Re: Cervical cancer screening

The article "Cervical cancer screening in BC Chinese women" (Hislop TG, Teh C, Lai A, et al. BCMJ 2000;42(10):456-460) confirms the suspicion of why the incidence of invasive cervical cancer is higher in Chinese women than in Caucasian women in BC (two to four times higher in BCCA study 1993).[1] The study concludes that the cervical cancer screening (Pap smear) rates in these Chinese women are about 20% below the provincial average. The authors will further evaluate a "culturally appropriate educational intervention" developed from the information gained on barriers and facilitators to Pap testing.

I would like to bring to our readers’ attention that several barriers that limit access to cervical cancer screening by Chinese women have been identified, and that there is an initiative in place, the Asian Women’s Health Clinic,[2] that addresses these barriers. This clinic provides Chinese women in the Lower Mainland with an alternative means of obtaining a Pap smear. It is the first documented Pap smear clinic to be established in North America. A similar clinic has recently been funded in Ontario.

The barriers to access to Pap testing include lack of education about preventive health care, as well as language and cultural barriers. This was confirmed in a recent study in ethnocultural groups (in press).[3] Cultural barriers are particularly significant. For example, the gender of the smear-taker is an important issue—the women are uncomfortable even with a male family physician’s offer to do a pelvic examination and Pap test.

For many immigrants preventive health care is not a familiar concept, and the lack of knowledge about Pap smears is directly related to lack of resources in their home country. Until recently, access to women physicians who are able to communicate in the Chinese language has been difficult, and continues to be limited.

The Asian Women’s Health Clinic was launched in 1994 to address these barriers. As part of the educational program, the clinic produced bilingual (Chinese/English) pamphlets on the Pap test and on breast self-examination, and corresponding videos in Cantonese and Mandarin. These are used at the clinic and at community workshops. Clinic staff members are all women who are fluent in Cantonese, Mandarin, and English.

A small number of women from other community groups also use the services in English. The clinic is centrally located in Vancouver at Mount St Joseph Hospital, and it operates in the evening to accommodate working women. There are three clinics per month and an average of 20 women are seen at each clinic.

The clinic confines its services to education and to Pap testing and breast examination alone, so as to maintain the ongoing support of the Chinese medical community. It is interesting that some women in the ethnocultural study expressed an expectation for services in counseling in, and management of, other women’s health issues, in addition to the education and screening.

The Asian Women’s Health Clinic has raised the awareness within the medical community of the higher cervical cancer rates, and it has precipitated changes in the patterns of practice with regard to Pap smear screening. Previously, most women were referred to a small number of Chinese-speaking gynecologists, an expensive means of performing routine screening. Many physicians now readily refer patients to the Asian Women’s Health Clinic.

Some male physicians themselves are now more willing and more comfortable in performing Pap smear testing. Others have chosen to practice in association with a woman colleague; others have arranged to have women colleagues come in on a regular basis to their office; and others have made arrangements with women colleagues outside their office to provide Pap smear testing and breast examinations.

This timely study by Hislop et al highlights a community health problem. It shows that Chinese women in BC continue to demonstrate a low rate of utilization of the provincial cervical cancer-screening program in 1999. The provision of services in a traditional family practice setting does not seem to address the problem, and the initiative of the Asian Women’s Health Clinic, with its limited resources, has been able to reach only a small proportion of the population.

The clinic has been unable to expand its existing services for the past 3 years because of inadequate funding. There is a need for formal funding from the Regional Health Board and the clinic’s partners, the Vancouver/Richmond Health Board, BC Women’s Hospital, Providence Health Care (Mount St Joseph Hospital) and SUCCESS (United Chinese Community Enrichment Services Society). Additional funding is required to expand the existing services to reach other ethnic groups that may encounter similar barriers in accessing health care. Consideration should also be given to developing a more comprehensive range of services in women’s health.

—Lorna Sent, MD
Former Medical Director, Asian Women’s Health Clinic