1. Total area of land donated by the rural community of Yantalo [70%) and purchased (30%) > 360 degrees of Tropical Jungle view.
2. Floor plan of the clinic under construction: total construction area: 4,000 sq mts.To date 1400 completed.
3. Areas for the future: dental unit, hemodialysis unit, Lipid Center Unit, Conference center, etc etc.. Areas circled in red reserved for housing development for workers and visitors.
4. Active reforestation process.. about 1400 new plants to date.. target 6000. Land was totally bare due to former agricultural use!

Kate Munger, MS2
Preceptors:
Cynthia Angel, M.D.
Department of Obstetrics and Gynecology
University of Rochester Medical Center
C. Luis Vasquez, M.D.
Yantalo Peru Foundation
Participation of Women in Cervical Cancer Screening in Yantalo, Peru: a Longitudinal
Study

INTRODUCTION:
Among women, cervical cancer is the second most common cancer and more than 80% of the
global burden of cervical cancer is found in developing countries, despite the fact that it is a
preventable cancer with efficacious screening methods (1). In South America, incidence rates of
cervical cancer are about 24 per 100,000 while that in most developed countries are less than 10
per 100,000. In Peru, cervical cancer is one of the leading causes of cancer deaths in women. The
incidence rate is estimated to be 34.5 per 100,000 and the mortality rate is estimated to be 16.3
per 100,000 (2). For cervical cancer, screening participation compliance is essential for detecting
early changes in cervical epithelium. Conventional cytology (Pap smear), liquid based cytology,
HPV testing and visual screening with acetic acid can detect changes in the cervix years before it
develops into invasive cancer (1). For early detection and management of invasive cancer, public
education and awareness on the sign and symptoms is critical. In 2000-2003, a study conducted
in San Martin, Peru demonstrated that the presence of and contact with health services played
a role in increasing the participation in screening of women not previously screening or not
screened in the past five years (3).

OBJECTIVE: To assess the number of women screened in Yantalo, Peru, given the availability
of screening provided by the easily accessible local clinics, as well as whether or not women
continued getting screening. The study also aimed to understand the reasons why certain women
have not obtained screening, as well as identify potential sub-populations with risk factors
that are not being screened to help target such populations for future education programs. This
follow-up study also allowed us to assess any changes from the 2010 results, as an indication of
educational efforts.

METHODS: This study was conducted in the northern Peruvian Amazon town of Yantalo,
located in the Province of Moyobamba in the San Martin Region. Surveys were read to
participants in Spanish. Information was collected in a door-to-door fashion in participants’
homes. After the interview, applicants were verbally educated about cervical cancer and were
given a chance to ask any questions they had. The survey was comprised of the same 27
questions used in the 2010 study in Yantalo. Several of these questions were adopted from the
World Health Organization health survey from 2002 as well as a similar previous study (4,5).
In addition to demographics and health care behavior, specific questinos about cervical cancer
included whether they had ever obtained a pelvic exam or Pap smear, where they obtained that
test, how many times they had obtained a Pap in their lifetime, if anyone in their family had
cervical cancer, if they had heard of the Human Papilloma Virus (HPV), and whether they would
be willing to receive a HPV vaccine. If participants had never gotten a Pap smear or other test for

cervical cancer, they were asked if they had ever heard of such tests, and if so, why they had not
had a Pap smear done previously.

RESULTS: We aimed to survey the 378 women over 18 years old living within the District
of Yantalo, among 38 blocks, according to the door-to-door census study conducted by a staff
member of the Yantalo Foundation. We were able to survey 160 of those women (42%). When
asked if they had ever received a pelvic exam, 39.4% of women never had. For the women
that had received a pelvic exam, 43.1% had obtained it in the last 3 years, 6.2% had obtained it
within the last 4-5 years, and 11.2% had obtained it more than 5 years ago. Out of all women
surveyed, 49.4% of women responded that they had received a test for cervical cancer (PAP
smear), and 26.9% of women claimed that they had never heard about cervical cancer testing.
For those that had received a PAP smear, 37.5% have only had 1 in their lifetime, 27.5% have
had 2, 17.5% have had 3, and 18.8% have had 4 or more or were screening annually. When
asked if they had a family member who suffered from cervical cancer, 21.2% of women have
had an afflicted family member. Of all women surveyed, 59.4% of women have never heard of
the Human Papilloma Virus, although 88.1% of them would be willing to be vaccinated against
it. Also, 75.6% of women claimed they were sexually active, but only 19.3% use some sort of
non-condom contraception and only 6.25% report using condoms. All other results are pending
statistical analysis.

CONCLUSIONS: Only 49.4% of women over 18 are obtaining PAP smears. This number is
better than a previously reported 40% in other areas of the country, most likely due to a health
care clinic within walking distance; however, this percentage is much too low in a country with
such a high prevalence of cervical cancer. Also there has been no improvement since last year in
the number of women who have ever obtained a Pap smear (p=0.87). However it appears that
there has been a significant increase in the number of women who have heard of the Human
Papilloma virus (p=0.03). Therefore, the efforts implemented in the past year have raised
awareness of HPV but have not been enough to encourage more women to get Pap smears.
Given that many women in Yantalo have had family members who have had cervical cancer,
education and awareness is imperative. Also, given anecdotal evidence and narratives of the
women interviewed, it would probably be helpful to emphasize the availability of a safe,
painless, and respectful environment for an admittedly uncomfortable and potentially
embarrassing procedure. Lastly, the majority of women would be willing to be vaccinated
against HPV, and thus it may be beneficial in trying to get vaccines into the clinic and
administered to women as early as possible.

REFERENCES:
1) Boyle P, Bernard L. World Cancer Report. Lyon, France: IARC Press, 2008.
2) Ferlay J, Bray F, Pisani P, and Parkin DM. “GLOBOCAN 2008: Cancer incidence, mortality and prevalence
worldwide.” IARC CancerBase (5), IARCPress: Lyon, 2004.
3) Robles SC, FerreccioC, TsuV, Winkler J, AlmonteM, BinghamA, LewisM, Sasieni P. “Assessing participation of
women in a cervical cancer screening program in Peru.” Pan Am J Public Health 25 (2009): 189-195.
4) Winkler J, Bingham A, Coffey P, Handwerker WP. “Women’s participation in a cervical cancer screening
program in northern Peru.” Health Educ Res. 23 (2008): 10–24.
5) World Health Organization World Health Survey 2002. <http://www.who.int/healthinfo/survey/
whsshortindividualc.pdf>. Accessed January 20, 2010.
6) “Yantalo International Clinic.” Yantalo Peru Foundation. <http://www.yantalo.org/clinic/yantalo_clinic.html>.
Accessed Jan 29, 2010.