Prevalence of precancerous cervical lesions in women attending Mezam Polyclinic Bamenda, Cameroon

Introduction Precancerous cervical lesion is significantly a health problem globally. Thus, screening targeting women between the ages of 17-60 is being undertaken in developing countries, including Cameroon. Over 50% (7.8 per 100,000) women die of cervical cancer every year. This study was to determine the prevalence of precancerous cervical lesion, the age demography and access the risk factor. Methods A hospital-based cross-sectional study was conducted from August 09th to October 17th 2017. A total of 60 women participated, and were screened for precancerous cervical lesion. Data were collected by using a questionnaire. Visual inspection with acetic acid and visual inspection with Lugol’s iodine was applied for the screening. SPSS version 16.0 was used for data entry and analysis. Logistic regression analysis was fitted and odds ratios with 95% confidence intervals and p-values were computed to identify factors associated with precancerous cervical cancer lesion. Results Out of 60 study participants, 2(3.33%) were found to be positive for precancerous cervical cancer lesion. Conclusion The prevalence of precancerous cervical lesion in women that consulted at the Mezam polyclinic is high.


Introduction
Women in Africa as well as those residing in Cameroon, suffer a disproportionate rate of cervical cancer morbidity and mortality [1].
Cervical cancer is the second leading cause of cancer-related deaths amongst Cameroonian women in West Africa. Human papillomavirus (HPV) leads to cervical cancer. Particularly, the strains HPV 16 and 18 have been especially known to be at high risk [2]. In Cameroon, cervical cancer screening services and testing for HPV are mostly available at private health clinics and some government hospitals in the urban areas. In Cameroon most cases of cervical cancer are diagnosed at later and more serious stages. Majority of the cervical cancer victims are poor rural women who are particularly unable to access screening and testing services [2,3]. Those who screen are unable to return for follow-up or complete treatment due to: inadequate medical advice, lack of awareness of the significance of their symptoms, cultural and religious factors as well as the lack of finances to pay for the services.
The cancer of the cervix is at the origin of 3 387 new cases and of 1000 deaths per annum corresponding to an average incidence of 8 per 100 000 person-years in 2000. It is located at the 2nd rank of female cancers in term of incidence and there thus remains a priority to public health [4]. In Cameroon one estimates that approximately 1400 to 1700 new cases of cancer of the cervix per annum and approximately 700 of them die each year [5]. The cancer of the cervix is preceded during 10 to 15 years by precancerous lesions. Those are detectable by the smear and their treatment makes it possible to avoid or reduce the risk of evolution towards an invasive cancer [6].
The screening of the cancer of the cervix in Europe (France) is individual but there are recommendations for clinical practice where it is advised to carry out a smear every 3 years after 2 normal annual smears for women from 25 to 65 years [7].
A precancerous state of the cervix is characterized by changes undergone by the cells of the collar which make them more likely to evolve in a cancer. This state is not yet a cancer, but it is strongly likely to be transformed into cancer of the cervix in 10 years or more if it is not treated in time [8]. One finds a cervical dysplasia at 1 to 5% of the women in the general population. They concern primarily the young, old women from 25 to 35 years [9]. It is estimated that each year, appear approximately 69 000 new cases of dysplasia of low rank and 15 000 cases of dysplasia of high rank in Europe [10].
The papillomavirus (human papillomavirus: HPV) are known and are very many, they are responsible for a multitude of lesions found on the skin or the mucous membranes [11]. By infecting the cells of the cervix, they lead to lesions which at term can evolve to a cancer. The co-infection by viruses AIDS and HPV is at the origin of a growing number of cancers for seropositive people. A new study on nearly a half-million patients shows it with force [12].
Five main types of cancer that affect a woman's reproductive organs are known as gynecologic cancer: cervical, ovarian, uterine, vaginal, and vulvar (Centers for Disease Control and Prevention) [13].
According to [14], of the 83,745 women diagnosed with gynecologic cancer in the United States died from the disease. CDC further stated that cervical cancer used to be the leading cause of cancer death for women in the United States. However, in the past 40 years, the number of cases of cervical cancer and the number of deaths from cervical cancer have decreased significantly because of the availability of regular Pap tests, which can locate cervical precancerous lesions before they turn into cancer. Mqoqi N et al. and Bailie RS et al. [14,15] said cervical cancer can be prevented using: the HPV vaccines, the Pap test (or Pap smear) looking for pre-cancers, and also using Visual inspection with acetic acid (VIA), Visual inspection with Lugol's iodine (VILI), the HPV test that looks for viruses that can cause cellular changes. Regular screening beginning at the age of 17 is the most important preventive measure. Other preventive measures include: the use of condoms during sexual contacts, limiting the number of sexual partners and avoid smoking [15]. In some cases, this may simply mean a repeat Pap test in a few months. A test with this kind of finding may be reported as "atypical squamous cells of uncertain significance," abbreviated as ASCUS

Study area, design and population
The study was carried out at Mezam polyclinic since they have the necessary facilities and the women who come are sure to be tested for and treated if need be. The study was a hospital based crosssectional survey. The study included all women who signed the inform consent form.

Sample size
The sample size was calculated based on the LORENTZ formula Calculated sample size r n = t × t × p (1 -p)/ m × n When n = required sample size; t = confidence level at 95% Sampling: a total of 60 (due to time constrains) women were recruited for the study, using the random sampling method.

Selection criteria
Inclusive criteria: only sexual active women of ages 17-60 will participate in the study. This is because this infection occurs most often in women within this age group.
Exclusive criteria: non-sexual active women within the said age range shall not take part in the study. This is because there is a lesser chance for non-sexual active women to come down with precancerous cervical lesions. Women who did not sign the consent form were excluded from the research work.

Results
Out of the 60 participants, two were screened positive for precancerous cervical lesion, and 58 were screened negative. The age range was 17-60 years with a mean age of 38.5 years.
Evaluation of risk factors: of the 60 participants, two were screened positive within the age group of 31-45 years of age. And there were fell in the group with more than two life partners, more than 3 children, early full term pregnancy between the ages 17-20 years. One of them had a family history of cervical cancer ( Table 2).  (Table 3).

Discussion
The prevalence of precancerous lesion of the uterine cervix in Cameroon is similar to that reported in 1992 (4.2%) [16]. However, data from other countries reported a higher prevalence rate such as 16.4% women in Central African Republic Africa. In the present study, patients were not tested for HIV. In developed countries as France, the prevalence of precancerous cervical lesion rate is much lower at around of 0.5%. The difference of prevalence of the precancerous lesions of the uterine cervix from one country to another is mainly due to the existence and consistency of screening programs and management options implemented in these countries. Higher prevalence of precancerous cervical lesions in women shown by this study has been reported in South Africa (66.3%), Uganda (73%), and Zambia (76%) [17]. Studies done in Kenya and Rwanda also found the prevalence of precancerous cervical cancer to be 26.7% and 24.3% respectively, which are very high as comparable to the result of the current study. A lower prevalence of precancerous cervical cancer than the current study has also been reported from studies done in Botswana, Côte d'Ivoire, and Nigeria. In Botswana, a cervical cancer screening program of 2,175 women based on VIA found that the proportion of precancerous cervical cancer lesion confirmed by histology was 15.2% [18]. Studies recently conducted in Côte d'Ivoire and Nigeria found the prevalence of precancerous cervical cancer lesion to be 11% and 6% respectively [19]. Cervical cancer is the most common cancer in women in Africa and second to breast cancer.
In Africa, it accounts for 22.2% of all cancers in women and it is also the most common cause of cancer-related death among women [20].
Knowing the prevalence and associated factors of precancerous cervical cancer lesion in women helps to take preventive measures and to know the screening requirements. In this study the prevalence of precancerous cervical cancer lesion in women was found to be 3.33% which is comparable with a previous report of Cameroon women resident in Maryland (3.9%) [21]. The high prevalence of precancerous cervical cancer lesion reveals that cervical cancer is a significant public health problem in women. Despite the high prevalence of the lesion, only four hospitals in the northwest of Cameroon were providing screening and treatment service, which significantly hampered the service accessibility to all women in the region. This could be because of the limited resources available for treatment of positive precancerous cervical cancer lesion after screening with VIA and VILI as the current limited available services are donor dependent [22].
The differences among findings of prevalence of precancerous cervical lesion in different regions of Africa could be partly due to differences in the sexual practices of the women studied [23]. Having multiple sexual partners because of cultural differences increases the risk of acquiring HPV, and in turn, the development of cervical precancer and cancer. In Nigeria, with a low prevalence was reported, 96% of the study participants had two or less lifetime sexual partners.
In South Africa, one of the highest reported, the median number of sexual partners was four [24]. In the present study the mean number of lifetime sexual partner is 3 and might be one of the contributing factors for the high prevalence. Unlike the findings from South Africa and Nigeria [25], though 56% of women had an average of five lifetime sexual partners, prevalence was lower than the finding in the present study, making the association unlikely. It could also be a result of the limitation of self-reported sexual practices. The other possible explanation for the different prevalences could be the differences in the study populations. The age ranged from 17 to 60 years with a mean age of 38.50 years and 85% of women were between the ages of 17-46 years. The mean number of deliveries for women with precancerous lesions of the uterine cervix was three childbirths and those with more than 3 deliveries represented 50%.
Multiparity in women with precancerous cervical lesion was previously seen in Burkina Faso, West Africa [26]. These data lead to suggest the possibility of an association between multiple childbirths and cervical premalignant lesions in Cameroon.

Conclusion
Much of the precancerous cervical lesion problem can be solved with existing or soon-to-be available technology, sufficient will, and modest resources. Early detection, screening, and treatment of precancerous cervical lesion as well as HPV will reduce the rate of

Competing interests
The authors declare no competing interests.

Authors' contributions
NCN TMM, TAT, BMY and SNC designed the study and were involved in all aspects of the study. SNC contributed to scientifically reviewing the manuscript for intellectual inputs and review. All authors reviewed the final manuscript and agreed for submission.

Acknowledgments
We are grateful to all the women who participated in this research.