I saw LW for the first time in 2007. She was forty-eight years old and had just moved to Hampton Roads from Phoenix to be near her family for her terminal care. She had no health insurance and had never had a PAP smear because of the cost. A year before she moved she developed severe lower abdominal and pelvic pain as well as vaginal bleeding and presented herself for medical attention somewhat against her will. She was found to have locally advanced cancer of the cervix and was treated with radiation and chemotherapy. There was too much cancer to remove surgically. By the time I first saw her the cancer had already recurred and her pain had returned. Despite my best efforts at more treatment she died a painful withering death within six months.
What is wrong with this story?
Death from cervical cancer should be extremely rare. One of the triumphs of modern cancer screening, the PAP smear is inexpensive, almost painless and pretty reliable. Cervical cancer takes years to develop: normal cells develop an atypical appearance, go through additional changes to develop dysplasia, then eventually look like cancer without being invasive (carcinoma-in-situ). Only later on does an invasive cancer develop. During this entire process an abnormal PAP smear can initiate an evaluation that interrupts these events.
Even if any given PAP smear misses an abnormality the smear the following year is likely to pick it up and the process can be intercepted then. The time to the development of invasive cancer is so long that with annual PAP smears it is very unlikely that a lethal cancer will develop even if one smear is misread. No one should go without a PAP smear because of cost or lack of access to health care.
Of all the cancer screening tests the PAP smear is the one with the highest return on investment. A disease that will kill if ignored can basically be prevented. There are exceptions (cancer can develop in the endocervical canal , where it is harder to get to with the PAP smear) but they are rare. Of all the suggestions put forth about health-care reform when first introduced in the 1990’s the one that made the least sense to me was to reduce the frequency of PAP smears to every other year. Since the test is not 100% accurate I believe this invites a bad outcome. Fortunately this idea has been dropped.
What about the cervical cancer vaccine? Most cervical cancer is caused by the Human Papillomavirus or HPV. This virus is transmitted through sexual encounters. Since about 2004 it has been known that vaccination of girls prior to sexual activity to prevent HPV infection is highly effective in preventing infection by the virus and initiation of the cascade that can lead to cancer. The vaccine is close to 100% effective in preventing those strains of HPV most often linked to cancer and if used widely could come close to eliminating this disease.