Introduction

Cancer is emerging as a major health problem globally. Gynecological malignancies are significant causes of morbidity and mortality in women throughout the world [1]. Over the years, irrespective of social class, the number of gynecological cancers is increasing, with more cases at the younger age in India [2].

Gynecological malignancies are a group of different malignancies of the female reproductive system. The most common types of gynecological malignancies are cervical cancer, ovarian cancer, and endometrial (uterus) cancer. There are other less common gynecological malignancies including cancer of the vagina and cancer of the vulva [3]. Gynecological malignancies also include gestational trophoblastic neoplasia [4], in which the tissues formed in the uterus following conception become cancerous.

In most of the developing countries, including India, carcinoma of the cervix is a major public health problem [3]. More than 80% of the cervical cancer cases occur in the developing countries [5]. India’s cervical cancer age-standardized incidence rate (30.7 per 100,000) and age-standardized mortality rate (17.4 per 100,000) are the highest in South-Central Asia [6]. Ovarian cancer has the highest fatality-to-case ratio of all the gynecological malignancies [7]. As the leading cause of death from a gynecological malignancy, ovarian cancer is of public health importance [8]. However, endometrial carcinoma and vulval/vaginal carcinoma are usually the malignancy of elderly women, thereby raising the mortality significantly. In the developing countries like India, poor knowledge and health care-seeking behavior of the patients add to this burden significantly. Health care-seeking behavior or utilization studies have been an important part of medical sociology for a long time.

Cancer Registries in different parts of India reveal that majority of cancer cases present in an advanced stage, when the likelihood of cure is considerably reduced and treatment options become prolonged and expensive [9]. This leads to the high number of deaths among cancer patients, which could be averted by early detection of these cancers and prompt institution of treatment. Therefore, prevention and early detection of cancer needs more attention. Adequate knowledge about cancer influences early detection and treatment-seeking pattern [10, 11]. Health care personnel have a major role in providing awareness, promoting early detection and prompt referral of suspected cases to a cancer treatment facility for appropriate management. The knowledge and skills in the above areas have to be enhanced.

With the above background, this study was undertaken with the following objectives:

  1. 1.

    To find out the knowledge about the gynecological malignancies among the patients.

  2. 2.

    To find out health care-seeking behavior of the patients suffering from gynecological malignancies.

Materials and Methods

Type of Study

Hospital-based cross-sectional observational study.

Place of Study

This study was conducted in the gynecology out-patient clinic, Department of Obstetrics and Gynecology, Nilratan Sircar Medical College and Hospital, a tertiary care hospital in Kolkata, West Bengal, India.

Duration of Study

One year, from May 2006 to April 2007.

Study Population

Newly registered patients with gynecological morbidity of variable severity, attending the gynecology out-patient clinic of the above-mentioned hospital.

Sampling

The number of days available for the data collection was two fixed days each week, which were chosen by lottery method. Thus, Friday and Saturday were chosen. According to the previous records (2002–2003, 2003–2004, and 2004–2005), the total number of gynecological malignancy patients reported annually on Friday and Saturday was on an average 215, among the average total number of 5,126 newly registered patients. Therefore, the expected percentage of the patients with gynecological malignancy, based on the previous records, was calculated as 4.2% among the total new gynecological morbidity cases on Friday and Saturday.

As the expected number of patients with gynecological morbidity during the period of study, based on the previous records, was approximately 4,272, around 50% of these patients, i.e., 2,136, were proposed to be selected for the study, with random selection of the first patient and then every alternate patient.

However, it was possible to cover 2,141 patients during the period of study.

Study Tools

(1) A pre-designed and pre-tested checklist and a pre-designed and pre-tested schedule; (2) hospital records; (3) past health records of the patients; (4) investigation reports, particularly histopathology reports; (5) Cusco’s bivalve self-retaining vaginal speculum; and (6) stethoscope and sphygmomanometer.

Study Technique

(1) Interview method and (2) clinical examination.

Methodology

Permission was obtained from the hospital authority. The checklist and the schedule were drawn up in English, translated in Bengali (local language), and back-translated in English to check the translation. Pre-testing of the checklist and the schedule were done in the gynecology out-patient clinic of the same hospital before starting the study on 10 patients, and accordingly necessary modifications were made and these were finalized. The gynecology out-patient clinic was visited as said. The patients with the symptoms suggestive of gynecological malignancies were screened out. Presence of at least two suggestive symptoms was considered for inclusion of the patients. The symptoms considered for screening were: contact bleeding; irregular, heavy, or prolonged vaginal bleeding; postmenopausal bleeding; excessive, offensive with or without blood-stained vaginal discharge; lump in abdomen; abdominal distension or discomfort; and vulval growth. Informed consent to participate in the study was obtained from all the eligible patients who agreed to cooperate in the physical examination and necessary investigations. Necessary examinations and investigations especially histopathological examination were done for confirmation of diagnosis. The checklist was used for screening, and the schedule was used for the patients with histopathologically confirmed gynecological malignancies. The schedule consisted of few sections, i.e., general information, detailed history (menstrual history including menstrual hygiene, obstetrical, medical, surgical, family, and personal history), presenting symptoms, clinical examination findings, histopathological examination reports, definitive diagnosis with FIGO staging of gynecological malignancies, and finally questions regarding knowledge about gynecological malignancies and health care-seeking behavior of the patients. The first question that was asked to elicit the knowledge of the patients about gynecological malignancies was whether they had heard about gynecological cancer. In case the answer was “yes”, what they had heard about this disease and from whom, whether the disease was treatable, etc. were asked. These questions were followed by with whom they had discussed their symptoms first, with whom they had first contacted for the management of their symptoms, what was the time interval between the onset of symptoms and first attendance in this hospital, etc. to elicit their health care-seeking behavior. In-depth interview was conducted to elicit the knowledge about gynecological malignancies and health care-seeking behavior of the patients.

Analysis of Data

Data obtained were collated and analyzed statistically by simple proportions and tests of significance (chi-square test), as and when necessary.

Limitations of the Study

As the study population was screened out to identify the possible cases of gynecological malignancies on the basis of certain symptoms, few cases of gynecological malignancies not having the suggestive symptoms might have been missed.

This study was undertaken among women who presented to a gynecology out-patient clinic for diagnosis and treatment of gynecological morbidities and who agreed to participate in the research. Care has to be taken not to extrapolate the findings of this study to all women suffering from gynecological malignancies in the community. It is likely that women who do not wish to be investigated and interviewed and particularly those who do not seek medical care may differ in their knowledge as well as health care-seeking behavior.

This study could possibly be compared with similar studies from the developing world. The findings of this study might not corroborate with similar studies from the developed nations.

Results

This study shows that, during the study period, among the 2,141 patients attending the gynecology out-patient clinic, Department of Obstetrics and Gynecology of the said hospital, 483 patients (22.6%) were suffering from the symptoms suggestive of gynecological malignancies. Six patients (0.3%) were lost to follow-up. Therefore, 477 patients (22.3%) could further be studied and the diagnosis of all of them was confirmed by histopathology. Finally, the diagnosis of 113 patients (5.3%) was confirmed as gynecological malignancies, of which cervical malignancy was the commonest (70 out of 113 patients or 61.9%), followed by ovarian malignancy (27 out of 113 patients or 23.9%).

More than two thirds of the patients with gynecological malignancies (78 out of 113 patients or 69.0%) were in the age range of 35–64 years with mean age of 45.8 years. More than two thirds of the patients with gynecological malignancies (78 patients or 69.0%) had come from a rural area. Almost all the patients with gynecological malignancies (109 patients or 96.5%) were “ever-married”, i.e., currently married or widowed or separated. More than half of the patients with gynecological malignancies (62 patients or 54.9%) were illiterate/just literate. Median value of the per capita monthly income of family of the patients was Rs. 400 and mean value was Rs. 543 with a range of Rs. 100–2,500. India’s per capita income, as per the revised estimates released by the Central Statistical Organization on May 31, 2006, has been estimated at Rs. 23,222 annually at current prices during the year 2004–2005. So, per capita monthly income would be Rs. 1,935, which is nearly four times the per capita monthly income of the family of the patients. Nearly two thirds of the patients with gynecological malignancies (73 patients or 64.6%) were of parity 3 or higher with mean parity of 3.6.

Table 1 shows that, out of 113 patients with gynecological malignancies, most of the patients (47 patients or 41.6%) said that they had never heard the name of the disease. Only 18 patients (15.9%) knew that it occurs in the breast or female genital organs, and a much smaller proportion of the patients (9.7% or 11 patients) knew that white discharge or bleeding per vagina was the early symptom of the disease.

Table 1 Distribution of patients with gynecological malignancies according to their knowledge about gynecological malignancies (n = 113)

Regarding the knowledge about treatment of gynecological malignancies, only about one third of the patients (38 patients or 33.6%) knew that gynecological malignancies were treatable. More than one fourth of the patients (32 patients or 28.3%) knew that the treatment was available in the government hospital, i.e., government-run hospital, whereas only three patients (2.7%) knew that it was available in the cancer hospital, i.e., specialized hospital for cancer care only.

Table 2 depicts that almost half of the patients (56 out of 113 patients or 49.5%) had discussed about their symptoms first with their husbands. Majority of the patients (48 out of 113 patients or 42.5%) had first consulted with a gynecologist for their symptoms, followed by a general physician (44 patients or 38.9%) and a homeopathic doctor (11 patients or 9.7%). However, 8.9% or 10 patients had first consulted with a quack practitioner for their symptoms. Most of the patients (91 patients or 80.5%) had visited a private health facility first for their symptoms.

Table 2 Distribution of patients with gynecological malignancies according to their health care-seeking behavior (n = 113)

Table 3 indicates that slightly more than half of the patients (58 out of 113 patients or 51.3%) had first visited this hospital within 6 months of onset of their symptoms. Minimum duration reported was 1 day and maximum duration was 66 months. Median duration of symptoms on presentation at this hospital was 5.0 months and mean duration was 10.0 months. A statistically significant association was observed between the time interval from onset of symptoms to first visit to this hospital and educational level of the patients (p < 0.05).

Table 3 Distribution of patients with gynecological malignancies according to time interval between onset of symptoms and the first visit to this hospital and their educational level (n = 113)

Discussion

This study indicates that very few patients had knowledge about the symptoms, possible causes, and treatment options of the disease, which is of significant concern for prevention, early detection, and timely treatment of the gynecological malignancies. A similar study on cancer of the cervix done by Kidanto et al. [12] in Tanzania had shown that cervical cancer patients had low knowledge of basic symptoms of cancer of the cervix, and as a result they reported late with advanced disease.

In the present study, more than one third of the patients (38.1%) had heard about gynecological malignancies from their neighbors, followed by 15.9% from their relatives. Other sources were friends (5.3%) and television (two patients or 1.8%). Above numbers call for immediate attention as the sources of knowledge in almost all the cases might not be reliable and there is an equally likelihood of being misinformed by the neighbors, relatives, or friends. In this study, only about one third of the patients (33.6%) knew that gynecological malignancies were treatable. More than one fourth of the patients (28.3%) knew that the treatment was available in the government hospital, i.e., government-run hospital, whereas only 2.7% patients knew that it was available in the cancer hospital, i.e., specialized hospital for cancer care only. These numbers are not very statistically encouraging so far as cancer awareness is concerned. As per medical literature, the exact cause of each gynecological cancer is not known [13]. Moreover, the prognosis of the disease varies from patient to patient. In this light, the earlier the diagnosis, the better it is. In Indian circumstances where regular medical check-up is not a routine practice, the knowledge of the patients regarding the disease is important for early presentation in an appropriate health facility.

In this study, almost half of the patients (49.5%) had discussed about their symptoms first with their husbands, followed by other relatives (13.3%), daughter-in-law (12.4%), and daughter (7.1%). Similarly, Were and Buziba [14], in a study of cervical cancer patients at a hospital in Kenya, observed that female relatives and husbands were the first to be told about the symptoms (90.3% patients) and husbands alone (48.8% patients).

In the present study, majority of the patients (42.5%) had first consulted with a gynecologist for their symptoms, followed by a general physician (38.9%) and a homeopathic doctor (9.7%). However, sadly enough, 8.9% patients had first consulted with a quack practitioner for their symptoms. Though health care is much less expensive in government settings in India and government health facilities are supposed to exist in rural areas too with an appropriate referral system, still there is a tendency among the patients to go to the quack practitioners in some places especially in rural areas. Though it has not been studied in the present study as to why some of the patients went to a quack practitioner first, some other studies indicate that lower cost, easy availability, and better accessibility of the services provided by the quacks play a major role behind this particular health care-seeking behavior. Moreover, health insurance in India is limited to only a small proportion of people in the organized sector, covering less than 10% of the total population. There is also lack of awareness among people about health insurance, and that is why it is not widely availed by the patients.

In this study, most of the patients (80.5%) had visited a private health facility first for their symptoms. Probably this preference reflects the faith of women on health care delivery received from the private health facility. Were and Buziba [14], in their study in Kenya, observed that more than 90% of patients sought health care for the first time at a facility staffed by trained health workers, with 39% visiting a dispensary or health center first. In the present study, most of the patients (93.8%) had contacted at least one physician prior to visit to this hospital. Only seven patients (6.2%) had reported for the first time at this hospital for their illness.

Slightly more than half of the patients (51.3%) had first visited this hospital within 6 months of onset of their symptoms. However, nearly one third of the patients (32.7%) had first visited this hospital 1 year and more after onset of the symptoms. The mean duration of symptoms on presentation at this hospital was 10.0 months with range from 1 day to 66 months, whereas median duration was 5.0 months. Similarly, Were and Buziba [14] in Kenya observed that the mean duration of clinical symptoms on presentation at their hospital was 8.2 months with a range of 1 to 24 months.

In India, there are quite a few health care choices, e.g., government-run health facilities with appropriate referral system where a patient can have access to specialist physicians and well-equipped diagnostic and treatment facilities at an affordable cost, private-run hospitals where a patient can access the same facilities at a huge cost, and private-run dispensaries or clinics or nursing homes where a patient may have access to a specialist physician, though these are not always well equipped with proper diagnostic and treatment facilities. Other choices are general practitioners and their clinics, practitioners of indigenous systems of medicine like homeopathy and ayurveda, and even quack practitioners. As the patients often do not have faith on the services of government facilities and most of them cannot afford the huge cost of the health care delivery offered by private hospitals, they often end up choosing the relatively less-expensive options initially, which might be a significant cause of late presentation in an appropriate health facility.

This study was conducted in a tertiary care hospital. The government health system in India has three levels of care. Primary care level is the first level of contact of the patient with the government health system and it is provided by the primary health centers and their sub-centers. Secondary care level is equipped to deal with more complex problems, which is provided by the district hospitals and community health centers. Tertiary care level is a more specialized level with specific facilities and highly specialized health personnel, which is provided by the regional and central level institutions. The government health system is supported by an appropriate referral system.

A statistically significant association was observed between the time interval from onset of symptoms to first visit to this hospital and educational level of the patients. A higher proportion of the patients with education grade V and above had first visited this hospital within 3 months of onset of their symptoms than those with education up to grade IV (35.2% versus 17.8%). However, no statistical association was observed between the stated time interval and occupation or place of residence of the patients or per capita monthly income of family of the patients. In this regard, the sample size used should be kept in mind. It might have been possible to find out a significant association between the stated time interval and the above-mentioned variables, had the sample size been larger.

This study reflects the poor knowledge and health care-seeking behavior of the patients and highlights the need for addressing and prioritizing resources towards educating women and the broader community about these malignancies, which affect women’s ability to fulfill a wide range of diverse roles.

Conclusions

Gynecological malignancies remain an important health concern for women. The disease can be identified promptly when women report the warning symptoms early. Therefore, all the women should be made aware about the gynecological malignancies, its warning symptoms, factors responsible, diagnosis, place of treatment, nature of treatment, feasibility of cure, and prognosis. All these information if imparted to the women will result in prevention, early diagnosis, and timely management of gynecological malignancies and therefore will have a major impact on reduction of burden of these cancers. This can be achieved through health personnel, educational radio/television programs, newspapers, magazines, and other media as well. Community-based activities, including support groups and volunteer health promoters, may also hold promise since they can maximize the interest and resources of the women themselves as well as the community. Women should also be made aware about the urgency of seeking appropriate health care on experiencing the possible warning symptoms because the earlier a cancer is detected, the easier it is to treat. Even after diagnosis and initiation of treatment, continuation of treatment and follow-up should be emphasized. Female literacy can go a long way in inculcating the above among the women population. Further, not only the women, awareness about the gynecological malignancies should also be provided to their husbands, other family members, and the community.

Primary care physicians should be made aware of the possible warning symptoms of gynecological malignancies, and they should refer women who present with the possible symptoms promptly to an appropriate health facility to exclude the possibility of malignancy. Private practitioners including the general physicians can play a vital role to decrease the burden of this disease.

Future research on knowledge about the disease and health care-seeking behavior of women suffering from gynecological malignancies should be undertaken in the community for further insight on prevention and early detection of gynecological malignancies.