1 MINISTRY OF EDUCATION AND TRAINING MINISTRY OF DEFENSE Medical military academy  DOAN TRONG TRUNG RESEARCH SOCIAL, ENVIRONMENTal FACTORS RELATING TO CERVICAL CANCER IN SOME NORTHErN PROVINCES Specialization: Social sanitation and health organization Code: 62.72.73.15 SUMMARY OF MEDICAL DOCTORAL THESIS HA NOI – 2012 THE THESIS WAS COMPLETED: Technical Supervisor: Prof PhD LUONG XUAN HIEN Prof PhD LE KHAC DUC REVIEWER 1: Prof PhD DANG DUC PHU REVIEWER 2: Prof PhD NGUYEN DUC VY REVIEWER 3: Prof PhD NGUYEN THI THU This project will be defended at Doctoral Thesis Scoring Council at Medical Military Academy At: 8h30, 18 - - 2012 The thesis can be found at: - National Library - Library of Medical Military Academy - Medical Information Library RELATED PUBLISHED PROJECTS OF THE AUTHOR Doan Trong Trung, Tran Van Thuan, Nguyen Phi Hung (2009), “Situation of cervical cancer, cervical body cancer of patients visiting K hospital in Hanoi from 2001-2006”, Practical Medical Magazine, Vol (665), page 120-121 Doan Trong Trung (2010), “Finding correlation among some social, environmental factors, health and cervical cancer of women in 12 provinces of Vietnam”, Practical Medical Magazine, Vol 11 (741), pg 86-87 Doan Trong Trung, Luong Xuan Hien (2010), “Finding impacts of some reproductive factors to rate of cervical cancer of northern women in”, Practical Medical Magazine, Vol 12 (745), page 48-50 BACKGROUND According to the World Health Organization’s predict for the disease model of the 21st century, non-infectious diseases, including cancer, is a major disease group that threats human health Cervical cancer is the cancer with a high mortality rate in women after breast cancer, especially in developing countries, including Vietnam It is one of the challenges in health care for women at health facilities and in the community In Vietnam, women are still a very important force in the structure of the labor force, the majority of the working conditions is affected adversely and hard Besides, large proportion of women is currently using family planning measures such as IUD, pills, tubal ligation sterilization and Quinacrine placed into the chamber uterus Therefore, one of the problems associated with cervical cancer is paid attention is whether the social, environmental factors have an impact on the increase the incidence of cervical cancer among Vietnamese women To 2001, the period before the implementation of the thesis, there is no deep research analyzing model of cervical cancer in Vietnamese women and the relevant factors including the sterilization by Quinacrine Only a few studies have focused on the recognition of cervical cancer in the hospitals, or conduct research screening cervical precancer of community in narrow areas Therefore, we conduct the topic "Research some social, environmental factors related to cervical cancer in some northern provinces" to respond above demands OBJECTIVES 1) Describe the current situation of cervical cancer in 12 northern provinces in Vietnam, 2001-2006 2) Identify some social, environmental factors related to cervical cancer in research area PRACTICAL MEANING AND NEW CONTRIBUTION OF THE PROJECT The topic is urgent, practical, helping the health sector has new discoveries about the characteristics of cervical cancer, an association between cervical cancer and some factors which have not been previously researched or insufficiently researched in Vietnam in general and 12 mentioned provinces in particular The research results will be the scientific basis for policy makers to develop policies, build up appropriate interventions and proper health communication to prevent cervical cancer in the community This will contribute to improving the quality of health care services for population in general and for women in particular The research results are also a scientific basis for clinical medical staff to take as reference and put into applications in improving the quality of care and treatment of cervical cancer STRUCTURE OF THE THESIS The thesis consists of 116 pages (not including the table of contents, list, references and appendices), including chapters: Chapter 1: Review documents, 32 pages, Chapter 2: Subjects and Methods, 20 pages, Chapter 3: Research results, 28 pages, Chapter 4: Discussion, 30 pages The thesis has 34 tables, 11 charts, figures and diagrams 140 References: 55 Vietnamese documents and 85 English ones CHAPTER REVIEW DOCUMENTS Every year there are estimatedly 471,000 cases of cervical cancer (CC) being newly diagnosed in the world, of which there are about 380,000 new cases in developing countries, with more than 273,000 deaths In Vietnam, CC is the second most common cancer in women, however, the incidence is very close to the incidence of breast cancer The incidence of CC in Ho Chi Minh City is specific to high-risk populations in the region, but times higher than that in Hanoi The incidence of CC in Hanoi is close to the low-risk populations This is more noticeable as the number of cancer patients in Vietnam are in the trend of increasing, there are about 120,000 people with cancer were detected, of which half of them are on the last stage of the disease The study of Hirohiko Tsujii noted that common age of CC is in the 50-59 range Dang Thi Phuong Loan author also noted the common age range is 40-49, mean age is 52 and another study of Le Phuc Thinh in Ho Chi Minh City found common age for cervical cancer is 40-50 years old In the correlation between CC and occupation, we find that women who are farmers accounted for the highest percentage of 53.6% CC The study of Coker Al showed that women with CC and smoking at the detecting time had higher risk of death by this disease than other women In addition, women who not have health insurance or themselves pay for medical care are at higher risk of death from the disease According to research by Martinez, early sexual intercourse is one of the factors that increases the risk of HPV infection It was found that cervical cancer related to external factors such as multiple births, many abortions, STIs The incidence of disease is detected at high levels in women of child marriage and early birth giving, multiple births Specifically, prostitutes, over time married women and women with ulcer in cervix have times higher risk of getting cancer than normal ones Quinacrine has been used as a contraceptive method in many countries around the world This method was first applied in Chile and subsequently replicated in many countries, including Vietnam In Vietnam, the sterilization program for women of childbearing age by Quinacrine has been done since 1989 By late 1993, the program was stopped to reassess after receiving a letter from the World Health Organization mentioned that Quinacrine can cause gynecological cancer for users So far this sterilization method has not yet to be carried out again due to the above concern Worldwide, there have been some researches to find out the correlation of Quinacrine with gynecological cancer issues One of them was the study of David C Sokal (FHI) about the cancer risk for women with Quinacrine sterilization in Chile by 1996 Although the research have come up with the conclusion that there was no possibility of Quinacrine causing cancer, but due to the sample size of the study was not really big enough, the number of detected cancer cases were small, so persuasiveness of the study was not really high Although there have been many studies on cancer being conducting in Vietnam, there are still no studies which is large enough about gynecological cancers, especially cervical cancer In Vietnam, there is a lack of official researches on the common risk factors associated with cervical cancer and does not have any official studies on the relationship between cervical cancer with Quinacrine sterilization in women CHAPTER SUBJECTS AND METHODOLOGY 2.1 Time and Venue The study was conducted in 12 northern provinces of Vietnam, including Nghe An, Ninh Binh, Nam Dinh, Ha Nam, Thai Binh, Hai Duong, Hung Yen, Ha Tay, Bac Giang, Bac Ninh, Vinh Phuc and Phu Tho These provinces were selected on purpose Selection criteria are as follows: - Provinces have provincial hospitals and / or provincial maternity hospitals which can perform clinical examination, subclinical examination, sampling, and fixed gynecologic cancerous specimens meeting standards of the Ministry of Health - Provinces have hospitals which agreed to participate in the research when invited after being selected Study period: years: From 9/2001 - 8/2006 2.2 Subjects Study subjects were women born in the period from 1947 through 1966 The subjects were divided into groups: case and control groups: + Case group: As all the women in the study age in 12 provinces, suffering from primary cervical cancer, found at selected hospitals and identified through histological diagnosis or cytology + Control group: Women without CC, randomly selected from people who stay in the same villages or have same age group with case group 2.3 Research Methodology * Research Design: case – control study, in which case groups included women with primary cervical cancer and control groups included women without cervical cancer who lived in the same villages / hamlets and in the same age group with responding cases * Sample size of case group: Calculated as following: n=Z2(1-α/2) {1/[p1(1-p1)] +1/[p2(1-p2)] [ln(1-€)]2 In which: p1 is percentage of individuals exposing to risk factors estimated for case group; p is percentage of individuals exposing to risk factors estimated for control group; € is the level of accuracy chosen by investigator;; Z(1-α/2) is reliability of the study With reliability of 95%, Reliability coefficient is 1.96; we get p1=0.047, p2=0.019; selecting €=0.5 so the sample size is 608 cases * Sample size of control group: Control group is selected on purpose times higher than case group: 608 cases x controls/case = 1824 controls * Selecting cases: Cases, who are living in 12 provinces, were selected from 15 participant provincial hospitals and 12 national hospitals in Hanoi Case selection was stopped till the number of case were over or equivalent to the sample size As result, 611 cases were selected and put into the research * Selecting controls: Each identified cervical cancer case will have controls which selected randomly from women who stay in the same villages and have same age with cases Totally, there were 1833 individuals for control group 10 * Exclusion criteria: Women who have moved away and no longer live locally, unable to keep track Women with mental impairment, unable to understand and respond to the questions raised during the interview The women refused to participate in the study * Diagnostic criteria: The diagnosis of cancer to determine the case was conducted by histopathological examination, it is required to diagnose the cases In some specific situation, due to lack of biopsy specimens, clinical diagnosis and cytology diagnosis methods can be used * Handling specimens and cervical cancer diagnosis: specimens after biopsy, surgery were fixed in formal 10%, transferring to Citadel-2000 of Shandon The specimen is then dyed, read the optical microscope by the pathologist doctor with experience at K Hospital in Hanoi The final decision was evaluated by the Confirm Board The board includes three prestigious professors of anatomy and clinical * Research Contents: - Status of cervical cancer: Distribution of cervical cancer cases in the study area (12 provinces), the type of cancer Characteristics of cervical cancer object on demographics, health, the use of contraceptives, living habits, lifestyle - The relationship of cervical cancer with the social and environmental factors, including demographics, health, living and lifestyle * The variables in the research: The variables used in the research were divided into two groups: Independent (The elements can be related to cervical cancer) and the dependent variable (cervical cancer): 16 Table 3.5 Relationship between cervical cancer and smoke level of their husband The total number of Cance No OR cigarettes smoked ≥1000 cigarettes