Well we finally made it back to the USA, and it definitely feels good to be home. However, I’m about a month behind in posting, so I’ll be continuing to update the blog periodically…thanks for checking it out.
HPI: 23 yo female presents for follow-up at CerviCusco clinic after high grade lesion (HGSIL) is detected on recent pap smear. Patient complains of frequent vaginal bleeding, pain/discomfort upon urination, and lower back pain. She reports being hospitalized twice in the past few months for vaginal hemorrhage. Per patient, a previous pap smear was done 5 years ago at outside institution, and reported normal.
Past Obsetrical History:
-G2 P1011 (1 gestations, 1 full term, 0 pre-term, 1 miscarriage, 1 currently living)
-Previous cesarean section about 2 months ago.
Past Medical History: None
Family History: Unremarkable
Social History: Patient lives 4 hours outside of Cusco, traveled to clinic alone. Single mother of 2 month-old child. Denies smoking or drug abuse. History of early sexual abuse was suspected, but not elicited from the patient.
Cervical Exam: Upon examination, the cervix was noted to be severely eroded, necrotic, and friable. Cancerous deterioration of the remaining cervix was noted, as well as involvement that extended into the patient’s bladder. Parts of the cervix and surrounding tissue were actually sloshing off during exam, with significant hemorrhaging.
Discussion: The mission of CerviCusco is to prevent cervical cancer, the #1 cause of female mortality in Peru. While the organization has already done a tremendous job in screening and treating cervical pre-cancerous lesions before they progress, unfortunately we sometimes encounter the tragic and serious consequences when prevention was eluded. In this particular case, the prognosis becomes even more heartbreaking in such a young patient, and mother of a newborn.
This case highlights some important topics. First, the gravity of this patient’s disease is very severe, and unfortunately her prognosis is very poor. Although no imaging could be done to confirm, it is likely based on the cervical exam and history of dysuria that the patient’s disease has already spread to her bladder. According to the staging criteria (see below), extension to the bladder mucosa or rectum already puts the disease at stage 4, with a very poor prognosis.
From Reference 1:
From Reference 2:
As mentioned previously, this patient’s prognosis is very poor. Some statistics for patients with different stages of cervical cancer are shown below, and the percentages can be interpreted as the percentage of patients with that typical stage of cancer that survive 5 years after the initial diagnosis. Furthermore, for stage 4 cervical cancer, there is no curative treatment, only palliative care. Even more tragic is that there is only 1 cancer treatment center in all of Peru, which is located in Lima. For our particular patient, a poor, uninsured, single mother who lives 4 hours outside of Cusco, the likelihood of having enough money even to travel and stay in Lima, let alone afford any treatments seems futile.
From Reference 1:
A very very difficult and sad conversation was had with this patient regarding her prognosis. Because we could not offer her any further treatment options, we discussed several end of life issues (family, finances, spiritual, etc.) before transporting her to a local hospital for acute management of vaginal hemorrhage.
Another topic of interest to discuss is this patient’s extremely young age for having such an advanced form of cancer. There are two considerations for her disease progression…either she contracted the human papilloma virus at a very early age through sexual abuse, or a very aggressive form of the virus was contracted during her late adolescence, which advanced rapidly to her current disease. Her advanced disease at such a young age also brings some attention to the current guidelines for cervical cancer screening (pap smears).
Both the American Cancer Society (ACS) and the American College of Obstetrics and Gynecology (ACOG) have recently adapted their guidelines to recommend that cervical cancer screening through pap smears should begin in women at the age of 21, regardless of age at onset of sexual activity.
In 2009 ACOG put out a statement in their practice bulletin as follows: “In contrast to the high rate of infection with HPV in sexually active adolescents, invasive cervical cancer is very rare in women younger than age 21 years. Only 0.1% of cases of cervical cancer occur before age 21 years. In a recent analysis of national data from 1998 through 2003, researchers from the Centers for Disease Control and Prevention identified an average of only 14 cases of invasive cancer each year in females aged 15–19 years. Cancer cases in adolescents younger than 15 years were too few to report. Based on this report and Surveillance Epidemiology and End Results (SEER) data from 2002–2006, this translates to an incidence rate of 1–2 cases of cervical cancer per 1,000,000 females aged 15–19 years.”
While this evidence is very compelling and supports the current guidelines that have been proposed, they can be sometimes be hard to accept in face of a 23 year-old patient, who will die of a preventable cancer most likely in the following few months to a year. I think this case is a very important less that while guidelines are important and can help guide clinical practice, they may not apply to every patient – each patient is an individual and may need individualized care to better their health and lives.
Lastly, I again would like to promote the work that CerviCusco is doing….and actually last that I heard, there was some discussion of future plans to build a cancer treatment suite on-site in Cusco for patients diagnosed with cervical cancer. Hopefully, such a center could give incredible hope and treatment for local women, who otherwise would have no other options. I encourage you to check out more about CerviCusco and their cause.
3. ACOG Practice Bulletin Vol. 114, No. 6, December 2009.