A health scandal

A health scandal


Updated 11:23am (Mla time) Jan 09, 2005
By Rina Jimenez-David
Inquirer News Service



Editor's Note: Published on page A13 of the January 9, 2005 issue of the Philippine Daily Inquirer


IN "THE V Book: A Doctor's Guide to Complete Vulvovaginal Health," Dr. Elizabeth G. Stewart and her co-author Paula Spencer have this to say about the Pap smear: "It's the single most cost-effective disease screening test known to modern medicine. Since the introduction of the Pap smear, cancer rates and death rates from cervical cancer have drastically dropped..."

I've put an ellipsis at the end of the sentence because what Dr. Stewart didn't mention is that the Pap smear has led to plunging cancer and death rates due to cervical cancer mainly in the developed world. This is because, thanks to widespread information drives and public health programs, women in developed countries are quite aware of the need to have the test done regularly, and can afford to pay for this fairly simple and low-cost procedure.

In the developing world, though, public awareness about the Pap smear and about cervical cancer is still fairly low, and only a few women have come to think of screening as part of their routine health care. Thus, while the World Health Organization estimates that about 510,000 women worldwide are diagnosed with cervical cancer each year and some 288,000 of them will die of the ailment, the vast majority of the fatalities will be from developing countries, including the Philippines.

While crucial for diagnosing cervical cancer, the Pap smear and similar tests are only screening tools. As Dr. Stewart notes: "While the Pap smear is a lifesaver when it comes to identifying abnormalities of the cervix before they develop into cancer, it's not a test for anything else. A normal Pap doesn't mean everything is all right with the V's (vagina and vulva); it only means no precancer cells were found in the cervix."

And yet many women, and doctors as well, seem to rely on the Pap smear to screen for other infections and problems. Dr. Wen del Rosario Raymundo, an OB-Gyn and investigator on the cervical cancer vaccine trial at the San Pablo Colleges Medical Center, tells of patients who think of Pap smear as "pagpapalinis" [cleansing] of genitals. Apparently, not even their doctors had told them what exactly a Pap smear is.

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AS I wrote in yesterday's column, cervical cancer is the only form of cancer whose cause is known and easily identifiable. The onset and even precursors of cervical cancer are also easy to identify and the precancerous cells themselves take from three to 10 years to develop into cancer. It is even possible to reverse cancerous or precancerous conditions, through strategies ranging from adapting a healthier lifestyle to laser or invasive surgery. And with the ongoing "Patricia" (PApilloma TRIal for the Prevention of Cervical Cancer in Young Adults) trial for a vaccine, it may well soon be the only preventable form of cancer.

Given all that we know about it, it's clearly a scandal why so many women continue to die of cervical cancer.

Dr. Genara Manuel-Limson, chief investigator for the Patricia trial in the Philippines, says without irony that cervical cancer "is a good cancer to fight," as both patient and doctor are given plenty of chances to diagnose, treat and recover from the disease. She outlines the following "protocol" for the diagnosis and treatment of cervical cancer:

A woman should go for her first Pap smear three years after her first intercourse. This, no matter how early she starts becoming sexually active, as early sexual initiation is considered a risk factor. She should then go for a Pap smear at least once a year, though after three consecutive "normal" Pap results, she may need to go for the tests only at two-three year intervals.

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THERE are alternative procedures to the Pap. Increasingly popular is the "acid wash," which calls for staining a woman's cervix with a solution and allows the doctor or clinic personnel to visually observe the presence of lesions. Doctors also warn against the many "false negatives" from "traditional" Pap smears, mainly because the commonly used cotton swabs don't easily offer up all the cells they harvest. Out on the market now are testing kits that use brushes and allow for better "harvests." It should also be clear that the accuracy of a Pap smear result depends highly on the skills of the lab technicians analyzing the samples. It also matters how soon the patient gets the lab results, not the least of which is to reduce the period of anxiety that she must endure.

If the clinician finds "abnormal" results from the Pap smear, the patient will most probably be told to undergo a colposcopy, which allows for a more detailed microscopic examination of the cervix. In case of "equivocal" findings, says Dr. Limson, the doctor will also probably order an HPV DNA test, which will confirm whether the patient has an HPV infection (two types of HPV -- out of possibly 100 -- are directly linked to cervical cancer). The problem with an HPV DNA test, at this point, is that it's fairly expensive, about P2,000 a procedure.

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BUT even with a positive HPV finding, it's still not the end of the world, or the beginning of cervical cancer. What doctors look for, says Dr. Limson, is "persistent" HPV infection. A sexually active woman in her 20s, she says, will probably test positive for HPV, which is fairly common, but will be able to get rid of it. But if she still tests positive for HPV 10 years later, her doctor will begin to watch her more closely as persistent infection could lead to cervical cancer.

All the doctors stress the need for regular screening, as cervical cancer in the early stages displays no symptoms. If a woman reports pain in her genital area, abnormal discharge or bleeding, "she's probably in the late stage already," says Dr. Limson.