Cervical cancer (CC) is more frequent and occurs at earlier ages among patients with psychosis compared to the general population.11. Ji J, Sundquist K, Ning Y, Kendler KS, Sundquist J, Chen X. Incidence of cancer in patients with schizophrenia and their first-degree relatives: a population-based study in Sweden. Schizophr Bull. 2013;39:527-36. CC screening as a preventive strategy is highly effective in reducing its incidence and mortality, but adherence to such screening among women with psychosis is significantly lower than in the general population.22. Martens PJ, Chochinov HM, Prior HJ, Fransoo R, Burland E, Need To Know Team. Are cervical cancer screening rates different for women with schizophrenia? A Manitoba population-based study. Schizophr Res. 2009;113:101-6. Non-adherence to screening protocols may be related to an increased risk of presenting with CC.33. Canfell K, Kim JJ, Brisson M, Keane A, Simms KT, Caruana M, et al. Mortality impact of achieving WHO cervical cancer elimination targets: a comparative modelling analysis in 78 low-income and lower-middle-income countries. Lancet. 2020;395:591-603. We aimed to explore the presence of differences in CC screening rates between women with psychosis and a control group.
We studied 286 women with psychosis and 86 women without mental disorders, all over 25 years old, from the First Episode Psychosis clinical Program cohort (PAFIP; Cantabria, Spain).44. Pelayo-Teran JM, Perez-Iglesias R, Ramirez-Bonilla M, Gonzalez-Blanch C, Martinez-Garcia O, Pardo-Garcia G, et al. Epidemiological factors associated with treated incidence of first-episode non-affective psychosis in Cantabria: insights from the Clinical Programme on Early Phases of Psychosis. Early Interv Psychiatry. 2008;2:178-87. The study was approved by the Clinical Research Ethics Committee of Cantabria. Cervical screening and pathology data were retrieved retrospectively from medical records in December 2021. Protocol adherence (yes vs. no) was defined according to previous literature22. Martens PJ, Chochinov HM, Prior HJ, Fransoo R, Burland E, Need To Know Team. Are cervical cancer screening rates different for women with schizophrenia? A Manitoba population-based study. Schizophr Res. 2009;113:101-6. and to international protocols, whereby women should undergo their first cytology at age 25 and every 3 years thereafter. We used analysis of variance (ANOVA) to compare continuous variables and the chi-square test for categorical variables. All statistical tests were two-tailed, and significance was determined at the 0.05 level.
A significantly greater proportion of women in the control group had undergone at least one cytology test in their lifetime compared to women in the psychosis group (81.6% vs. 67.1%; χ2 = 5.986, p = 0.009). Women with psychosis also entered the CC screening protocol significantly later than healthy controls (33.4 vs. 28.7 years; F = 12.433, p = 0.001). Fewer women with psychosis (34.3%) met criteria for CC protocol adherence compared to those in the control group (55.3%; χ2 = 11.162, p = 0.001). Moreover, the time elapsed since last cytology was significantly longer among psychosis patients than in the control group (4.7 vs. 3.3 years; F = 4.808, p = 0.029). We found no significant differences between groups (14 women with psychosis vs. 6 controls) in the proportion of altered cytology tests, nor in the proportion of biopsies with pathological results (3.5% of women with psychosis vs. 1.3% of controls; Yates’ χ2 = 0.537; p = 0.463): one woman with cervical intraepithelial neoplasia (CIN)-III in the control group versus 10 cases of cervical pathology among women with psychosis (one of cervical cancer, seven of CIN-III, and two of CIN-II). Comparisons between women in the psychosis group with (n=98, 34.3%) or without (n=188, 65.7%) CC protocol adherence showed relevant differences (Table 1).
Clinical and sociodemographic differences at psychosis breakout predicting poor cervical cancer screening in women with psychosis
Over one-third of women diagnosed with psychosis in our cohort had never undergone a CC screening test; those who had ever attended screening did so at an older age than the general population, and 8 years after the optimal age defined in international protocols.55. Cibula D, Potter R, Planchamp F, Avall-Lundqvist E, Fischerova D, Haie Meder C, et al. The European Society of Gynaecological Oncology/European Society for Radiotherapy and Oncology/European Society of Pathology guidelines for the management of patients with cervical cancer. Radiother Oncol. 2018;127:404-16. Furthermore, women with psychosis presented a significantly lower rate of good screening protocol adherence, which is consistent with previous research.22. Martens PJ, Chochinov HM, Prior HJ, Fransoo R, Burland E, Need To Know Team. Are cervical cancer screening rates different for women with schizophrenia? A Manitoba population-based study. Schizophr Res. 2009;113:101-6. Women in the psychosis group were three times more likely to present with cervical pathology and 10 times more likely to exhibit high-grade cervical pathology than control women. These differences in abnormal findings, although not statistically significant due to the small number of cases, may be the result of patients not attending CC screening.
These results should be taken into account when treating women with psychosis, who should be encouraged to enter a CC screening program if they are sexually active.
Acknowledgements
The study was supported by Instituto de Investigación Marqués de Valdecilla (INT/A21/10, INT/A20/04).
References
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1Ji J, Sundquist K, Ning Y, Kendler KS, Sundquist J, Chen X. Incidence of cancer in patients with schizophrenia and their first-degree relatives: a population-based study in Sweden. Schizophr Bull. 2013;39:527-36.
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2Martens PJ, Chochinov HM, Prior HJ, Fransoo R, Burland E, Need To Know Team. Are cervical cancer screening rates different for women with schizophrenia? A Manitoba population-based study. Schizophr Res. 2009;113:101-6.
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3Canfell K, Kim JJ, Brisson M, Keane A, Simms KT, Caruana M, et al. Mortality impact of achieving WHO cervical cancer elimination targets: a comparative modelling analysis in 78 low-income and lower-middle-income countries. Lancet. 2020;395:591-603.
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4Pelayo-Teran JM, Perez-Iglesias R, Ramirez-Bonilla M, Gonzalez-Blanch C, Martinez-Garcia O, Pardo-Garcia G, et al. Epidemiological factors associated with treated incidence of first-episode non-affective psychosis in Cantabria: insights from the Clinical Programme on Early Phases of Psychosis. Early Interv Psychiatry. 2008;2:178-87.
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5Cibula D, Potter R, Planchamp F, Avall-Lundqvist E, Fischerova D, Haie Meder C, et al. The European Society of Gynaecological Oncology/European Society for Radiotherapy and Oncology/European Society of Pathology guidelines for the management of patients with cervical cancer. Radiother Oncol. 2018;127:404-16.
Publication Dates
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Publication in this collection
29 Aug 2022 -
Date of issue
Sep-Oct 2022
History
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Received
05 Mar 2022 -
Accepted
30 Apr 2022
