Beyond Vaccination Rates: Puerto Rico and Its Cervical Cancer Problem | Nicole Lugo Santiago, MD

Nicole Lugo Santiago, MD

My journey as a medical trainee has been significantly shaped by my encounters with cervical cancer, a disease that disproportionately affects young, active individuals who often carry significant societal and family responsibilities. Many of these patients, often mothers and caregivers, grapple with social and economic hardships. Not uncommonly, these patients are non-primary English speakers. Our current treatments, though beneficial, often interfere with their complex lives, resulting in missed treatments and documented worse oncologic outcomes.

Despite it being perceived as an illness exclusive to developing countries, the U.S. and its territories still grapple with its effects, with especially high mortality rates among Black and Latinx patients. Many of these patients are diagnosed between the ages of 35 and 45, with Black patients being more likely to die from the disease. Advanced diagnoses among these communities limit the possibility of a cure, with structural racism and social health determinants exacerbating these outcomes.

As one of the two active gynecologic oncologists in training from Puerto Rico, I found the findings of Ortiz et al¹ deeply disturbing. Despite historically high HPV vaccination and cervical cancer screening rates, Puerto Rico witnessed one of the most significant increases in cervical cancer incidence by 2017 in the U.S. This paradox is currently the subject of investigation at the University of Puerto Rico Comprehensive Cancer Center and other institutions.

Puerto Rico, home to 3.2 million US citizens, with females constituting over 50% of the population, is served by seven committed gynecologic oncologists. However, they report facing numerous social, economic, and bureaucratic challenges, with the current situation further deteriorated by natural disasters, the COVID-19 pandemic, government austerity measures, and political turmoil, all contributing to a mass exodus of young citizens and medical providers. Coupled with an aging population and the natural retirement of pioneering oncologists, the burden is growing exponentially.

Without intervention, I fear these conditions could further escalate cervical cancer rates. The situation is complicated by the lack of a gynecologic oncology fellowship in Puerto Rico, necessitating trainees to seek training elsewhere. However, these individuals often face increased scrutiny regarding their language proficiency, citizenship status (all native-born Puerto Ricans are U.S. Citizens by birth), and training qualifications, as corroborated by a Latino Medical Student Association survey.

Nevertheless, I firmly believe that the eradication of cervical cancer is both feasible and attainable. The Society of Gynecologic Oncology (SGO) can play a vital role in this endeavor by establishing mentorship programs and task forces to support aspiring trainees from affected communities, aiding in their professional development to be competitive fellowship applicants. Additionally, initiatives should focus on providing frontline providers with grants and funding opportunities to build much-needed comprehensive community programs.

I also invite all gynecologic oncology program directors to reevaluate their candidate selection processes. Consider the questions being asked at interviews, and limit scrutinizing an individual’s place of origin, primary language spoken, or accent. We need to look beyond standardized test scores and acknowledge the resilience these applicants have displayed. Imagine the profound impact the opportunity to train as a gynecologic oncologist could have on a dedicated, resilient, and competent individual, and how it could help transform affected communities. Give individuals and the communities they serve a chance.

As a senior fellow preparing to return home, I am thankful for the unwavering support from my mentors and partner. I hope that by fostering an active collaboration between Puerto Rican gynecologic oncologists, aspiring trainees, and the SGO, we can provide the support those serving affected communities need and deserve. Only then can we stand a chance against cervical cancer.

References

1. Ortiz AP, Ortiz-Ortiz KJ, Colón-López V, et al. Incidence of Cervical Cancer in Puerto Rico, 2001-2017. JAMA Oncol. 2021;7(3):456–458. doi:10.1001/jamaoncol.2020.7488
2. Equity for medical students in Puerto Rico. LMSA Faculty/Physician Advisory Council. (n.d.). https://fpac.lmsa.net/equity-for-medical-students-in-puerto-rico/

Nicole Lugo Santiago is a second-year gynecologic oncology fellow at City of Hope National Cancer Center located in Duarte, California. She completed her medical training at the University of Michigan followed by obstetrics and gynecology residency training at the University of Illinois at Chicago. Originally from San Juan Puerto Rico, her professional and research interests lie in surgical education, the humanization of end-of-life care, cultural sensitivity integration in healthcare, and healthcare access improvement for all communities.