well as emergency room, thus closer to a population-based study. Also, the number of patients was relatively large for a single-center study.
The main weaknesses of our study are inherent to its retrospective nature, including potential selection bias due to missing data. These were numerous for certain socio-demographic variables and social deprivation was not assessed with a systematic scale, such as the EPICES score13,14 , because not all of the variables were routinely collected. The power was also limited, so we could not perform a multivariate analysis.
Interpretation in view of the literature
In previous studies15–19, mainly from Africa, where health infrastructures for screening and prevention differ, the factors associated with a diagnosis at an advanced stage of cervical cancer were high parity as in our study, and also low education level, long distance from the health center, and young age at first sexual intercourse, variables which were not available in our study, as well as living with HIV. The number of women with HIV in our population was insufficient to conclude, but it should be noted that we offer yearly gynecologic visits for these patients in our center.
In France, the coverage of cervical cytology was estimated in 2016 at 61.9%20. It was recommended every 3 years for women between 25 and 65 years of age. However, despite information campaigns on screening and the relative accessibility of gynecological follow-up by general practitioners, midwives or gynecologists, in the office or hospital, a large proportion of patients do not access such care.
In our center there is a structured network, with close collaboration allowing physicians and midwives to refer patients to our cervical diseases clinic through a dedicated channel, with access to colposcopy for low grade lesions within 1 month and for high grade lesions within 2 weeks of the cytology results. None of the patients diagnosed at an advanced stage accessed the cervical diseases channel. It is therefore essential to reinforce training for general practitioners, midwives, and healthcare providers in general.
Nevertheless, the performance of cytological screening is imperfect, with a sensitivity of only 58%21. Because the HPV subtype is highly associated with cervical transformations and cancer, and because the reproducibility of HPV testing is better than for cytology, the most recent guidelines recommend HPV testing as the first line of screening for all women between ages 30 and 64, with cytologic screening maintained in women from ages 24 to 2922. Also, whereas the incidence of squamous carcinoma of the cervix has declined in countries with cytologic screening, the proportion of adenocarcinoma of the cervix has increased23, which is less amenable to prevention through cervical screening by cytology24.