PANAJACHEL, Guatemala — If someone had come to her community in western Guatemala sooner to offer cervical cancer screening, perhaps Micaela Yac Jeteya, 56, wouldn’t be fighting for her life. Now Yac Jeteya, a mother of six whose youngest son is 16, is suffering from a disease that is both very common and highly preventable.
“Almost no one needs to die of cervical cancer,” said Dr. Kirsten Austad, the director of women’s health for the Maya Health Alliance, the organization that tested Yac Jeteya and is now trying to help her navigate treatment options.
Yet, in 2018, cervical cancer killed more than 311,000 women — one woman every two minutes. More than 85 percent of those deaths were in low- and middle-income countries. During the same year, the World Health Organization estimates there were 570,000 new cases.
There are lots of global health problems, from AIDS to maternal mortality, but the lives lost to cervical cancer should be among the easiest to save. Although cervical cancer is the fourth most common cancer for women globally, claiming more lives than pregnancy and childbirth, we can save those lives if we can only summon the will.
Health experts say that the battle against cervical cancer has two fronts. First, we need to scale up HPV vaccination to prevent cervical cancer. Second, we need to expand screening and treatment for women now in danger. These are relatively affordable, straightforward interventions that can make a big difference in a lot of lives.
In 2018, the director general of the World Health Organization, Dr. Tedros Adhanom Ghebreyesus, called for coordinated global action to eliminate cervical cancer. Dr. Silvia de Sanjosé, the director of women’s cancer for PATH, a nonprofit focused on global health, told me this was crucial to elevating the issue, which had previously received little attention.
“I would not say that that’s enough,” she said. “But it’s clearly a turning point.”
The World Health Organization recommends that 9- to 14-year-old girls receive two doses of the HPV vaccine (boys can also benefit from the vaccine, but vaccinating girls is the priority). The vaccines protect against HPV infections responsible for 70 to 90 percent of cervical cancers.
But here’s the problem: Only around 25 percent of 10-year-old girls live in countries that have introduced the HPV vaccine, according to W.H.O. estimates from October 2018.
There are a variety of challenges to expanding access to the vaccine, according to de Sanjosé of PATH. It needs to be given when children are at least 9, later than most other routine vaccinations. Then there’s the price tag. While the vaccine costs around $4.50 for the lowest-income countries, globally the cost can go up to around $150, according to the W.H.O. To address those problems, researchers are studying whether just one dose of the vaccine is sufficient (originally, three doses were recommended by the W.H.O., but that has been knocked down to two).
These challenges are not insurmountable. In Rwanda, 93 percent of girls are vaccinated for HPV in sixth grade, according to Unicef, suggesting that cervical cancer could be largely eliminated there.
In countries also stepping up HPV vaccination, “we will start to see a generational shift in incidence of this cancer,” said Dr. Justin Parkhurst, who researches global health politics at the London School of Economics.
If vaccines are the sword in the battle of eliminating cervical cancer, screening initiatives are the shield. If we don’t offer unvaccinated women effective screening, de Sanjosé and Francesca Holme wrote in a recent paper, those women “will generate about 35-40 million cancer cases over the next 65 years.”
Most women in the United States are probably familiar with a Pap smear, recommended for women after they turn 21. While the Pap test is effective if conducted regularly, it requires a medical structure often lacking in poor countries. So public health experts have experimented with two other screening tests, one that uses vinegar to identify cancer and precancerous lesions, and another that uses DNA to identify HPV infections that could cause cervical cancer.
They’re both useful. The HPV DNA test, as Austad put it, is “like looking in a crystal ball that tells you which women are going to have cervical cancer in 10 years, and so you can treat them before they ever even develop those precancerous changes.” But these tests are relatively expensive.
The vinegar test, on the other hand, is simple and cheap: A health worker applies vinegar to the cervix and watches for color changes that can indicate cancer or precancerous lesions. For women who test positive, lesions can be frozen off or burned off.
Researchers are also experimenting with mobile screening technology, which would generate an automatic diagnosis using artificial intelligence. In a study in Costa Rica, researchers found that a computer analysis of images was more effective at identifying precancer than a human analyzing samples from a Pap test.
Here in Guatemala, Austad worries that Trump’s threatened withdrawal of humanitarian aid could harm preventive health services, with devastating results for the women themselves.
In the meantime, Yac Jeteya is trying to navigate her own cancer treatment while also focusing on another goal: making sure the women in her community get screened. This is no easy task — she’s asking women who have often been failed by health systems to submit to a very personal exam. That takes trust.
“I tell women not to be ashamed to get a Pap smear,” she said. “The majority of women are embarrassed, but I tell them they’re only going to see the person who takes the sample once.”
Yac Jeteya says that when they did a round of Pap screening in her community last month, four women had abnormal results. The screening may have saved their lives.
Mia Armstrong, a 2019 graduate of Arizona State University, is the winner of Nicholas Kristof’s 2019 “win a trip” contest, allowing a student to accompany him on a reporting trip and write about it for The Times. This is the third of several articles she will write from the trip.
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