Person:

Goodman, Annekathryn

Cervical cancer is a preventable disease. The risk factors for the development of cervical cancer include both biologic factors and social factors. In the United States, the leading risk factor for the development of cervical cancer is not having a Pap smear for five years prior to the diagnosis of cancer. In low and middle income countries, cervical cancer incidence and mortality are directly related to the lack of both screening programs and cancer treatment facilities. This paper examines the social ecology of cervical cancer. The literature is reviewed on social and cultural barriers to access to health care and its effect of cervical cancer rates and outcomes.

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.

Background: Radiation-induced pelvic insufficiency fracture (PIF) is an important complication associated with pelvic radiation therapy (RT) for patients with gynecologic malignancies. Despite known risk factors and recent reports describing the incidence on the order of 30 percent, there has been a dearth of translational research or consensus statements to guide clinical management. Objective: The aim of this study is to describe seven cases of PIF diagnosed and managed at the Massachusetts General Hospital during a 5-year period and to perform a focused review of the literature to inform several clinical questions that remain unanswered. A secondary aim of this study is to highlight the need for additional research related to screening, prophylaxis, diagnostics, and treatment of PIF in patients with gynecologic malignancy. Methods: In the current retrospective review, we report 10 cases of PIF diagnosed over a 5-year period in 7 patients with vulvar (4), vaginal (2), and cervical (1) cancer following chemoradiation therapy at a single institution. Data were collected from the medical records by a single investigator and all diagnostic imaging was reviewed by a single radiologist to confirm the presence or absence of PIF. Results: All 7 patients were post-menopausal and received concurrent chemoradiation, 3 were over the age of 65 years old (42.8%), 3 had BMI < 25 kg/m2 (42.8%), 2 had a history of osteoporosis (28.6%), and 1 had a history of hormone replacement therapy use (14.3%). No patients underwent standard screening for PIF and no patients were started on prophylaxis prior to diagnosis. The plain film was the most common initial imaging performed while MRI was the most common overall study used to diagnose PIF. Median time to the development of fracture was 16 months (range 4-114) with femoral neck fracture being the most common (40%) and sacral fractures trailing close behind (30%). 7 of 10 fractures were initially managed expectantly with 1 ultimately failing expectant management and requiring surgical intervention. 4 of 10 fractures required surgical intervention. All patients had resolution of symptoms by 12 months after diagnosis. Conclusion: Radiation-induced PIF remains an important complication associated with pelvic RT. Significant risk factors have been identified and studies have compared various diagnostic imaging modalities. Future studies are needed to compare screening algorithms and evaluate the comparative effectiveness of prophylactic pharmacotherapies. Future studies are also needed to determine the cost-effectiveness of PET/CT versus MRI and compare the morbidity associated with expectant management versus surgical intervention in patients with symptomatic fractures.