American College of Physicians: Internal Medicine — Doctors for Adults ®

 
Advertisement
Monday, August 22, 2016

Preventing cervical cancer in Tanzania

I visited Tanzania again this summer, once again helping a group of amazing University of California, Irvine medical students with their summer not-a-vacation trip to teach bedside ultrasound and do other research projects.

One of the projects this year sprung out of a request by a doctor we have worked with on Ukerewe Island. The island he serves is rural, primarily supported by fishing, and has a high rate of sexually transmitted diseases due to fishermen visiting prostitutes on the mainland and bringing home infections to their wives and girlfriends. This translates to high rates of HIV infection, pelvic inflammatory disease and the spectrum of disease caused by human papillomavirus (HPV). HPV can cause genital warts, which are only mildly distressing, but it can also set in motion cellular changes of the cervix that can lead to cervical cancer. Tanzania has a distressingly high incidence and death rate from cervical cancer and this Tanzanian physician asked one of the students if we could do a project that would help reduce cervical cancer.

The high mortality and incidence of cervical cancer in sub-Saharan Africa can be (and has been) addressed in many ways. Primary prevention would involve using condoms or maintaining celibacy or reliable monogamy. We have a vaccine now that can prevent persistent infection, but it is still very expensive and not used much in resource poor countries like Tanzania. Pap testing is the method we use in the U.S. to prevent cervical cancer, and its use is widespread and effective here. It involves taking a sample of the cells of the cervix during a speculum exam, sending this to a pathologist for evaluation, and repeating that test at regular intervals. Abnormal pap tests are reported to the patient who is notified to return for further testing and eventually removal of the infected tissue if it persists. The abnormal tissue is visualized by applying acetic acid to the skin of the cervix, then using a cervical microscope or colposcope to either biopsy, cut or freeze away abnormal tissue. In most of Africa this is not even vaguely practical since women go to the doctor infrequently and speculum exams are not often performed. It is not always practical to contact people by phone, and they often come from far enough away that returning for multiple visits to deal with an abnormal pap is not likely to happen. In addition, were physicians to start performing regular pap testing, there are not enough pathologists to process the specimens.

About 10 years ago I read an article in one of the large medical journals which described an abbreviated screening test for HPV infection in which vinegar (acetic acid) was applied to the cervix, abnormal areas that looked HPV infected were identified with the naked eye and those areas were simply frozen, destroying the infected and precancerous tissue. This sounded amazing. Since then this procedure has become well accepted, though certainly not universally available, to people living in many African countries. The World Health Organization has studied it and pronounced it to be practical and recommends it for resource poor settings.

The students heard about an organization, CureCervicalCancer, which teaches healthcare workers visual inspection with acetic acid (VIA) and supplies a gun which can deliver compressed carbon dioxide (available in poor countries because it is used to make soda pop) to the infected tissue of the cervix, to freeze it off.

This year several people affiliated with Cure Cervical Cancer came to Tanzania with us, trained Tanzanian MD and non-MD healthcare workers to perform visual inspection and cryotherapy and gave them supplies they would need to make the service ongoing.

The idea of being able to provide that kind of immediate and practical service was very exciting. I just thought it wouldn't work. Doctors and nurses in Tanzania are so overworked that I doubted they would come for a few days to learn a new technique. I also thought that a pelvic exam using a speculum would be a VERY hard sell for women who have never had a pelvic exam, especially since they would be feeling fine. I thought that the doctors wouldn't have time to continue to do these exams after we left. It turns out I was wrong: health care workers were enthusiastic and attended the trainings and women lined up for testing.

The first day we had fewer patients than the leaders felt was acceptable, about 60 patients total I think. So the students who knew Tanzania from previous trips made flyers which they handed out, used their large word of mouth network and finally hired guy in a truck with a loud speaker to drive around the streets advertising the free clinic. The next two days doubled or even tripled the number of patients screened! Several cases of HPV infection were seen and treated and a few early cervical cancers were identified and referred for likely surgery.

This project may persist. They were able to train people from the city of Mwanza as well as Ukerewe Island and they promise to continue to do screening after we leave, free of charge. We shall see. There is some kind of audit planned for 6 months out. Clearly more nurses and doctors need to be trained to do this. This is clearly the right kind of screening to do in this setting and may reduce the burden of cervical cancer. In our screening clinic the host hospital also offered free HIV screening which was fantastic since treatment of HIV in Tanzania is free. Cervical cancer is more common and more aggressive in HIV infected women, so combining the screenings is really powerful.

I think this will help. I do have some reservations, though. In the US, 80% of people will be infected with HPV during their lifetimes, and the vast majority will kick it and have no ill effect. At any one time, I've read, 10% of women will have HPV infections. Only a fraction of the types of HPV that are out there are able to cause cervical cancer. The point here is that all HPV infection does not necessarily need treatment. We don't have evidence yet that VIA with cryotherapy saves lives, though it seems likely that it will and there have been mathematical models that evaluate this. VIA is, though, a sustainable method to treat HPV infection early and thus to prevent late sequelae including cancer Clearly real prevention of infection would be the most valuable intervention in prevention of cervical cancer. This could be by vaccination, if the vaccine were affordable, or use of condoms to prevent transmission of infection. More important even than that would be changes that allow women to have more control of what happens to them sexually. This will require improved education and economic opportunities so that women have value in the society outside of their roles as mates and mothers.

Janice Boughton, MD, ACP Member, practiced in the Seattle area for four years and in rural Idaho for 17 years before deciding to take a few years off to see more places, learn more about medicine and increase her knowledge base and perspective by practicing hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling. Disturbed by various aspects of the practice of medicine that make no sense and concerned about the cost of providing health care to every American, she blogs at Why is American Health Care So Expensive?, where this post originally appeared.

Labels: , , , , , ,

0 Comments:

Post a Comment

Subscribe to Post Comments [Atom]

<< Home

This is a printer-friendly version of this page

Print this page  |  Close the preview

Advertisement

Share

 

Contact ACP Internist

Send comments to ACP Internist staff at acpinternist@acponline.org.

Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

Powered by Blogger

RSS feed