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The Washington Post
May 2, 2011
Laura Ungar

In her early 20s, Tamika Felder skipped seeing her gynecologist and getting
Pap smears for a few years because she couldn’t afford health insurance.

She was working part time in a job that paid only about $6 an hour, and “it
was either go to the doctor’s or pay the rent,” she recalled. But her health
was good, and Felder figured she’d be fine.

Except she wasn’t.

In 2001, at age 25, Felder learned that she had cervical cancer. She needed
a hysterectomy, chemotherapy and radiation. And she was left unable to bear
children.

“I didn’t want to lose my womb. I didn’t want to lose my fertility. But I
was tossed into this world of cancer,” said Felder, now 35 and a television
producer living in Upper Marlboro. “It changes you in such a profound way.
You have to rebuild your whole life.”

Each year, about 12,000 U.S. women receive diagnoses of cervical cancer and
4,000 women die of the disease. Yet doctors view cervical cancer as a
disease that can easily be prevented and treated. Precancerous lesions and
early cancer are easily detected through Pap smears; lesions can be removed
in a minimally invasive procedure before they turn into cancer. And since
2006 there has been a vaccine against human papillomavirus, or HPV, the
sexually transmitted virus that causes most cases of cervical cancer.

But Felder’s case is a good example of why this disease remains a threat.
Too often, doctors and public-health experts say, women who don’t get
regular screenings — because they don’t have health insurance or for other
reasons — discover the problem when the disease has already progressed.

“In most cases, women who get cervical cancer in this country are those who
did not get a Pap smear,” said Robert Hilgers, a gynecologic oncologist in
Kentucky, one of the states with the highest incidence of cervical cancer.
(The District also has a relatively high rate.) “I have been here — in all
aspects of this disease — having cared for over 1,000 women with cancer of
the cervix, and don’t want to see another woman die of this disease.”

Hilgers and other doctors say cervical cancer is highly correlated with
poverty and a lack of health insurance. The Centers for Disease Control and
Prevention cites disproportionate levels of cervical cancer among the
uninsured and underinsured.

For instance, in the Appalachian region of Kentucky, where the poverty rate
was 24.5 percent in 2005-2009 — compared with the national rate of 13.5
percent — women get cervical cancer at a rate that is one-third higher than
the national rate, and they die at a rate that is 37 percent higher,
according to statistics from the Kentucky cancer registry and the National
Cancer Institute.

Hilgers and others say they believe income disparity, and the resulting
disparity in access to health insurance and health care, contribute to an
elevated death rate from cervical cancer in African American women.
According to statistics from the National Cancer Institute, African American
women died of cervical cancer at a rate of 4.4 per 100,000 vs. 2.2 per
100,000 for white women.

“Socioeconomic factors that people live under affect their health,” said
Hilgers, founder of the Kentucky Cervical Cancer Coalition.

Shobha Krishnan, a gynecologist in New York who is the president of the
Global Initiative Against HPV and Cervical Cancer, says one way to reduce
cervical cancer rates would be to bring help, screening and education to
vulnerable women instead of waiting for them to seek it out. “There are
uninsured and underinsured who lack access to care. There are people living
in rural areas without access to care. . . . If we can adapt what we do in
the developing world [where health-care workers visit homes to provide
information and treatment] we might make more progress. Four thousand deaths
is 4,000 too many."

Pap smears

Cervical cancer used to be a much bigger scourge in America. Before Pap
screening began in the 1940s, about 26,000 women died each year of the
disease. But the American Cancer Society promoted the screening, and rates
fell steadily as physicians began to routinely perform it. The test involves
a quick, painless scraping off of cells from the cervix, which are then
examined in a lab for abnormalities.

Not only did fewer women die when the test became widely used, but fewer got
the disease because doctors found and then could deal with the changing
cells before they turned into cancer. In 1973, the incidence rate was 14.2
per 100,000; by 2003-2007 it had fallen to 8.1 per 100,000.

The American College of Obstetricians and Gynecologists recommends that
women get their first screening at age 21 and that most women younger than
30 get screened every two years. After age 30, if a woman has had three
negative tests in a row she should be screened only every three years. And
many doctors believe that by age 65 to 70, most women can stop getting Pap
smears altogether if they have a history of normal ones. (Some doctors
disagree with this and say checkups are still needed in this age group.)

Almost all cervical cancer is caused by HPV, according to the CDC. Roughly
half of all sexually active people get HPV at some point in their lives, but
the body’s immune system clears the virus in most people. For those who do
develop cancer, it’s typically slow-growing and easily detectable by Pap
smears before it becomes extremely dangerous.

According to the CDC, in 2008 about 83 percent of American women 18 and
older with insurance had gotten a Pap smear within the previous three years;
for uninsured women, the figure was 67 percent. The Agency for Healthcare
Research and Quality says that about half of women with newly diagnosed
cervical cancer had not received a Pap test in the previous five years.

A. Bennett Jenson, a University of Louisville physician who has researched
cervical cancer for decades and helped invent the HPV vaccine, said even
though the disease spreads slowly, he believes it’s important to get yearly
Pap smears. The tests have a 30 percent false-negative rate, he said, so
frequent tests increase the likelihood that any abnormality will be
detected. He said young women should also protect themselves by getting
vaccinated against HPV before becoming sexually active.

He also suggested that women get a separate test for HPV along with their
Pap smear; a positive HPV tests means a woman has the virus on her cervix
and should be monitored more closely by her doctor. The American Cancer
Society says this option is best for women 30 or older, since HPV is so
common among younger women and the body usually fights it off.

Pap smears are generally covered by health insurance, and many plans also
cover the HPV tests and vaccine. But those without insurance face high costs
— about $360 for the vaccine (plus administrative costs, which can raise
that figure to $400 or more), about $20-$40 for a Pap smear (plus the charge
for the office visit) and $80 to more than $100 for an HPV test.

However, there are programs that can help women struggling with the costs,
including the CDC’s National Breast and Cervical Cancer Early Detection
Program, which screens low-income women who are uninsured or underinsured.

Still, some people fall through the cracks. And sometimes, just a few years
without screening can spell trouble.

At great risk

Tamika Felder got Pap smears regularly when she was attending college and
was still covered by her mother’s health insurance. But when she outgrew
that insurance, Felder skipped screenings for three years. She wasn’t too
worried when she began having bad menstrual cramps and lower back pain.
After landing a full-time job with insurance, she went in for a checkup and
got a Pap smear. She could hardly believe the cancer diagnosis and sought
several other opinions.

“I was thinking I was in some bad movie,” she said.

Felder said three things would have made a difference for her: being better
educated about cervical cancer and its causes, having insurance and not
acting as if she were invincible health-wise.

Hilgers said these factors affect many patients. But experts say changing
attitudes, getting health messages out to everyone, and improving access to
health care are some of the thorniest challenges in medicine.

Krishnan, the New York gynecologist, said she hopes for improvements because
the new health-care law should mean fewer uninsured women. “We hope that . .
 . providing coverage for millions more will reduce the number of cervical
cancer cases in this country,” she said.

Hilgers said bringing down the numbers will take a while. “I think we’ve hit
a wall in terms of making progress in Pap smears,” he said. “Now, we have to
wait for the impact of the [HPV] vaccine. . . . If you immunize today,
you’re not going to get a reportable outcome for 10 to 20 years.”

Felder, meanwhile, is doing her part. In 2005, she started a nonprofit
group, Tamika & Friends, which seeks to draw attention to cervical cancer
and its link to HPV. On May 14 it is sponsoring an awareness walk at RFK
Stadium.

“I don’t know if we’ll ever eliminate it completely. But I think we can
lower it,” Felder said. “This is a preventable cancer.”

Ungar is the medical writer for the Courier-Journal in Louisville.

http://www.plannedparenthoodnj.org/news/articles/20110502_cervicalcancer