LETTERS TO EDITOR
Religion-Related Factors and Cervical Cancer Screening To the Editor he recent report on “Religion-related factors and cervical cancer screening” is very interesting.1 Padela et al.1 concluded that, “negative religious coping (e.g., viewing health problems as a punishment from God) is associated with a lower odds of obtaining a Pap test.” This result is concordant with a previous report on “Attitudes toward cervical cancer screening among Muslim women” by Matin and LeBaron,2 stating that cervical cancer screening practices “threaten their cultural and religious values.” In fact, not only religious coping but also social coping is strongly related to cancer screening behaviors. In developing Asian and African countries, talking about the female genitalia is considered taboo.3,4 To manage the problem, it should be taken into consideration that it can be due to both religious and nonreligious beliefs.
T
Sora Yasri Primary Care Unit KMT Center Bangkok, Thailand [email protected]
Response to Yasri, “Associations Between Religion-Related Factors and Cervical Cancer Screening Among Muslims in Greater Chicago.” J Low Genit Tract Dis. 2014 June 9. [E-pub ahead of print]
W
e thank Yasri and colleagues for their careful reading and interest in our paper. Their brief correspondence brings up the key point that social coping may impact the cancer screening behaviors of Muslim patients. However, the studies referenced in the correspondence also do not assess the strength of such relationships, and it is not immediately clear how religiocultural taboos regarding discussing women’s health and other social coping– related mores associate with screening behaviors. We also support the authors’ advocacy for considering both religionrelated and non–religion-related barriers to cancer screening and believe much more research is required to fully flesh out such relationships toward the goal of designing effective interventions.
Aasim I. Padela, MD, MSc
Viroj Wiwanitkit
The Initiative on Islam and Medicine Department of Medicine The University of Chicago Chicago, IL [email protected]
Visiting Professor Hainan Medical University, China Visiting Professor Faculty of Medicine University of Nis, Serbia
REFERENCES 1. Padela AI, Peek M, Johnson-Agbakwu CE, Hosseinian Z, Curlin F. Associations between religion-related factors and cervical cancer screening among Muslims in Greater Chicago. J Low Genit Tract Dis 2014 [Epub ahead of print]. 2. Matin M, LeBaron S. Attitudes toward cervical cancer screening among Muslim women: a pilot study. Women Health 2004;39:63–77. 3. Williams MS, Amoateng P. Knowledge and beliefs about cervical cancer screening among men in Kumasi, Ghana. Ghana Med J 2012;46: 147–51. 3. Bethune GR, Lewis HJ. Let’s talk about smear tests: social marketing for the National Cervical Screening Programme. Public Health 2009; 123(Suppl 1):e17–22.
Letter to the Editor Regarding “Evaluation of a Cervicography-Based Program to Ensure Quality of Visual Inspection of the Cervix in HIV-Infected Women in Johannesburg, South Africa” by Firnhaber et al To the editor: irnhaber et al.1 made oversimplified statements regarding the cost and value of a quality assurance (QA) program using digital cervicography to improve visual
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Journal of Lower Genital Tract Disease • Volume 19, Number 2, April 2015
inspection with acetic acid performance. First, the program's impact on cancer is uncertain. As previously reported,2 the prevalence of cervical intraepithelial neoplasia grade 2 or worse (CIN2+) in this population was 26%, two thirds of which was CIN2. Thus, the review of images would result in an additional 31 CIN2+ detected in the 1,193 screened or 2.6 (not 10) CIN2+ per 100 screened. However, since CIN2 is an equivocal precancer diagnosis that often regresses,3,4 and not all CIN3 becomes invasive cancer,5 it is unclear how many cancers would actually be prevented by this QA program. Second, the authors contrast the cost of several fixed-cost items required for the program (i.e., digital camera, monitor, and computer) against the treatment cost of one cervical cancer case but fail to acknowledge important variable costs that would be required, including provider time spent training and reviewing images for all women screened. Furthermore, the feasibility and costs of scaling up such a program and the generalizability to settings with limited computing capacity are not known. Finally, to determine whether a particular intervention is “worth the resources,” one must consider the opportunity costs; for example, could the investments in equipment and personnel time for the QA program be better expended on having women come back for a second screen or improving follow-up of treated women? Alternatively, could using the resources to increase access to human immunodeficiency virus care more effectively improve cervical cancer prevention? An intervention's value should be critically appraised, involving a thorough inventory of the resources required to implement and sustain the program, firm evidence of health benefit, and consideration of competing choices. Until then, we feel that the authors' conclusion that the QA program is “well worth the resources” cannot be made.
Sincerely, Jane J. Kim, PhD Philip E. Castle, PhD Jane J. Kim, PhD Center for Health Decision Science Department of Health Policy and Management Harvard School of Public Health Boston, MA [email protected]
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Copyright © 2015 American Society for Colposcopy and Cervical Pathology. Unauthorized reproduction of this article is prohibited.
Religion-Related Factors and Cervical Cancer Screening To the Editor he recent report on “Religion-related factors and cervical cancer screening” is very interesting.1 Padela et al.1 concluded that, “negative religious coping (e.g., viewing health problems as a punishment from God) is associated with a lower odds of obtaining a Pap test.” This result is concordant with a previous report on “Attitudes toward cervical cancer screening among Muslim women” by Matin and LeBaron,2 stating that cervical cancer screening practices “threaten their cultural and religious values.” In fact, not only religious coping but also social coping is strongly related to cancer screening behaviors. In developing Asian and African countries, talking about the female genitalia is considered taboo.3,4 To manage the problem, it should be taken into consideration that it can be due to both religious and nonreligious beliefs.
T
Sora Yasri Primary Care Unit KMT Center Bangkok, Thailand [email protected]
Response to Yasri, “Associations Between Religion-Related Factors and Cervical Cancer Screening Among Muslims in Greater Chicago.” J Low Genit Tract Dis. 2014 June 9. [E-pub ahead of print]
W
e thank Yasri and colleagues for their careful reading and interest in our paper. Their brief correspondence brings up the key point that social coping may impact the cancer screening behaviors of Muslim patients. However, the studies referenced in the correspondence also do not assess the strength of such relationships, and it is not immediately clear how religiocultural taboos regarding discussing women’s health and other social coping– related mores associate with screening behaviors. We also support the authors’ advocacy for considering both religionrelated and non–religion-related barriers to cancer screening and believe much more research is required to fully flesh out such relationships toward the goal of designing effective interventions.
Aasim I. Padela, MD, MSc
Viroj Wiwanitkit
The Initiative on Islam and Medicine Department of Medicine The University of Chicago Chicago, IL [email protected]
Visiting Professor Hainan Medical University, China Visiting Professor Faculty of Medicine University of Nis, Serbia
REFERENCES 1. Padela AI, Peek M, Johnson-Agbakwu CE, Hosseinian Z, Curlin F. Associations between religion-related factors and cervical cancer screening among Muslims in Greater Chicago. J Low Genit Tract Dis 2014 [Epub ahead of print]. 2. Matin M, LeBaron S. Attitudes toward cervical cancer screening among Muslim women: a pilot study. Women Health 2004;39:63–77. 3. Williams MS, Amoateng P. Knowledge and beliefs about cervical cancer screening among men in Kumasi, Ghana. Ghana Med J 2012;46: 147–51. 3. Bethune GR, Lewis HJ. Let’s talk about smear tests: social marketing for the National Cervical Screening Programme. Public Health 2009; 123(Suppl 1):e17–22.
Letter to the Editor Regarding “Evaluation of a Cervicography-Based Program to Ensure Quality of Visual Inspection of the Cervix in HIV-Infected Women in Johannesburg, South Africa” by Firnhaber et al To the editor: irnhaber et al.1 made oversimplified statements regarding the cost and value of a quality assurance (QA) program using digital cervicography to improve visual
F
Journal of Lower Genital Tract Disease • Volume 19, Number 2, April 2015
inspection with acetic acid performance. First, the program's impact on cancer is uncertain. As previously reported,2 the prevalence of cervical intraepithelial neoplasia grade 2 or worse (CIN2+) in this population was 26%, two thirds of which was CIN2. Thus, the review of images would result in an additional 31 CIN2+ detected in the 1,193 screened or 2.6 (not 10) CIN2+ per 100 screened. However, since CIN2 is an equivocal precancer diagnosis that often regresses,3,4 and not all CIN3 becomes invasive cancer,5 it is unclear how many cancers would actually be prevented by this QA program. Second, the authors contrast the cost of several fixed-cost items required for the program (i.e., digital camera, monitor, and computer) against the treatment cost of one cervical cancer case but fail to acknowledge important variable costs that would be required, including provider time spent training and reviewing images for all women screened. Furthermore, the feasibility and costs of scaling up such a program and the generalizability to settings with limited computing capacity are not known. Finally, to determine whether a particular intervention is “worth the resources,” one must consider the opportunity costs; for example, could the investments in equipment and personnel time for the QA program be better expended on having women come back for a second screen or improving follow-up of treated women? Alternatively, could using the resources to increase access to human immunodeficiency virus care more effectively improve cervical cancer prevention? An intervention's value should be critically appraised, involving a thorough inventory of the resources required to implement and sustain the program, firm evidence of health benefit, and consideration of competing choices. Until then, we feel that the authors' conclusion that the QA program is “well worth the resources” cannot be made.
Sincerely, Jane J. Kim, PhD Philip E. Castle, PhD Jane J. Kim, PhD Center for Health Decision Science Department of Health Policy and Management Harvard School of Public Health Boston, MA [email protected]
e45
Copyright © 2015 American Society for Colposcopy and Cervical Pathology. Unauthorized reproduction of this article is prohibited.
