Person:

Goodman, Annekathryn

Language plays a central role in how gender and sexuality are described. In Bangla or Bengali, physicians, when educating and counseling women patients, do not have a socially acceptable word for “vagina”. If language is missing for female genitalia or important female sexual functions, could this absence reflect on the position of women in society, reproductive rights, and access to healthcare? Is there a relationship between language and the high rates of the gender-based cervical and breast cancers in some low and middle-income countries? This commentary examines scholarship on the topic of language, the female body, gender-based violence, disparities of healthcare for women, and the consequences of language on sexual attitudes and health.

Objective: In Bangladesh, cervical cancer is the second most common cause of cancer deaths in women. Annually, over 50 million women are at risk for cervical cancer, with 17,686 cases diagnosed and 10,362 deaths each year. Visual inspection with acetic acid (VIA) is a well validated tool in low resource areas for identifying cervical lesions. In this pilot study, AK Khan Health Care Trust (AKKHCT), in collaboration with oncologists at Massachusetts General Hospital (LB, BD, AG), launched a VIA cervical cancer-screening program. Methods: A clinic was established in the Korail Slum of Dhaka, a 90-acre slum with over 70,000 inhabitants, in the summer of 2011. From September 17, 2011 to November 1, 2011, ten women living in the Korail Slum were recruited and completed the three-month training program to learn how to do a pelvic examination and to evaluate the cervix using VIA. Three of the ten women performed VIA screening during the study period. Results: 44 patients were recruited and 8 women were identified to have VIA-positive results for a screen-positive rate of 18.2%. Two of the eight women underwent treatment. One woman underwent an excisional procedure for pre-invasive disease in the slum clinic. The other woman had an early invasive cervical cancer and was successfully treated in a local hospital. Conclusion: Our pilot project demonstrates some important factors in developing and implementing a successful screening program. Involving laywomen as healthcare workers provides a strong tie to community, as well as education, economic independence, and empowerment for women who would otherwise occupy a lower social standing in their community. VIA is feasible in the complicated environment of an inner city slum. It was feasible to perform minor excisional procedures to treat pre-invasive cervical disease in the slum clinic.

Objective: This study describes the characteristics of patients with primary malignant melanoma of the vagina and their treatment at National Institute of Cancer Research and Hospital in Dhaka, Bangladesh, from February 2013-January 2015. Materials/Methods: Eight patients with primary malignant melanoma of the vagina were identified. Medical records were reviewed for demographic information, treatment, and outcomes. This investigation was approved by the Ethics Committee of the National Institute of Cancer Research and Hospital. Results: The median age was 48 years (range: 35 - 65 years) and most patients were premenopausal. Seven of the eight patients presented with International Federation of Gynecology and Obstetrics (FIGO) stage II. The five patients had disease confined mainly to the upper and middle thirds of the vagina. One patient was diagnosed with stage IV disease. In two patients, cervical metastases were present. Almost all patients received radiotherapy. Two patients with stage II disease developed local recurrences within eighteen months. The one patient with stage IV disease died ten months after diagnosis. Conclusion: Primary malignant melanomas of the vagina are uncommon, highly aggressive tumors that are associated with poor overall survival. Surgery is the mainstay of treatment. Nearly 80% of vaginal melanomas will recur. Overall 5-year survival ranges from 5% to 25%. The size of the tumor (>than 3 cm) and the presence of lymphadenopathy at diagnosis worsen the overall survival.

Cervical cancer is the second most common cause of female cancer mortality worldwide. Concurrent chemoradiotherapy represents the standard of care for patients with stages IB2 to IVa cervical cancer. Unfortunately radiation therapy capacity is severely limited to non-existent in many Low and Middle-Income Countries. One solution has been to use chemotherapy to reduce tumor size to allow for radical surgery or in the case of inoperable cancers, as a placeholder until radiation is available. In Bangladesh, there has been the progressive development of resources for the treatment of women with gynecologic cancers. However, radiation therapy resources are limited with a six-month waiting period to receive radiation. Neoadjuvant chemotherapy (NACT) remains the main primary treatment intervention for women with advanced cervical cancer in Bangladesh. This implementation study summarizes of the experience and challenges to caring for women in a new gynae-oncology ward at Dhaka Medical College Hospital, a 2600 bed government hospital in Dhaka, Bangladesh.

Recurrent high-grade epithelial ovarian cancer is usually associated with a short-term survival. There are few guidelines to surgically and medically treat long-term survivors with ovarian cancer. We report the case of a woman who presented at the age 40 years with an advanced epithelial cancer. With the interventions of multiple surgeries and multiple lines of chemotherapy, she survived for twelve years. We also comment on the feasibility of complex oncology care in a low-middle income country such as Bangladesh. Complex care is only available for patients who can afford the out of pocket expenses. The development of universal healthcare insurance must be part of the strategy for the development cancer care services in Bangladesh.