Cervical Cancer

I have been planning to write about this for a while now, but this past week it really hit home. I recently started working with an organization that works closely with street kids. They currently provide a space for these kids & adolescents to spend time during the day away from the streets with structured activities, a place to stay over night, rehabilitation from glue sniffing (the most common/cheapest drug around), and transition services back to their families or into boarding school or job training programs. They also have healthcare services, especially for HIV positive street kids, and we are working to start a contraception/gynecology clinic. 15% of the girls living on the street are HIV positive. Of the HIV positive girls, almost 70% engage in transactional sex (compared to about over 40% of the HIV negative girls). In talking to the director of the center, she told me about a young woman in her early 20’s who lives on the streets who is HIV positive and died this week of cervical cancer.

Statistically, Kenya has a rate of cervical cancer of 40 per 100,0000 compared to the US rate of 7 per 100,000 and cervical cancer is the number one cause of cancer and cancer deaths in women due to high mortality. Everyone you talk to has a story about a family member with cervical cancer. A few weeks ago I was on the way to one of our outreach clinics for our cervical cancer screening program in which we are training nurses to perform LEEP (a key treatment for cervical dysplasia or pre-cancerous lesions) and I was traveling with one of our recently graduated Gyn Oncology fellows, Dr. Itsura. I am incredibly proud to say that the hospital & organization I work for started the first cervical cancer screening program in Western Kenya and the first Gyn Oncology fellowship in Kenya. They started by training our faculty generalist OBGYNs who had a special interest in Oncology and this year started taking international fellows- one of whom is a wonderful woman from Uganda whose family is still there, so she travels to Kampala every weekend by bus to see her two children and husband. You can only imagine what a phenomenon that is here, in a culture and system that is incredibly sexist and patriarchal. (Perhaps that will be the topic of my next post.) I asked Dr. Itsura why he decided to go into Oncology after having a successful generalist practice. First he said that he had seen the lack of Gyn Oncology to be a huge gap in care. He had so many patients he had seen in practice who had cancer and there was nowhere to send them, no one to take care of them, and due to no comprehensive treatment (the best they could do was sometimes to operate & then send them to a medical oncologist for chemotherapy), the outcomes were incredibly poor.  Then he told me it was also because he watched his mother die of cervical cancer when he was in primary school and she was in her 30’s. He said he always wondered why she was bleeding so much and why she was in so much pain before she died. He said if he could prevent other women and their families from going through what his mother and his family went through then he would have felt he had a successful career.

That same day before Dr. Itsura picked me up for our two-hour trip to the outreach clinic, I was talking with the guard who works at the gate of our compound. When I told him Dr. Itsura was picking me up, he said “Please tell him hello from me, he is a wonderful doctor and a wonderful man.” I figured Eldoret is a pretty small town so maybe they just know each other.  When I gave Dr. Itsura the message, he told me that he had treated the guard's daughter for cervical cancer. She is in her 30s and was diagnosed with stage 3 cervical cancer a few years ago. They had somehow managed to raise the money to send her to Uganda for radiation therapy, since it is not available here, but she had a recurrence and now has no other treatment options.  A few days ago I heard that she is now requiring large amounts of pain medicine and is in hospice care in one of a the few inpatient facilities available in Kenya. 

After going once with Dr. Itsura, I now travel almost every week to one of the outreach clinics. The AMPATH cervical cancer screening program reached over 10,000 women in 2012 with incredible nurses who do all of the screenings themselves, then refer patients who need treatment to the consultant clinic held one day per week. Women travel hours and spend money they can barely scrape together to reach these clinics so we try to limit the number of times they have to come. Training nurses to be able to treat cervical dysplasia is key to this, so I feel incredibly lucky to be able to be a part of training these amazing women in a skill that can help save women’s lives. The nurses are so good at what they do and know many of their patients so well: who comes in with frequent sexually transmitted infections because her husband is sleeping with other women, who has been too busy working to support her family to follow up on her abnormal results, who comes from far and can't afford the travel expenses (so we must do as much as we can in one visit because she may not be able to come again). The stories are endless and often incredibly sad, but you would never know it from the strength, grace, and calm these women project. 

The strides that we have made to develop an effective screening program within this system of many rural health centers and coordinate follow up with patients who often have no way of being contacted is inspiring. But we still have a lot of work to do. In one of my clinics I saw a woman who had had a pap smear done at this clinic over a year ago that showed cancer. The results had somehow gotten lost and the clinic had just received them and called her back. When we did an exam she clearly had a large cervical cancer. We referred her to our Gyn Oncology program and explained that she must start raising the money to pay for the surgery.  If women and their families have the means, they can travel to Nairobi or Kampala for radiation therapy but most can only afford to have surgery, which luckily enough they can have in Eldoret. Another woman had previously been diagnosed with advanced cervical cancer but could not afford radiation therapy and was not a candidate for surgery. She had come with her sister back to the first clinic she had come to for screening because she wanted to “start over.” We tried to figure out what she meant and the nurses realized that she had not yet come to terms with the fact that she had no more treatment options so she wanted to see if there had been a mistake, that she had hope for a cure.  The nurse agreed to do another exam for her. Indeed, she had a large cervical cancer for which no treatment would be possible.  She explained that to the patient who calmly climbed off the table, thanked the nurse, and left holding her sister’s arm.


The door to our CCSP clinic in Webuye, Kenya

Our first year registrars at a recent neonatal resuscitation simulation program