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Year : 2015  |  Volume : 59  |  Issue : 1  |  Page : 45-48  

Risk factors for cancer cervix among rural women of a hilly state: A case-control study

1 Assistant Professor, Department of Community Medicine, Indira Gandhi Medical College (IGMC), Shimla, Himachal Pradesh, India
2 Ex-Professor and Head, Department of Community Medicine, Indira Gandhi Medical College (IGMC), Shimla, Himachal Pradesh, India
3 Associate Professor, Department of Community Medicine, Indira Gandhi Medical College (IGMC), Shimla, Himachal Pradesh, India
4 Senior Resident, Department of Community Medicine, Indira Gandhi Medical College (IGMC), Shimla, Himachal Pradesh, India

Date of Web Publication9-Mar-2015

Correspondence Address:
Anita Thakur
Assistant Professor, Department of Community Medicine, Indira Gandhi Medical College (IGMC), Shimla, Himachal Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0019-557X.152862

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In Himachal Pradesh, cancer cervix is a major public health problem since it ranks as the number one female cancer. A case-control study of 226 newly diagnosed, histopathologically confirmed cases of cancer cervix and equal number of matched controls was conducted at Regional Cancer Center, Himachal Pradesh during the period from July 2008 to October 2009 with the objective to study the common factors associated with cancer cervix. Univariate analysis identified 10 risk factors associated significantly with the disease. On multiple logistic regression, however, only seven risk factors were found to be associated significantly with the disease. These were: Age at birth of first child, spacing between two children, age at marriage, literacy, socioeconomic status, multiparity, and poor genital hygiene. Risk factors such as poor genital hygiene, age at birth of first child <19 years, early marriage, illiteracy, multiparity, and low socioeconomic status were highly prevalent in the study subjects and were found to be significantly associated with cancer cervix.

Keywords: Cancer cervix, Case-control, Multivariate, Odds ratio, Risk factor

How to cite this article:
Thakur A, Gupta B, Gupta A, Chauhan R. Risk factors for cancer cervix among rural women of a hilly state: A case-control study. Indian J Public Health 2015;59:45-8

How to cite this URL:
Thakur A, Gupta B, Gupta A, Chauhan R. Risk factors for cancer cervix among rural women of a hilly state: A case-control study. Indian J Public Health [serial online] 2015 [cited 2022 Jan 26];59:45-8. Available from:

Cancer of uterine cervix is one of the leading causes of cancer deaths among women worldwide. The estimated number of new cervical cancer cases per year is 500,000 of which 79% occur in developing countries, whereas in affluent countries cervical cancer does not find a place in the top leading cancers in women. [1] In India, it is the most common cancer among women, constituting one-sixth to one-half of all female cancers. [2]

The epidemiology of cancer cervix has been very challenging. Various studies have confirmed the link with sexual activity, multiparity, early marriage, multiple sexual partners, illiteracy, and low socioeconomic status. Human papillomavirus (HPV) infection, particularly with type 16, 18, and 31, is quite likely the cause of cervical carcinogenesis, but it is not the sufficient cause. Most of the women infected with HPV do not develop invasive cervical carcinoma. It is only in a proportion of women in whom the infection is persistent and several other co-factors that persist help in the development of disease. [3],[4]

In the hilly state of Himachal Pradesh, cancer cervix is a major public health problem since it ranks as the number one female cancer as per the annual reports of Regional Cancer Center, Himachal Pradesh for the last 10 years. [5] No study has been undertaken so far in this regard in the region. The present case-control study was, therefore, planned to evaluate the association of certain risk factors with cervical cancer among the rural women in the state, so that certain state-specific strategies could be formulated.

A case-control study was undertaken in Regional Cancer Center, Himachal Pradesh, which is the only cancer hospital in Himachal where nearly all the cases of cancer cervix from the state are referred for curative and palliative therapy. Only histopathologically confirmed cases diagnosed during the study period of 15 months (from July 2008 to October 2009) were included in the present study.

Sample size was calculated at a Confidence Interval (CI) of 95%, power of 80%, assuming 20% of the controls would be exposed to risk factors, and an odds ratio (OR) of 2. After taking a non-response rate of 20%, a sample size of 226 each for cases and controls was calculated. Two hundred and twenty-six cases that fulfilled the inclusion criteria, i.e., histopathologically confirmed cases diagnosed during the study period, were selected. Cases with only cytological evidence were excluded from the study. Equal numbers of controls were selected from various female patients admitted in Indira Gandhi Medical College for non-gynecological conditions. Women who had undergone hysterectomy or were admitted with endocrine or smoke-related diseases were not regarded eligible as controls. Cases and controls were group-matched for age (P-value 0.89, unpaired t-test), occupation (P-value 0.76, chi-square test) and background - rural/urban (P-value 0.78, chi-square test) for 5-year class intervals. A predesigned and pretested schedule was filled via interview method, after taking informed consent from both cases and controls. The risk factors included were illiteracy, low socioeconomic status (according to modified Prasad classification), early menarche <13 years, age at marriage <18 years, age at birth of first child <19 years, multiparity >3 children, spacing between two children <2 years, poor genital hygiene (bath <4 times a week, menstrual hygiene, i.e., type of napkin used, frequency of change, practice of washing genitalia during periods, type of latrines used, post-coital washings), duration of married life >20 years, use of contraceptives (both oral and barrier methods), multiple sexual partners of both study subjects/spouses, history of smoking, and history of recurrent genital infection (>3 episodes/year for which treatment had to be taken).

Univariate analysis was carried out by estimating OR and their 95% CI values. Chi-square test was used as a test of proportion. Unconditional multiple logistic regression (MLR) analysis was carried out using SPSS 10. This analysis excluded redundant variables to take care of co-variance.

Majority [85 (37.9%)] of our patients were in the age group of 45-54 years. Mean age of the cases was 48.1 ± 5.4 years. Majority of the cases [214 (94%)] were Hindus by religion and most of them, i.e., 164 (72.6%), were illiterate. Majority of the cases [190 (84.07%)] were married before the age of 18 years and out of these, 30.9% of the cases were married before the age of 14 years. There was no significant difference between the age groups of cases and controls (P-value 0.89 on unpaired t-test). Also, 154 (68.1%) cases had their children before the age of 19 years and 176 (77.8%) cases had >3 children. One hundred and fifty-six (69.02%) of the cases had children within a gap of <2 years. Majority [212 (94.2%)] had never used any method of contraception during their lifetime. There were very few [21 (9.2%)] smokers in our series and only 22 (9.73%) of them had more than one sexual partner (most of these had married more than once).

Univariate analysis identified 10 risk factors associated significantly with the disease. [Table 1] shows the results of univariate analysis of risk factors for carcinoma cervix.
Table 1: Univariate analysis of risk factors for carcinoma cervix

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On MLR, however, only seven risk factors were found to be associated significantly with the disease; these were: Age at birth of first child <19 years (OR 2.91, 95% CI 1.846-3.529), spacing between two children <2 years (OR 2.88, 95% CI 1.846-3.629), age at marriage <18 years (OR 1.93, 95% CI 1.271-2.798), illiteracy (OR 1.64, 95% CI 1.0616-2.245), low socioeconomic status (OR 1.39, 95% CI 1.256-2.647), and poor genital hygiene (OR 1.69, 95% CI 1.0716-2.265), as presented in [Table 2].
Table 2: Association of various factors with cancer cervix on multivariate analysis

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Rath et al. [6] and Reeves et al. [7] have cited early marriage as the best predictor of the disease status in their study. In our study, women marrying before the age of 18 years were found to be almost 3 times at risk (OR = 2.88) as compared to women marrying after the age of 18 years. Similar findings were also observed by Brinton et al. [8]

A national case-control study on cervical cancer in the UK conducted by Green et al. has also found the risk of cervical cancer to be threefolds higher among women who gave history of age at first intercourse to be <17 years as compared to women who had their first sexual debut at >20 years of age. [9] The possible explanation for the significance of this factor is the fact that early sexual debut results in more frequent and prolonged sexual activity and prolonged hormonal stimulation, and the young cervical tissue is more susceptible to oncogenic change. [10] In addition, those marrying at younger age are exposed to sexually transmitted diseases including HPV which is the prime factor in this disease as mentioned by Hawkins et al. [10] Age at birth of first child was found to be significantly lower in cancer cervix patients as compared to the control group in our study. This finding was consistent with that of Prabhakar et al. [11]

High parity with >3 children was found to be a significant risk factor (OR = 2.88). Munoz et al., in a pooled analysis of 10 case-control studies on HPV-positive women, found the risk becoming twice higher with the number of pregnancies. Parity is probably a good marker of hormonal environment throughout the fertile years of women, as well as a marker of repeated cervical trauma predisposing to infection. [12]

Illiteracy is a common factor that not only lowers the age at marriage and encourages high parity but also influences genital hygiene, menstrual hygiene, dietary deficiencies, and utilization of health services. There was a significant association in our study also, as was observed by Bayo et al. [12] Similarly, OR of 1.39 times was found in women with low socioeconomic status, which is consistent with the finding of Rohilla et al. [13]

Although smoking is quite common among rural women in Himachal Pradesh, we did not find any significant association in the present study. But Schiffman et al. have found an independent association of smoking with the disease. [14]

In our study, we found spacing between pregnancies to be one of the significant factors with a relative risk of nearly 3 times (OR = 2.88). Trauma to cervix during delivery as well as increased susceptibility to infection can be given as the possible explanations. Immunosuppression, hormonal influences, and dietary deficiencies due to repeated pregnancies are the other possible alternative mechanisms. This observation also finds its support in a recent report from the American Cancer Society which states that hormonal influences during pregnancy make women more susceptible to HPV infection. Poor genital and menstrual hygiene was also found to be a strong predictor of this disease in our study, which is in conformity with several other studies. [15]

No association was found of cervical cancer with the use of barrier methods or oral contraceptive pills (OCPs). Only 1.33% of our cases had used OCPs for a period of 2 years or less. But a study conducted by the American Cancer Society has found a significant association with both. [15]

In a study conducted by Thulaseedharan et al., it was observed that compared to those with no formal education, women with some formal education had a reduced risk of cervical cancer. Similar findings were seen in our study also. [16]

Risk factors such as poor genital hygiene, age at birth of first child, age at marriage, illiteracy, multiparity, and low socioeconomic status were highly prevalent among the cases and the association was found to be significant statistically. Efforts should be made to innovate ways to reach and educate illiterate women. Intensive Behavior Change Communication (BCC) of the target group is the need of the hour using local dialect in Information Education Provided Communication (IEC) material, pictorial depiction of warning signs of cancer cervix, etc. Awareness can be increased by target group discussion involving the women of reproductive age, conducting essay competition and debate among school-going adolescent girls, etc. Stress should be laid on increasing female literacy as it is closely linked to their socioeconomic status, poor genital hygiene, and early marriage. A public health policy with strong inter-sectoral coordination is required for conducting widespread cost-effective screening programs to detect cases in early stages and anticancer campaigns utilizing the available health care resources at grass-root level.

   References Top

Shanta V, Krishnamurthy S, CK, Swaminathan R, Ravichandran K. Epidemiology of cancer of the cervix; global and national perspective. J Indian Med Assoc 2000; 98:49-52.  Back to cited text no. 1
Nandakumar A, Anantha N, Venugopal TC. Incidence, mortality and survival in cancer of the cervix in Bangalore, Indian. Br J Cancer 1995;71:1348-52.  Back to cited text no. 2
Taylor RS, Carroll BE, Lloyd JW. Mortality among women in 3 Catholic religious orders with special reference to cancer. Cancer 1959;12:1207-25.  Back to cited text no. 3
, et al. Human Papillomaviruses and cervical cancer in Bangkok. II. Risk factors for in situ and invasive squamous cell cervical carcinomas. Am J Epidemiol 2001;153:732-9.  Back to cited text no. 4
Annual Reports. Himachal Pradesh: Regional Cancer Centre; 1998-2008. p. 116-418.  Back to cited text no. 5
Leibel SA, Phillips TI. Textbook of Radiation Oncology. 1 [st] ed: B I Churchill Living Stone; 2001. p. 134-8.  Back to cited text no. 6
Reeves WC, Brinton LA, Brenes MM, Quiroz E, Rawls WE, De Britton RC. Case control study of cervical cancer in Herrera Province, Republic of Panama. Int J Cancer 1985; 36:56-60.  Back to cited text no. 7
Brinton LA, Hammen RF, Huggins GR, Lehman HF, Levin RS, Mallin K, et al. Sexual and reproductive risk factors for invasive squamous cell cancer. J Natal Cancer Inst 1987;79:23-30.  Back to cited text no. 8
Green J, , Sweetland S, Beral V, , Crossley B, et al. Risk factors for adenocarcinoma and squamous cell carcinoma of the cervix in women aged 20-44 years: The UK National Case- Control Study of Cervical Cancer. 2003;89:2078-86.  Back to cited text no. 9
Howking J, Bourne G, Shaw W. Shaw's Text Book of Gynaecology. 13 [th] ed. Churchill Livingstone; 2003. p. 286-302.  Back to cited text no. 10
Prabhakar AK. Cervical cancer in India - strategy for control. Indian J Cancer 1992;29:104-13.  Back to cited text no. 11
Bayo S, Bosch FX, de S, N, Combita AL, Coursaget P, et al. Risk factors of invasive cervical cancer in Mali. Int J Epidemiol 2002;31:202-9.  Back to cited text no. 12
Rohilla M. Risk factors for carcinoma of cervix. J Obstet Gynecol 2000;2:24-7.  Back to cited text no. 13
Schiffman MH, Brinton LA. The epidemiology of cervical carcinogenesis. Cancer 1995;76:1888-901.  Back to cited text no. 14
American Cancer Society (Cancer Reference Information). What Are the Risk Factors for Cervical Cancer? Available from on 2008 May 28].  Back to cited text no. 15
Thulaseedharan JV, Malila N, Hakama M, Esmy PO, Cheriyan M, Swaminathan R, et al. Socio demographic and reproductive risk factors for cervical cancer - a large prospective cohort study from rural India. Asian Pac J Cancer Prev 2012;13:2991-5.  Back to cited text no. 16


  [Table 1], [Table 2]

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