THE CORRELATION BETWEEN PARITY AND CERVICAL CANCER

AMONG PATIENT IN DR. SAIFUL ANWAR HOSPITAL MALANG

by:

Meilia Zainudin batch 2012

Putu Ijiya Danta Awatara batch 2014
Reselina Utami batch 2016
Yogesvara batch 2016

FACULTY OF MEDICINE
BRAWIJAYA UNIVERSITY
MALANG
2017
1. INTRODUCTION
Cancer is a disease caused by an abnormal physical condition and unhealthy
lifestyle. Cancer may occur in female reproductive organs, such as breasts, cervix,
ovaries, and vagina1
Worldwide, Cervical cancer is the second most common cancer, with the number of
cases reached 471.000 and accounting for nearly 123.000 deaths2. In 2006, Anatomy
Pathology Association of Indonesia reported that mortality rates due to cervical cancer in
Indonesia is very high because most of the patients came with cervical cancer at an
advanced stage or terminal stage 3.
Human papilloma virus (HPV) is the main cause of cervical cancer. Cervical cancer
may also caused by other risk factors such as health and sexual factors, socio-economic
factors, low economic rates, ethnic minorities, and other factors including tobacco
exposure, lack of appropriate screening, and treatment of previous intraepithelial cervical
neoplasia4. Several factors are thought to increase the incidence of cervical cancer,
namely parity, lack of genital hygiene, chronic trauma to the cervix, and oral
contraceptive use in long term that is more than 4 years5.
According to Surbakti (2004), parity has a significant relationship with the
occurrence of cervical cancer. Women with parity ≥3 had 4.375 times higher odds of
having cervical cancer compared to those in the lower parity (<3). It can be caused by
cervical trauma in vaginal delivery that cause an inflammation and subsequently turn into
cancer, and also hormonal change and immunosuppression condition in pregnancy make
the cervix more vulnerable to HPV exposure.
This study aims to investigate the correlation between parity and occurrence of
cervical cancer in General Hospital of Dr. Saiful Anwar Malang Period 2012-2014 ".

2. MATERIAL AND METHODS

This research is an analytic observational method using case control design, a case
report that provides an overview or profile of cervical cancer patients in General Hospital
of Dr. Saiful Anwar Malang from Januari 2012 to December 2014 and an analysis the
relationship between parity and occurrence of cervical cancer in General Hospital of
Dr. Saiful Anwar Malang from Januari 2012 to December 2014.
The population of this research were all patients of SMF Obstetrics and Gynecology
at General Hopital of Dr. Saiful Anwar Malang from Januari 2012 to December 2014.
The sample of this study is part of the population that fulfill the inclusion and
exclusion criteria. The sample size is calculated by a large sample formula for unpaired
categorical analytic research (Dahlan, 2005)
The unpaired categorical analytic research :
[zα √2pq + zβ √(p1q1 + p2q2)] 2
n =
( p1 – p2 )2
n = the size of each group sample
Zα = the average deviation value of a standard normal distribution bounded by α ≈
1.96
Zβ = the average deviation value of a alternative distribution bounded by β ≈ 0.84
the number of cervical cancer patients that fulfill the inclusion exclusion
criteria

p11 = the total number of cervical cancer and non – malignant patients that
fulfill the inclusion exclusion criteria
289
= = 0,4676
618
q1 = 1 - p1
= 1 – 0,4676
= 0,5323
p2 = the proportion of parity in non-malignant patients that fulfill the inclusion
exclusion criteria ≈ 0,5
q2 = 1 - p2
= 1 - 0,5
= 0,5
p1 + p2 0,4676 + 0,5
p = = = 0,4838
2 2
q =1–p
= 1 - 0,4838
= 0,5162

Thus, the sample size obtained for each group :

n = [1,96 √2 x 0,4838 x 0,5162 + 0,84 √(0,4676 x 0,5323 + 0,5 x 0,5)]2

(0,2)2
n = (1,96 √0,4994 + 0,84 √0,4989)2

0,04
n = (1,3851 + 0,5933)2

0,04
n = 3,914 = 97,85 ≈ 98
0,04
Thus, the total number of cervical cancer and non-malignant patients required for
this research at least 98 people divided into 49 cervical cancer patients and 49 non-
malignant patients.
Sample Inclusion Criteria:
- All patients with cervical cancer
- Examined at General Hospital of Dr.Saiful Anwar Malang
- The period from January 2012 to December 2014
- Has no history of oral contraceptives
- Socio-economic middle to top

Inclusion Control Criteria:

- All non-malignant patients in SMF Obstetrics and Gynecology
- Examined at General Hospital of Dr.Saiful Anwar Malang
- The period from January 2012 to December 2014
- Has no history of oral contraceptives
- Socio-economic middle to top

Exclusion Criteria:
- Patients with cervical cancer and accompanied by other cancers
- Examined outside General Hospital of Dr.Saiful Anwar Malang
- The period before January 2012 and after December 2014
- Have a history of oral contraceptives
- Low socio-economic
Based on the purpose of the research, then the variables studied is the variable
number of parity and variable of cervical cancer patients in General Hopital of Dr. Saiful
Anwar Malang from Januari 2012 to December 2014
 Independent variable : Number of parity
 Dependent variable : Cervical cancers
 Control variable : Non-malignant
 Materials and research instruments used are medical records of cervical cancer
patients and non-malignant patients of SMF Obstetrics and Gynecology at General
Hospital of Dr. Saiful Anwar Malang from Januari 2012 to December 2014
Calculation the Collection of files Data recording:
number of samples (medical records) Name
using statistical according to inclusion Age
formula and exclusion criteria Address
Work
Weight
Height
Class treatment
Final diagnosis
Parity data

Analyze the results Data analysis

Data will be processed using SPSS application with spearman and chi square
correlation statistic analysis with 95% confidence level and α 0,05.

3. RESULTS
Based on the results of data processing, it can be described characteristics of cervical
cancer patients in General Hospital of Dr.Saiful Anwar Malang Period 2012-2014
Table 1.1 Patient Age
Age Frequency Percentage (%)
≤30 years old 0 0
31 - 40 years old 10 20.4
41 - 50 years old 16 32.7
> 50 years old 23 46.9
Total 49 100

Table 1.1 shows that patients aged between less than or equal to 30 years old are
0 people or 0 %, patients aged between 31-40 years old are 10 people or 20,4%, patients
aged between 41-50 years old are 16 people or 32,7%, and patients over he age of 50
years old are 23 people or 46,9%
 Then, the data processing comparison the number of parity with the incidence of
cervical cancer is attached in the following table:

Jenis kanker Paritas

Spearman’s rho Jenis Kanker Correlation Coefficient 1.000 .246*

Sig. (2-tailed) .

N 98

Paritas Correlation Coefficient .246*

Sig. (2-tailed) .015

Table 1.2 Relationship Between The Number of Parity and Cervical Cancer
Correlations
Source : secondary data
Table 1.2 shows a correlation coefficient of 0.246 that the relationship between
parity and cervical cancer is categorized as weak and positive because it is at the interval
of 0.2 to 0.4. If the parity is more than or equal to 3, then the higher rates of cervical
cancer patients
The results of analysis using Chi Square test (2) :
The cross-tabulation that can describe the dissemination of detailed data between
the number of parity and cervical cancer patients can be seen in Table 1.3

Tabel 1.3 Cross-tabulation between the number of parity and type of cancer
Parity * type of cancer Cross-tabulation
Type of cancer Total

Non Cervical

Malignant Cancer

Parity <3 Count 33 21 54

% of Total 33.7% 21.4% 55.1%

≥3 Count 16 28 44

% of Total 16.3% 28.6% 44.9%

Total Count 49 49 98

% of Total 50.0% 50.0% 100.0%

Table 1.3 shows that from 98 people are divided into four groups. Cervical cancer
patients with parity <3 are 21 people or 21.4% and patients with parity ≥ 3 are 28 people
or 28.6%. Non-malignant patients with parity < 3 are 33 people or 33.7% and patients
with ≥ 3 are 16 people or 16.3 %.
 The associaton between the number of parity and cervical cancer patients can be
seen on the Chi Square test below.

Table 1.4 Chi Square Test

Value df Asymp. Sig.

(2-sided)

Pearson Chi-Square 5.939 1 .015

Table 1.4 shows that the result of Chi Square test with p value is 0.015 and χ2 =
5,939, and the value of χ2 tables with degrees of freedom = 1, and the error rate of 5% is
3.841, , then the value of χ2 = 5,939 is bigger than value χ2 table = 3,841 or p value =
0,015 <5% (α = 5%), so it can be concluded that there is a significant relationship
between the number of parity with cervical cancer. The results of the analysis also
obtained Odds ratio at 0,364 which means that patients with parity more than or equal to
3 increases the risk of cervical cancer 3 times greater than patients with parity less than 3.

4. DISCUSSION

The results of analysis using Chi Square test (2) :

Table 1.3 shows that from 98 people are divided into four groups. Cervical cancer
patients with parity <3 are 21 people or 21.4% and patients with parity ≥ 3 are 28 people
or 28.6%. Non-malignant patients with parity < 3 are 33 people or 33.7% and patients
with ≥ 3 are 16 people or 16.3 %. The results are in line with research by Nasution (2010)
who found that 58.5% of cervical cancer patients are multiparous.
Irianti (2003) in her research found that the most common cervical cancer patients
are having parity >3 times with the percentage at 82.1%, whereas according to Aida’s
research (2010) the most frequent parity are ≥6 times with the percentage at 58.7%. in
this study, however, it is rare to find the number of parity ≥6 times due to the habitual
changes of having many children in ancient times compared to modern era.
The result of Chi Square test with p value is 0.015 and χ2 = 5,939, and the value of
χ2 tables with degrees of freedom = 1, and the error rate of 5% is 3.841, , then the value
of χ2 = 5,939 is bigger than value χ2 table = 3,841 or p value = 0,015 <5% (α = 5%), so it
can be concluded that there is a significant relationship between the number of parity with
cervical cancer. The results of the analysis also obtained Odds ratio at 0,364 which means
that patients with parity more than or equal to 3 increases the risk of cervical cancer 3
times greater than patients with parity less than 3.
The results are in line with research by Surbakti E (2004) that shows women with
parity ≥3 have 4.375 times greater risk of cervical cancer . according to the results of the
IARC (2002), nulipara women (parity 1-2) had a cervical cancer risk at 1.8 times, while
women with parity 3-6 had a cervical cancer risk at 2.6 to 2.8, and women with parity ≥7
had a cervical cancer risk at 3.8 times.
 The IARC study shows an increased number of parity is directly proportional to the
increased risk of cervical cancer, this is related to the theory of cervical cancer in
general, ie cervical cancer is the most prevalent in women who often give birth.
Hormonal changes that occur during pregnancy and cervical trauma that occur during
childbirth are thought to be factors that causes cervical cancer 8. In addition, there are
other factors causing cervical cancer associated with pregnancy and parity. Pregnancy is
associated with the occurrence of immunosuppression that allows the process of
malignancy and replication of HPV9. According to Manuaba (2002), an increased
incidence of infection is greater in pregnancy and childbirth ≥3 times, estimated risk of
cervical cancer is 3-5 times greater in women who are often give childbirth. According to
Harahap (1997), high pervaginam childbirth causes the number of cervical cancer
increases due to the frequency of a woman giving birth, it willl affect the frequent
occurrence of injuries in the reproductive organs in which the wound will facilitate the
emergence of HPV as a cause of cervical cancer
5. CONCLUSION
There is a significant relationship between parity as one of the risk factors of cervical
cancer. The incidence of cervical cancer are higher in samples with the number of partial
≥3 as evidenced in the study that women with parity ≥3 had a risk of cervical cancer ± 3X
compared with women with parity <3 with the largest proportion is women with the
number of parity 3. In addition, population of cervical cancer patients most found in the
age group more than 50 years.
We are expecting that there will be further research regarding this study that discuss
other cervical cancer risk factors with different variables and methods for educational
progress as well as decreased incidence rates of cervical cancer.
To the government and other related institutions are expected to increase the extension
efforts to the community about the benefit of Keluarga Berencana (KB) program as one
of the strategies for women in reproductive age in limiting the number of pregnancies and
childbirths,namely 2 children are enough to reduce the risk of cervical cancer.

6. REFERENCES

1. Mangan,Y. 2003. Cara Bijak Menaklukkan Kanker. Jakarta: Agromedia Pustaka

2. Alejandro mohat, M. F. 2000. Epidemiology of cervical cancer. cancer
investigation, p. 584-590.Alliance for Cervical Cancer Prevention, 2004. Risk
Factors for Cervical Cancer: Evidence to Date, USA.
http://screening.iarc.fr/doc/RH_fs_risk_factors.pdf.
3. Depkes RI. (2009). Buku Saku Pencegahan Kanker Leher Rahim dan Kanker
Payudara. Jakarta: Ditjen PP & PL.
4. Aida. 2010. Karakteristik Penderita Kanker Serviks yang Dirawat Inap di RSUP.
H. Adam Malik Medan tahun 2009. Tugas Akhir. Tidak diterbitkan, Fakultas
Kedokteran Universitas Sumatra Utara, Medan.
5. Diananda R. 2007. Mengenal Seluk Beluk Kanker. Yogyakarta : Katahati.
6. Arifuddin, Djuanna. 2000. Penanganan Neoplasma Intraepitel Serviks, Buku
Kedokteran EGC, Jakarta.
7. Belinson S.,Smith J.S.,Myers E.,Olshan A.,Hartmann K., 2002, Descriptive
Evidence That Risk Profiles for Cervical Intraepithelial Neoplasia 1,2 & 3 are
Unique,Am.J, p. 189:295-304.
8. Dahlan, Sopiyudin. 2005. Besar Sampel dalam Penelitian Kedokteran Kesehatan
Arkans, Jakarta, hal. 42-46.
9. Harahap, Rustam E. 1984. Neoplasia Intraepitel pada Serviks, UI-PRESS,
Jakarta.
10. Hoyo, C., Yarnall, K., & Fortney, J., 2007. Short Birth Intervals and Uterine
Cervical Cancer Risk in Jamaican Women, North Carolina: NIH Public
Acces.http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2074891/pdf/nihms26881.
pdf.
11. International Agency for Research on Cancer (IARC), 2002. Oral
Contraceptives, Parity, and Cervical Cancer, USA: Alliance for Cervical Cancer
Prevention.http://www.thelancet.com/journals/lancet/article/PIIS01406736%2802
%29 08125-4/fulltext#bib10.
12. Irianti, E., 2003. Karakteristik Penderita Kanker Serviks Uteri Rawat Inap Di
Rumah Sakit Umum Pusat Haji Adam Malik Medan Tahun 1998 – 2002. Tugas
Akhir. Tidak diterbitkan, Fakultas Kedokteran Universitas Sumatra Utara,
Medan.
13. Manuaba. 2002. Kapita Selekta Penatalaksanaan Rutin Obstetri Ginekologi/KB,
1st ed., Buku Kedokteran EGC, Jakarta.
14. Melva. 2008. Faktor-faktor yang Mempengaruhi Kejadian Kanker Leher Rahim
Pada Penderita yang Datang Berobat di RSUP. H. Adam Malik Medan Tahun
2008. Tesis. Tidak diterbitkan, Fakultas Kedokteran Universitas Sumatra Utara,
Medan.
15. Nasution, P. S. 2010. Karakteristik Penderita Kanker Serviks yang Dirawat Inap
di RSU dr. Pirngadi Medan. Tugas Akhir. Tidak diterbitkan, Fakultas
Kedokteran Universitas Sumatera Utara, Medan.
16. Surbakti, E. 2004. Pendekatan Faktor Risiko Sebagai Rancangan Alternatif
dalam Penanggulangan Kanker Serviks Uteri di RSU Pirngadi Medan. Tesis.
Tidak diterbitkan, Fakultas Kedokteran Universitas Sumatera Utara, Medan.
17. Tambunan, G. W., 1996. Diagnosis dan Tatalaksana Sepuluh Jenis Kanker
Terbanyak di Indonesia, Penerbit Buku Kedokteran EGC, Jakarta.
18. Zai, Alfian Elwin. 2009. Karakteristik Penderita Kanker leher Rahim Yang
Dirawat Inap Di Rumah Sakit Umum Pusat Haji Adam Malik Medan. Medan:
Universitas Sumatera Utara. http://repository.usu.ac.id/handle/123456S