May 2nd, 2019 by leahtourtellotte

Last week, I was very saddened by a patient who came to the clinic. She was 49 years old and postmenopausal, but was presenting with one year of vaginal bleeding. In my first world mind, my first differential was endometrial cancer… She had cervical cancer. She was also hypoxic in the 80s while on 5L O2 by nasal cannula and in renal failure with ultrasound confirmed hydronephrosis which indicated at least stage 3. Gyn surgery/hysterectomies are rather rare here, radiation is closest in the Dominican Republic, and chemo has some availability. However, she in particular clearly couldn’t tolerate it even if it were available. She was given lasix, but a foley catheter was placed with no drainage of urine. There was nothing more we could do and she was essentially brought home by her family to hospice.

What perhaps makes this even more sad and crazy is that I have seen two other patients with similar presentations. Cervical cancer and advancement of the disease has been made preventable with Pap smears, colposcopies, cone biopsies, and hysterectomies but these require pathologists, technology, and surgeons.

Here, as in other resource poor countries, prevention is performed with visual inspection with acetic acid (VIA). Essentially, a pelvic exam is performed with a speculum (steel and reusable of course) and the cervix is coated with acetic acid (regular vinegar) for 1 minute. Abnormal tissue stains white as the acetic acid reversibly coagulates nuclear protein. If that happens (VIA positive), a Pap smear is performed. This is collected on a slide and fixated with hair spray as that is easier to store and transport than the ethanol cups. These are sent to the US for pathology read and results come back in 3 months.

I did a quick internet search and found that, consistent with intuition, VIA is more sensitive and less specific than Pap smear. Percentages have of course varied by study, but it does seem that VIA has similar accuracy to Pap smear. I do wonder what other clinics in Haiti do for cervical cancer prevention. One can only hope at least VIA is attempted.