Most women dread their first female exam with the doctor. I can tell you my first experience was not fun. I was shaking like a leaf as I took off my clothes for the exam. The room was right off of the waiting room and the doctor opened the door with his back to me. With the door open, he continued to talk to his nurse. I was standing there naked trying to find my clothes to cover myself from the eyes in the waiting room. Then, there was no explaining, just doing the exam. No matter how much we dislike the pelvic exam or how bad our experience have been, there are very good reasons for it. One is the Pap smear.
Short history lesson for you. In 1912, Dr. Papanikolaou (see where the name comes from?) incidentally discovered that he could see cervical cancer by looking at vaginal fluid. In 1928, he did a presentation on his smear for detection of cancerous and precancerous cells. (For all you Michiganders, this was presented in Battle Creek.) His findings were met with much skepticism and were not widely accepted until the 1940s. The Pap smear is the most successful cancer screening technique ever discovered. Let me repeat that sentence… The Pap smear is the MOST successful cancer screening technique EVER discovered. Because of the Pap, cervical cancer USED to be the most common cancer killer of women.
Cervical cancer is almost always caused by a sexually transmitted virus, HPV. What happens is the virus gets into the cells of the cervix. The most common result? With time, the body takes care of the virus and it is gone. If the virus stick around in the cervix, you get an abnormal pap smear. It can take over 10 years for the cells to turn into a cancer.
Every year, approximately 3800 women in the US die from cervical cancer; In Ethiopia, over 3200 women die each year. What I want to point out is that the female population that is at risk for cervical cancer in the US is 6 times larger than that of Ethiopia. East Africa has one of the highest incidences and mortality of cervical cancer in the world and remains the most common cancer in women. In the US, cervical cancer is the 14th most common cancer of women. In Ethiopia, it is the second.
So, why the big contrast? Here, we have one hospital in the entire country that does Pap smear. Yes, one for all 20+ million women at risk for cervical cancer. There are now 14 hospitals in the country that are doing cervical cancer screening for women that are HIV+. Most cases of cervical cancer here are caught too late for surgery and their only treatment is palliative. From what I have been told there are a total of three radiation/medical oncologists in the entire country, for ALL types of cancer. Here is a very exciting fact. When cervical cancer screening is introduced into a community, the rates of cervical cancer and mortality are reduced by 60-90%. (USPTF).
Did I just hear you all chanting, “Pap smear. Pap smear.”? Calm down! Ethiopia is not ready for the Pap smear. But, we do need cervical cancer screening. Here is what is being done in the developing world, visual inspection of the cervix with acetic acid (VIA). Laymans’ terms: soak the cervix in vinegar and see if any of the tissue turns white. If it does, it is most likely a precancerous lesion and should be treated. It is called a “see and treat” method. This means the woman comes in and if we see an abnormality we treat it at that visit by freezing the cervix.
Dr. Mark Karnes and I have been screening women using VIA when they come to us. The problem is we do not have the appropriate tools to treat. A scalpel handle that can safely remove a section of the cervix is about $50 and a cryotherapy gun (the freezing machine) is about $1800. The rest of the supplies we already have or are cheaply available here. The government hospital already has a cryo-gun, but they do not have any surgical blade handles for cones, so I would like to buy two for each hospital.
Before I end, I want to add one thing. The most common reason for developing cervical cancer, no matter where you live, is NOT being screened. For those of you that live in the US, go get screened! There are national programs that provide free Paps if your income is low enough and you are older than 21. The health department and Planned Parenthood offer free or reduced cost Pap smears ($90 for an annual exam at most). The cost of a Pap smear, at most physicians’ offices, is around $200. It will be money well spent.
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