Knowledge, practices, and barriers to access of emergency contraceptive pills in married women and men: a multicenter clinic-based cross-sectional study from Karachi, Pakistan.

BACKGROUND: Emergency contraceptive pills (ECPs) are significantly underutilized in many parts of the world, especially in South-Asia. Within Pakistan, despite the population surge, the utilization of ECPs remains alarmingly low. The purpose of this study was to investigate the knowledge and practices regarding ECPs amongst married women and men in Karachi, Pakistan and the possible barriers hindering access to and use of these contraceptives. METHODOLOGY: A multi-centric cross-sectional study was conducted in Karachi, Pakistan. Interviews were conducted with participants using validated questionnaire involving different sections on demographics, knowledge, practices, and barriers to ECP use. Categorical variables were summarized as frequencies and percentages while continuous variables were characterized using mean and standard deviation. A chi-square test of variance was used for association between knowledge scores and different categorical values. A p-value of < 0.05 at 95% CI was statistically significant. RESULTS: Over half of the respondents (52.5%) were not using any method of contraception. 11.1% of respondents had used ECP at some point in their life. 337 (85.8%) participants had low knowledge, 55 (14%) had moderate while only 1 (0.25%) had high knowledge regarding ECPs. There was no significant association of knowledge scores with gender, age, employment status or parity. However, participants who had received counseling for family planning in the past or had previously used ECPs had significantly higher knowledge regarding ECPs. A majority 58% (221) of the participants expressed concerns about the potential side effects and 128 (33.9%) of them believed that ECPs were in contradiction to their religious and moral values. CONCLUSION: Our study in Karachi, Pakistan, highlights critical challenges in ECP awareness, utilization, and family planning. Although the results show improved ECP usage than studies previously done in Pakistan, there is a further need to increase the reach of ECPs through a variety of methods. Persistent myths and misconceptions and a severe lack of awareness further hinders their use.

National cervical cancer burden estimation through systematic review and analysis of publicly available data in Pakistan.

BACKGROUND: Cervical cancer is a major cause of cancer-related deaths among women worldwide. Paucity of data on cervical cancer burden in countries like Pakistan hamper requisite resource allocation. OBJECTIVE: To estimate the burden of cervical cancer in Pakistan using available data sources. METHODS: We performed a systematic review to identify relevant data on Pakistan between 1995 to 2022. Study data identified through the systematic review that provided enough information to allow age specific incidence rates and age standardized incidence rates (ASIR) calculations for cervical cancer were merged. Population at risk estimates were derived and adjusted for important variables in the care-seeking pathway. The calculated ASIRs were applied to 2020 population estimates to estimate the number of cervical cancer cases in Pakistan. RESULTS: A total of 13 studies reported ASIRs for cervical cancer for Pakistan. Among the studies selected, the Karachi Cancer Registry reported the highest disease burden estimates for all reported time periods: 1995-1997 ASIR = 6.81, 1998-2002 ASIR = 7.47, and 2017-2019 ASIR = 6.02 per 100,000 women. Using data from Karachi, Punjab and Pakistan Atomic Energy Cancer Registries from 2015-2019, we derived an unadjusted ASIR for cervical cancer of 4.16 per 100,000 women (95% UI 3.28, 5.28). Varying model assumptions produced adjusted ASIRs ranging from 5.2 to 8.4 per 100,000 women. We derived an adjusted ASIR of 7.60, (95% UI 5.98, 10.01) and estimated 6166 (95% UI 4833, 8305) new cases of cervical cancer per year. CONCLUSION: The estimated cervical cancer burden in Pakistan is higher than the WHO target. Estimates are sensitive to health seeking behavior, and appropriate physician diagnostic intervention, factors that are relevant to the case of cervical cancer, a stigmatized disease in a low-lower middle income country setting. These estimates make the case for approaching cervical cancer elimination through a multi-pronged strategy.

The Modified Alternate Healthy Eating Index-2010 and Breast Cancer Risk among Women from Karachi, Pakistan.

OBJECTIVE: To determine any relationship of diet with breast cancer risk. METHODS: The case-control study was conducted at Aga Khan University Hospital and the Karachi Institute of Radiation and Nuclear Medicine, Karachi, from February 2015 to July 2017, and comprised of cases with a confirmed diagnosis of breast cancer and healthy controls. Data was collected using the Alternate Healthy Eating Index 2010, which was modified according to the particular cultural patterns of diet in the Pakistani population. Data was analysed using SPSS 21. RESULTS: Of the 1124 subjects, 374(33.3%) were breast cancer cases and 750(66.7%) were controls. High intake of grains, both whole and refined including white rice, was associated with breast cancer (odds ratio: 2.53; 95% confidence interval: 1.69-3.79; p<0.001). There was no association of breast cancer with Alternate Healthy Eating Index 2010 score (odds ratio: 1.85; 95% confidence interval: 0.61-1.17; p=0.291). CONCLUSIONS: There was found a need for awareness of a healthy diet based on more of whole grains and brown rice replacement with refined grains and white rice, respectively. Limiting refined carbohydrate intake might be a useful public health message and may reduce breast cancer incidence in the long term.

Frequency and determinants of vitamin D deficiency among premenopausal and postmenopausal women in Karachi Pakistan.

BACKGROUND: Vitamin D deficiency is becoming a serious public health problem, even in sun-drenched cities like Karachi, Pakistan. We investigated the prevalence of vitamin D deficiency and its association with sociodemographic characteristics, anthropometric measures, and lifestyle factors among premenopausal and postmenopausal women (n = 784). METHODS: Face-to-face interviews were conducted to collect information and serum concentrations of 25-hydroxyvitamin D were measured after the interviews. RESULTS: A total of 57% of women were vitamin D deficient with higher vitamin D deficiency found among premenopausal women (64.7%) compared to postmenopausal women (49%). The median serum concentrations of 25-hydroxyvitamin D (IQR) were 16.7 ng/ml (IQR 9.8-30.0). Factors associated with vitamin D deficiency were lower socioeconomic status (OR 2.00; 95% CI 1.15-3.48), younger age with highest vitamin D deficiency found in < 35 years of age group (OR 3.11; 95% CI 1.76-5.51), and winter season (OR 1.51, 95% CI 1.07-2.15) after adjusting for multiple confounders. The use of vitamin D supplement (OR 0.59, 95% CI 0.38-0.92) and vigorous exercise (OR 0.20, 95% CI 0.05-0.80) were protective against vitamin D deficiency. CONCLUSIONS: The study shows a high prevalence of vitamin D deficiency, with detrimental health effects, among younger women belonging to lower socioeconomic status and during the winter season. The use of vitamin D supplements and vigorous exercise were protective measures. Public health campaigns are needed for education and awareness about vitamin D deficiency to improve vitamin D status for younger women living in poor environments.

Factors associated with mammographic breast density among women in Karachi Pakistan.

BACKGROUND: There are no studies done to evaluate the distribution of mammographic breast density and factors associated with it among Pakistani women. METHODS: Participants included 477 women, who had received either diagnostic or screening mammography at two hospitals in Karachi Pakistan. Mammographic breast density was assessed using the Breast Imaging Reporting and Data System. In person interviews were conducted using a detailed questionnaire, to assess risk factors of interest, and venous blood was collected to measure serum vitamin D level at the end of the interview. To determine the association of potential factors with mammographic breast density, multivariable polytomous logistic regression was used. RESULTS: High-density mammographic breast density (heterogeneously and dense categories) was high and found in 62.4% of women. There was a significant association of both heterogeneously dense and dense breasts with women of a younger age group < 45 years (OR 2.68, 95% CI 1.60-4.49) and (OR 4.83, 95% CI 2.54-9.16) respectively. Women with heterogeneously dense and dense breasts versus fatty and fibroglandular breasts had a higher history of benign breast disease (OR 1.90, 95% CI 1.14-3.17) and (OR 3.61, 95% CI 1.90-6.86) respectively. There was an inverse relationship between breast density and body mass index. Women with dense breasts and heterogeneously dense breasts had lower body mass index (OR 0.94 95% CI 0.90-0.99) and (OR 0.81, 95% CI 0.76-0.87) respectively. There was no association of mammographic breast density with serum vitamin D levels, diet, and breast cancer. CONCLUSIONS: The findings of a positive association of higher mammographic density with younger age and benign breast disease and a negative association between body mass index and breast density are important findings that need to be considered in developing screening guidelines for the Pakistani population.

Colorectal Cancer Survival and Its Prognostic Factors in Karachi, Pakistan.

OBJECTIVE: To determine the survival rates of colorectal cancer (CRC) in the Pakistani population and determine the prognostic factors for survival among the CRC patients. STUDY DESIGN: Retrospective cohort study. Place and Duration of the Study: The cancer registry of the Aga Khan University Hospital, Karachi, Pakistan, from 2010 to 2016. METHODOLOGY: The abstracted data from the cancer registry was cleaned and updated regarding the vital status at the last follow-up. Survival analyses were performed using the Kaplan-Meier method. Adjusted hazard ratios (aHR) and their 95% confidence intervals (CIs) were estimated using a cox regression model to assess the prognostic factors for survival. RESULTS: The overall proportion of late-onset CRC (>50 years of age) was 55.3% and early-onset CRC (<=50 years of age) was higher than expected (45.7%). A high level of carcinoembryonic antigen (CEA) (>5 ng/ml) was associated with poor survival compared to patients with CEA levels of ≤5 ng/ml (aHR = 1.68, 95% CI = 1.04, 2.72). Patients, who experienced recurrence, showed poorer survival (aHR = 4.27, 95% CI = 2.55, 7.14). Patients, who did not undergo surgery, showed significantly poorer survival compared to those who underwent surgery (aHR = 5.53, 95% CI = 2.35, 13.03). CONCLUSION: The findings suggest that monitoring CEA levels, ensuring prompt surgical treatment and follow-up care for recurrent cases can improve survival outcomes in patients with colorectal cancer. KEY WORDS: Colorectal cancer (CRC), Surgery, Recurrence, Grade, Cancer registry.

Oral mucositis & oral health related quality of life in women undergoing chemotherapy for breast cancer in Karachi, Pakistan: A multicenter hospital based cross-sectional study.

BACKGROUND: Oral mucositis is an inflammatory condition of oral cavity which is a common and serious side effect of cancer treatment. Severe oral mucositis compromises basic functions like eating and swallowing causing malnutrition also affecting overall patient's oral health related quality of life. The aim of the study was to find the frequency of oral mucositis in patients with breast cancer during their chemotherapy, the factors associated with oral mucositis & the overall patient's oral health related quality of life. METHODS: A cross-sectional study was conducted and a total of 160 women diagnosed with breast cancer, receiving chemotherapy and who had undergone at least one cycle of chemotherapy were recruited from two hospital settings. In-person interviews were done, patients were asked questions about their sociodemographic history, personal habits, oral history and oral findings, breast cancer stage, chemotherapy history and Oral Health Related Quality of Life. Their oral examination was done at the end of the interview to assess presence or absence of oral mucositis, using World Health Organization oral mucositis tool. Oral Health Related Quality of Life was assessed using Oral Health Impact Profile-14 questionnaire. RESULTS: Our results showed that out of 160 patients 88 (55%) of the breast cancer cases developed oral mucositis during chemotherapy. The mean Oral Health Impact Profile -14 scores in patients with oral mucositis was high 18.36±0.96 showing poor Oral Health Related Quality of Life. Occasional frequency of brushing was significantly associated with oral mucositis (Prevalence ratio:2.26, 95%_CI 1.06-4.84) compared to those patients who brushed once and twice daily. Low level of education showed negative association with oral mucositis (Prevalence ratio:0.52, 95%_CI 0.31-0.88). CONCLUSION: Our study showed significant positive association of occasional brushing with OM and protective association of low level of education with the development of OM. Emphasis should be given to oral hygiene instructions and dental education to cancer patients in oncology clinics with the prescription of mouth washes, gels and toothpaste to patients to decrease OM during chemotherapy.

Human Papillomavirus Vaccine Awareness and Acceptability for Primary Prevention of Cervical Cancer in Pakistan: A Cross-Sectional Study.

BACKGROUND: Human papillomavirus (HPV) vaccine is the most effective option for primary prevention HPV, a well-known cause of cervical cancer.  The objective of the study was to assess awareness of HPV, the acceptability of its vaccine and factors associated with the acceptability among the adult population in Pakistan. MATERIALS & METHODS: A cross-sectional survey was conducted among adult population of Pakistan from January 2022 and March 2022. Due to the ongoing COVID-19 pandemic, instead of face-to-face interviews, a self-administered questionnaire was developed and distributed through Google Forms. The questionnaire was available in both English and Urdu languages to cater to a diverse population. RESULTS: Overall, 313 (65.2 %) study participants had heard about HPV infection, while 297 (61.9%) knew HPV as the cause of genital warts and 256 (53.3 %) knew that HPV can cause any type of cancer, with a higher percentage of awareness among those who were in any health care setting compared to those who were in a non-healthcare setting. Regarding the acceptability to get HPV vaccine, 320 (66.7%) of the study participants were willing to get vaccinated, while only 15(3.1%) of the study population had previously received HPV vaccine. The most important factors associated with HPV vaccine acceptability were younger age of 18-25 years (Prevalence Ratio (PR) =1.60, 95% Confidence Interval (CI) =1.11, 2.32), and 26-35 years (PR= 1.65, 95% CI=1.09, 2.50). HPV vaccine acceptability was also associated with working in a healthcare setting due to better awareness of HPV vaccine (PR= 1.29, 95% CI=1.03, 1.62). CONCLUSION: It is important to address the knowledge gaps existing in the community about HPV vaccine acceptability and barriers against it for the successful rollout of the HPV vaccination program in Pakistan. Mass awareness campaigns about HPV, HPV vaccine, and cervical cancer are needed to increase the acceptability of HPV vaccine among public at the time of reintroducing HPV vaccine.

Time for Reintroducing HPV Vaccine in Pakistan for Primary Prevention of Cervical Cancer.

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A single centre experience of local perforator flaps in oncoplastic breast surgery; a cross-sectional study.

Background & objectives: Various oncoplastic techniques have emerged over the years to preserve breast cosmesis and symmetry without compromising the principles of tumor excision. One of the newer techniques for breast volume replacement to achieve symmetry and cosmesis is the use of fasciocutaneous pedicled chest wall perforator flaps or local perforator flaps (LPF). The objectives of this study were to document the details of the surgical procedure as well as patient-reported satisfaction and well-being following the procedure using a validated BREAST-Q tool among Pakistani women. Materials & methods: This cross-sectional study was conducted from March 2019 to February 2021 enrolling 25 female patients who underwent breast conservative surgery using LPF for breast tumors at The Aga Khan University Hospital, Karachi. Data related to the procedure was collected on a pre-designed proforma. Cosmetic outcomes and patient satisfaction were evaluated using 2 scales from BREAST-Q BCT domain version 2.0. The questionnaire was self-administered by the patients during their routine follow-up in the clinic. Data was analyzed using the Statistical Package for Social Sciences (SPSS) version 23. Mean (SD)/median (IQR) were computed for quantitative variables and frequency and percentages were calculated for qualitative variables. 2 sample t-test was applied. P-value ≤0.05 was considered significant. Results: 25 patients underwent LPF with a mean age of 47 ± 13.1 years. 8 LICAP, 7 AICAP, and 10 LTAP flaps were performed. Two postoperative complications of wound site erythema were encountered. 23 women were eligible for the BREAST-Q survey. Median (IQR) postoperative satisfaction with breasts and physical well-being chest (equivalent Rasch transformed score) was 100 (41) and 76 [18] respectively. We found high satisfaction with breasts and comparable physical well-being among Pakistani women after LPF surgeries. Conclusion: Local perforator flaps in oncoplastic breast-conserving surgery are a good option showing high satisfaction with breasts and physical well-being in Pakistani women.

A multicentre matched case control study of risk factors for preeclampsia in healthy women in Pakistan.

BACKGROUND: Preeclampsia is one of the leading causes of maternal and perinatal morbidity and mortality world-wide. The risk for developing preeclampsia varies depending on the underlying mechanism. Because the disorder is heterogeneous, the pathogenesis can differ in women with various risk factors. Understanding these mechanisms of disease responsible for preeclampsia as well as risk assessment is still a major challenge. The aim of this study was to determine the risk factors associated with preeclampsia, in healthy women in maternity hospitals of Karachi and Rawalpindi. METHODS: We conducted a hospital based matched case-control study to assess the factors associated with preeclampsia in Karachi and Rawalpindi, from January 2006 to December 2007. 131 hospital-reported cases of PE and 262 controls without history of preeclampsia were enrolled within 3 days of delivery. Cases and controls were matched on the hospital, day of delivery and parity. Potential risk factors for preeclampsia were ascertained during in-person postpartum interviews using a structured questionnaire and by medical record abstraction. Conditional logistic regression was used to estimate matched odds ratios (ORs) and 95% confidence intervals (95% CIs). RESULTS: In multivariate analysis, women having a family history of hypertension (adjusted OR 2.06, 95% CI; 1.27-3.35), gestational diabetes (adjusted OR 6.57, 95% CI; 1.94 -22.25), pre-gestational diabetes (adjusted OR 7.36, 95% CI; 1.37-33.66) and mental stress during pregnancy (adjusted OR 1.32; 95% CI; 1.19-1.46, for each 5 unit increase in Perceived stress scale score) were at increased risk of preeclampsia. However, high body mass index, maternal age, urinary tract infection, use of condoms prior to index pregnancy and sociodemographic factors were not associated with higher risk of having preeclampsia. CONCLUSIONS: Development of preeclampsia was associated with gestational diabetes, pregestational diabetes, family history of hypertension and mental stress during pregnancy. These factors can be used as a screening tool for preeclampsia prediction. Identification of the above mentioned predictors would enhance the ability to diagnose and monitor women likely to develop preeclampsia before the onset of disease for timely interventions and better maternal and fetal outcomes.

Patient Delay in Breast Cancer Diagnosis in Two Hospitals in Karachi, Pakistan: Preventive and Life-Saving Measures Needed.

PURPOSE: Patients with breast cancer in Pakistan commonly present with advanced disease. The objectives of this study were to evaluate the frequency and length of delays in seeking medical consultation and to assess the factors associated with them. METHODS: Four hundred ninety-nine patients with newly diagnosed breast cancer were enrolled and interviewed over the period from February 2015 to August 2017. Information on sociodemographic factors, delay to medical consultation, stage of breast cancer at presentation, and tumor characteristics of the breast cancer were collected through face-to-face interviews and medical file review. RESULTS: The mean (standard deviation) age of patients with breast cancer was 48.0 (12.3) years. The mean (standard deviation) patient delay was 15.7 (25.9) months, with 55.2% of women detecting a breast lump but not seeking a medical consultation because of a lack of awareness about the significance of the lump. A total of 9.4% of the women decided to seek treatment initially using complementary and alternative medicine and traditional treatment; 9.4% of the women presented to a health care provider with a breast lump but no action was taken, and they were wrongly reassured about the lump without mammography or biopsy. For 26% of the women, the delay in presentation was caused by anxiety, fears and misconceptions regarding diagnosis and treatment, and other social factors including possible adverse effects on their relationship with their husband. Multivariable analysis showed a strong association of lower socioeconomic status (odds ratio [OR], 8.11 [95% CI, 2.46 to 26.69]) and late stage of breast cancer (OR, 4.83 [95% CI, 1.74 to 13.39]) with a patient delay of ≥ 3 months. CONCLUSION: Patient delay is a serious problem in Pakistan. There is an urgent need for intensive and comprehensive breast cancer education that addresses the myths and misconceptions related to breast cancer.

A multicenter case control study of association of vitamin D with breast cancer among women in Karachi, Pakistan.

BACKGROUND: The prevalence of vitamin D inadequacy and breast cancer are both high among women living in Karachi, Pakistan. METHODS: A matched case control study was conducted in two hospitals of Karachi, Pakistan to evaluate the association of vitamin D (serum 25-hydroxyvitamin D) concentrations, vitamin D supplementation and sun exposure with breast cancer among Pakistani women. A total of 411 newly diagnosed histologically confirmed primary breast cancer cases were enrolled and 784 controls, free of breast and any other cancers, were matched by age (year of birth ± 5 years), residence in the same geographic area and study site. Information was collected on sociodemographic history, history of vitamin D supplementation, past medical and obstetrical history, family history of breast cancer, sun exposure history, histopathology reports and anthropometric measurement and venous blood was collected to measure serum 25-hydroxyvitamin D (25(OH)D) concentration. RESULTS: Compared to patients with sufficient serum vitamin D (>30 ng/ml), women with serum vitamin D deficiency (<20ng/ml), had a higher risk of breast cancer (OR = 1.65, 95%CI: 1.10, 2.50). Women with history of vitamin D supplementation one year prior to enrollment, had significant protective effect against breast cancer (OR = 0.32, 95% CI: 0.24, 0.43). CONCLUSIONS AND RECOMMENDATION: Serum vitamin D deficiency was associated with increased risk of breast cancer, while vitamin D supplementation was associated with decreased risk of breast cancer. In Pakistani women, where vitamin D deficiency is common, raising and maintaining serum vitamin D at population level is a safe and affordable strategy. It may play a role in reducing the incidence of both vitamin D deficiency and breast cancer, particularly among poor women where the breast cancer mortality is highest due to limited resources for early detection, diagnosis, and treatment. The effects of vitamin D with regard to breast cancer risk in Karachi Pakistan should be further evaluated.

Risk factors for deliberate self-harm in patients presenting to the emergency departments of Karachi.

OBJECTIVE: To determine the risk factors for Deliberate Self-Harm (DSH) in patients presenting to the Emergency Departments (EDs) of three tertiary care hospitals of Karachi, Pakistan. STUDY DESIGN: Multicentre matched case control study. PLACE AND DURATION OF STUDY: EDs of the Aga Khan University Hospital, Karachi, Civil Hospital, Karachi and Jinnah Postgraduate Medical Centre, Karachi, from March 2011 to February 2012. METHODOLOGY: A total of 201 cases and 201 matched controls were taken from three hospitals situated in Karachi. All patients of 16 years and above presenting to the EDs of the hospitals with DSH attempt were invited to participate in the study. Controls were ED patients with complaints other than DSH. A control was matched with case for hospital, gender and age. Two questionnaires were used to collect information on the risk factors of DSH. Conditional Logistic Regression (CLR) was used to assess the association of various risk factors with DSH. RESULTS: Risk factors of DSH in Karachi included current history of mental disorder (OR = 4.53, 95% CI = 1.59 - 12.92), not sharing problems with someone (OR = 4.67, 95% CI = 2.4 - 9.0), living in rented houses (OR = 2.58, 95% CI = 1.37 - 4.84), Pathan ethnicity (OR = 5.05, 95% CI = 1.01-25.38) followed by others (OR = 3.88, 95% CI = 0.77 - 19.69) and Urdu speaking (OR = 2.71, 95% CI = 0.59 - 12.45). Absence of physical illness in the past month had an inverse association with DSH (OR = 0.17, 95% CI = 0.07 - 0.37). CONCLUSION: Mental illnesses, low socio-economic status and loneliness were the risk factors of DSH patients presenting to the three EDs of Karachi. Physical illness in the last month was protective against DSH in these patients. Psychiatric evaluation of DSH patients in the ED is important for early diagnosis and management of mental disorders.

A multicenter matched case control study of breast cancer risk factors among women in Karachi, Pakistan.

BACKGROUND: Breast cancer (BC), the most common female cancer in Pakistan, is associated with a very high mortality. However, the roles of individual risk factors for BC among Pakistani women are still controversial. To assess potential risk factors for BC, a matched case-control study was conducted in two tertiary care hospitals of Karachi, Pakistan. MATERIALS AND METHODS: The study population included 297 pathologically confirmed incident cases of BC patients diagnosed between January 2009 and December 2010. 586 controls without any history of BC were matched on a hospital basis, within 5 years of patient ages. RESULTS: Family history of BC (MOR=1.72; 95%CI: 1.10, 2.80 for first degree vs. none), single marital status (MOR=1.55; 95%CI: 1.10, 2.39 for single women vs. married women), older age at menopause (MOR=3.92; 95%CI: 2.52, 6.18 for menopausal women aged below 45 years, MOR=6.42; 95%CI: 3.47, 11.98 for menopausal women above 45 years of age compared with premenopausal women) conferred an increased risk of BC for women. Increasing parity decreased the risk of BC (MOR=0.90; 95%CI: 0.85, 0.97 for each live birth). Intake of Vitamin D supplements (MOR=0.30; 95%CI: 0.12, 0.81 for <3 years and MOR=0.27; 95%CI: 0.13, 0.56 for >3 years) was protective compared to non-users of Vitamin D. CONCLUSIONS: This study confirmed only few of the recognized risk factors in Pakistani women. The protective effect of Vitamin D is important from public health perspective and needs to be further explored through a randomized controlled trial.