title: Why are women with cervical cancer not being diagnosed in preinvasive phase? An analysis of risk factors using a hierarchical model.
abstract: OBJECTIVE
  To assess the risk factors for delayed diagnosis of uterine cervical lesions.
  
  
  METHODS
  This is a case-control study that recruited 178 women at 2 Brazilian hospitals. The cases (n = 74) were composed of women with a late diagnosis of a lesion in the uterine cervix (invasive carcinoma in any stage). The controls (n = 104) were composed of women with cervical lesions diagnosed early on (low- or high-grade intraepithelial lesions). The analysis was performed by means of logistic regression model using a hierarchical model. The socioeconomic and demographic variables were included at level I (distal). Level II (intermediate) included the personal and family antecedents and knowledge about the Papanicolaou test and human papillomavirus. Level III (proximal) encompassed the variables relating to individuals' care for their own health, gynecologic symptoms, and variables relating to access to the health care system.
  
  
  RESULTS
  The risk factors for late diagnosis of uterine cervical lesions were age older than 40 years (odds ratio [OR] = 10.4; 95% confidence interval [CI], 2.3-48.4), not knowing the difference between the Papanicolaou test and gynecological pelvic examinations (OR, = 2.5; 95% CI, 1.3-4.9), not thinking that the Papanicolaou test was important (odds ratio [OR], 4.2; 95% CI, 1.3-13.4), and abnormal vaginal bleeding (OR, 15.0; 95% CI, 6.5-35.0). Previous treatment for sexually transmissible disease was a protective factor (OR, 0.3; 95% CI, 0.1-0.8) for delayed diagnosis.
  
  
  CONCLUSIONS
  Deficiencies in cervical cancer prevention programs in developing countries are not simply a matter of better provision and coverage of Papanicolaou tests. The misconception about the Papanicolaou test is a serious educational problem, as demonstrated by the present study.
authors.affiliation: MSc/PhD Graduate Program, A C Camargo Hospital, São Paulo, Brazil. andrezza@ispon.com.br
authors.forename: Andrezza Viviany
authors.initials: AV
authors.lastname: Lourenço
authors.forename: Cristiane M S
authors.initials: CM
authors.lastname: Fregnani
authors.forename: Priscila C S
authors.initials: PC
authors.lastname: Silva
authors.forename: Maria R D O
authors.initials: MR
authors.lastname: Latorre
authors.forename: José Humberto T G
authors.initials: JH
authors.lastname: Fregnani
mesh_terms: D000328:Adult; D001938:Brazil; D016022:Case-Control Studies; D002584:Cervix Uteri / Q000473:pathology; D003906:Developing Countries; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D015233:Models, Statistical; D060787:Neoplasm Grading; D009361:Neoplasm Invasiveness; D009367:Neoplasm Staging; D065006:Papanicolaou Test; D027383:Papillomaviridae; D030361:Papillomavirus Infections / Q000175:diagnosis / Q000517:prevention & control / Q000821:virology; D011379:Prognosis; D012307:Risk Factors; D002583:Uterine Cervical Neoplasms / Q000175:diagnosis* / Q000517:prevention & control* / Q000821:virology; D014626:Vaginal Smears; D002578:Uterine Cervical Dysplasia / Q000175:diagnosis* / Q000517:prevention & control* / Q000821:virology