By Anne Harding
MONDAY, April 6, 2009 (Health.com) — Jade Goody, the 27-year-old British reality-TV star, died in March of cervical cancer, a disease that rarely gets to a life-threatening stage—particularly in young people in developed countries. How could it happen?
Experts say her case makes it clear that Pap smears alone don’t save lives, and that some women end up with cancer because of inadequate care after a Pap smear.
From a disadvantaged background, Goody first had an abnormal Pap smear at age 16. She did have precancerous cells removed from her cervix, but when the hospital urged her to come back for follow-up care due to another abnormal Pap, she ignored it. “I was too scared,” she told the U.K. magazine Heat.
In contrast, Peri Smilow was age 33 and living in Boston when she had a “suspicious” Pap smear at the doctor’s office, but nobody followed up with her to recommend additional testing. Although she saw her primary care doctor every year, she didn’t return for another Pap smear for five years. By then, she was experiencing some unusually heavy bleeding. Her gynecologist diagnosed a ‘fibroid,’ and Smilow underwent a dilation and curettage (D and C ) to remove it. Lab tests showed that the tissue collected during surgery was cancerous.
“With proper follow-up of an abnormal screening test women really shouldn’t die from cervical cancer,” says Kathleen Brookfield, MD, PhD, of the University of Miami Miller School of Medicine. But they do.
Every year, 10,000 U.S. women are diagnosed with cervical cancer, and 3,600 die from the disease, according to Debbie Saslow, PhD, director of breast and gynecologic cancer at the American Cancer Society in Atlanta. Most—but not all—of these women either were never screened or had not had a Pap test for several years. However, appropriate follow-up is important, too, and it’s far from universally available in the United States.
Cigarette smoking can increase your risk of cervical cancer
The American Cancer Society recommends that women who are older than 21 (or younger, if sexually active) be screened for cervical cancer at least every three years. But many doctors will keep it simple and just do an annual Pap smear.
Every year, tens-of-thousands of U.S. women have abnormal Pap smears, get treated, and go on to be perfectly healthy, says Mark Schiffman, MD, director of cancer epidemiology and genetics at the National Cancer Institute. Goody was actually “a success story of Pap smear screening,” Dr. Schiffman notes.
But what about those women who lack health insurance? The Centers for Disease Control and Prevention spends $200 million a year to provide cervical cancer screening for uninsured women, and the CDC and all state governments have mandated that follow-up care be paid for if a test identifies problems. However, Saslow points out, the CDC funding is only enough to cover one in every five women who need it.
Proper treatment can save lives. Dr. Brookfield and her colleagues studied Florida women with invasive cervical cancer and found that white or Hispanic women lived longer than African-Americans (who tended to be diagnosed later than other women), as did those with health insurance or who lived in wealthier neighborhoods.
The recent introduction of vaccines, such as Gardasil, can prevent infection with some strains of human papillomavirus (HPV). Almost all cases of cervical cancer are caused by infection with the sexually transmitted virus—certain strains cause genital warts; others, cancer. However, it won’t be clear for decades how effective the vaccines are in preventing cervical cancer.
Although the majority of women are infected with HPV at some point (80% by age 50), the virus simply goes away on its own most of the time. Only if the infection persists over time can it result in damage to cells of the cervix (which can be detected during a Pap test) and, eventually, cervical cancer.
Abby Lippman, PhD, a women’s-health researcher at McGill University in Montreal says she’s skeptical that the HPV vaccine will “level the playing field” for all women when it comes to cervical cancer prevention. She argues that the entire system needs to be overhauled to address women’s sexual and reproductive health in a more holistic way. For example, she points out, many women have no idea that cigarette smoking boosts the risk of persistent HPV infection.
What happens if you have an abnormal Pap test
If a woman has an abnormal Pap smear, her gynecologist may test for HPV or do a colposcopy, a procedure in which a doctor uses a special scope to closely examine the cervix and take samples.
If this test reveals cells that are abnormal but not precancerous, a woman can have this tissue removed. If cancer has developed and spread more deeply into the cervix, it may still be possible to have the tissue removed—and many woman can go on to have children. But when the disease is more advanced, more extensive surgery is necessary, along with radiation.
That was the case for Smilow. Childless, she was offered the opportunity to take part in a research study to have the tumor removed but retain fertility. Some of the women in the study had become pregnant, but there were no long-term results on the risk of their cancer recurrence. “I did a lot of soul-searching,” Smilow recalls. “I knew that if I was going to have a child, I didn’t want to then die of the disease, so I decided to have a radical hysterectomy.”
She had the surgery and underwent a course of radiation. She was also given the option by her physicians to receive chemotherapy, but she chose not to for several reasons. Chemotherapy drugs available at the time did not specifically target cervical cancer. In addition, the drug of choice was cisplatin, which can sometimes cause deafness. Smilow, a singer and musician, wanted to keep her organs as healthy as possible for as long as possible and didn't want to risk hearing loss.
Smilow recovered from the surgery, married her boyfriend, and adopted a daughter. But seven years after her diagnosis, doctors found several tumors in both of her lungs. She underwent two surgeries to remove the tumors, which left her with diminished lung capacity. “The next year was emotionally very difficult,” she recalls.
But the disease didn’t return. Smilow has rebuilt her lung capacity by singing and swimming. Her career as a performer and composer has taken off. And she revels in being a mom.
“I feel really good about all the decisions that I made,” Smilow says. “I'm really happy that I was a strong partner in directing my own health care, including the decision to reject chemo. I think that as a result I’m in really good physical and mental health.”
“The only thing I would have done differently in this entire scenario, if I could change anything, would have been to have annual Pap smears,” she says. “I get annual letters from my dentist letting me know that I need a checkup … there’s no excuse for women across this country to not get a letter from their doctor indicating that it’s time for their Pap smear. It’s a simple fix.”