Dr. Shivani Samlall. MBBS, Specialist in Obstetrics and Gynecology with a sub-specialty in Gynecology Oncology, with over 10 years of practice. Dr Samlall can be contacted at drshivanisamlall26@gmail.com

AS it is Cervical Cancer Awareness Month, I have decided that my first column for this year will focus on this cancer type. It is an area that I have been ardently trying to raise awareness of because Cervical Cancer is killing too many of our women.

CERVICAL CANCER INCIDENCE
According to Globocan (Global Cancer) estimates, we are rated amongst the highest in the world for Cervical Cancer incidence and deaths. And for a cancer that is 100 per cent preventable and curable, this is unacceptable.

THE STORY OF CAROL DABIE — THE CANCER WARRIOR
Today as I sat scrolling through my Facebook page, I saw the story of Carol Dabie — a Cervical Cancer warrior. Carol Dabie started having abnormal bleeding in her teenage years. She sought medical attention and was placed on oral contraceptive pills for years. She had several diagnoses made (UTI, hormone imbalance, Kidney Stones), before her eventual diagnosis of a rare type of Cervical Cancer called Clear Cell Adenocarcinoma. She also has a family history of her mother of using hormones to conceive and of suffering similar symptoms and subsequently dying at the age of 48 years without a diagnosis.

WHAT IS CLEAR CELL ADENOCARCINOMA (CCADC)?
This is a rare histologic subtype of adenocarcinoma and can occur anywhere — from the vagina to the cervix (mouth of the womb), the uterus and even to the ovaries). It is one of the most aggressive subtypes of cancers. This means that for most women, when the diagnosis is made, it is already at a later stage as compared to the most common subtypes.

DOES THIS MEAN THAT CAROL DABIE HAD THIS CANCER SINCE SHE WAS 16? OR THAT THE CANCER IS HEREDITARY?
It is well-established that almost all Cervical Cancers are caused by persistent HPV infection (which is sexually transmitted). However, the exact cause of this rare subtype of cancer is unclear. In the past, it had been linked to in-utero exposure to Diethylbestrol (a hormone that was given to women). Because this hormone is banned, the incidence of this cancer has become scarcer over the years. The few cases that are now seen are non-DES related. Evidence suggests that this rare cancer (non-DES related CCADC) can affect women in menarche and menopause. It generally presents with abnormal bleeding, which is often misdiagnosed in adolescents, as seen in Carol Dabie’s case. Some studies have shown an association between this cancer subtype and cervical endometriosis.

WHY HER LATE DIAGNOSIS
This type of cancer (CCADC) falls in the family of Adenocarcinomas. This cancer type generally produces lesions that are endophytic, meaning that they grow inwards. This makes it difficult to diagnose through visual examination of the cervix since it may appear healthy and is the reason why it is often missed on pap smears. Additionally, because of the aggressive nature of this type of cancer, often when diagnosed, the cancer has already spread.

Therefore, a high level of suspicion of this cancer is often warranted or additional study must be done in patients with unexplained and persistent vaginal bleeding. One such study to diagnose these lesions is an endocervical curettage (scraping the inner canal of the cervix) and sending that for a biopsy.

One might also argue that Carol had abnormal bleeding and pelvic pain. However, it is important to note that many other conditions can cause these very symptoms and when a woman presents with these symptoms, the cancer is already spread outside of the cervix and to other organs.

It is for these reasons that “continuous” screening of Cervical Cancer is warranted, so that abnormal changes to the cervix can be diagnosed and treated before they progress to cancer.

TREATMENT OF CERVICAL CANCER
The treatment of Cervical Cancer depends mostly on the stage at diagnosis. Early-stage disease can be managed with surgery alone. Sometimes however, the patient might need additional treatment. In patients with advanced stage cancer, Chemo-radiation therapy is the indicated treatment. It is therefore important for women to be properly staged and managed by specialists who are trained in this field. In patients with cancer type (Clear Cell Adenocarcinoma) such as Carol Dabie, if they are fortunate to be diagnosed early, because of the aggressive nature of these cancers, they might need more radical management. The bottom line is no two cancer patients are alike.

PREVENTION OF CERVICAL CANCER
This cancer is one of the most preventable cancers. It can be prevented through HPV vaccination of our boys and girls and through regular screening. HPV vaccines are available for boys and girls so parents must play their part to encourage their kids to get vaccinated.

RECOGNITION FOR CAROL DABIE
Carol Dabie’s courage to share her story, in order to bring awareness to our women, is commendable. Too often, cancer diagnoses are discussed behind closed doors and patients lack the support that they need to fight. This support system should not only come from the family, but from communities and other support groups.

We must use Carol Dabie’s story to highlight how deadly Cervical Cancer is and why regular screening is important. Also, we must recognise that if a patient has persistent symptoms despite treatment, a high level of suspicion must be there to warrant further studies or referral. The bottom line is — screening and regular screening — lead to early detection which saves lives!