SGO Ethics Series: Justice In Cervical Cancer | Helen L. Frederickson, MD
Helen L. Frederickson, MD
January is Cervical Cancer Awareness Month, and the disparities in access and care for cervical cancer patients raise an ethical issue.
“Justice is generally interpreted as fair, equitable and appropriate treatment of persons.”1 What are the barriers to access and care that exist in the United States?
Insurance plays a large role in limiting access to healthcare. Frequently, the patients with the smallest risk of developing cervical cancer (due to lifestyle factors) have insurance and receive the most screening and care. In contrast, the patients with higher risk of developing cervical cancer often do not have insurance and, therefore, are not screened and treated.
Ironically, Native Americans are twice as likely to develop cervical cancer as white women and four times as likely to die of cervical cancer, but they have universal insurance through the Indian Health Service. Why is this the case?
Northern plains Native Americans have the highest incidence of cervical cancer among Native populations.2 After spending 22 years working with this population, I suggest there are multiple factors at work that prevent care for this population. A large part is cultural distrust of the healthcare system in general; this distrust is based on past experiences with the system. In addition, transportation is a significant problem since patients live in remote areas. The tribes supply transportation for their members to reach specialized care. Still, the patients have trouble getting to the vans to benefit from the available transportation. Another factor is an underlying fear of treatment, causing patients to miss appointments and ultimately reject available care.
Cultural distrust of healthcare providers leads to lack of utilization of screening and vaccination, the two most important factors for prevention.3 Education and compassionate care for these patients are ways that this distrust can hopefully be eliminated over time. Societal issues, poverty, long waits for appointments, and difficulty getting referrals to specialists are additional factors preventing care. Many patients have trouble accessing providers who will listen to them and realize they need additional care.
Treatment for cervical cancer is very difficult for the patients and requires frequent appointments and treatments while away from home and family. Continuity of care for these patients helps support them through these difficult treatments.
The goals of the Task Force to eradicate cervical cancer are:4
1. Vaccination of 90% of girls by age 15
2. Screening of 70% of women by age 35
3. Treatment of 90% of precancerous and invasive cancers
To accomplish these goals, we need to look at societal programs. A nationwide school-based vaccination program has been very successful in Australia. This could be government sponsored or private foundation funded (i.e. the Gates Foundation). American Indians have a higher vaccination rate than the general population in the US, but the vaccines may not be as effective in this population, as they have a high incidence of high risk HPV strains that are not included in the current HPV vaccines. More research into individual populations’ HPV types needs to be done.
Screening programs are already widely available. Unfortunately, these programs are underutilized. Childcare and time away from employment are factors in preventing patients from accessing screening options. Self-screening with HPV testing could potentially increase compliance with screening programs.5
Treating cervical cancer is even more challenging. Gynecologic oncologists have the opportunity to impact the success of this Task Force goal by giving consistent care throughout treatment and post treatment visits, regardless of a patient’s ability to pay, social background, or culture.
The most important aspect of justice in healthcare is to remember the words of Dr. F.W. Peabody, “medicine is not a trade to be learned, but a profession to be entered. The secret of the care of the patient is caring for the patient.”6
Dr. Frederickson is a gynecologic oncologist at Monument Health in Rapid City, South Dakota. She is the Vice Chair of the SGO Ethics Committee, and the opinions listed are her own and do not constitute SGO policy.
References:
1. Varkey, Basil: Principles of Clinical Ethics and Their Application to Practice. Med Princ Pract 2021;30:17-28.
2. Downs, Levi S, Smith, J, Scarinci, I, Flowers, L, and Parham, G. The Disparity of Cervical Cancer in Diverse Populations. Gynecologic Oncology 109 (2008) S22-S30.
3. Bordearx S, Baca A, Begay R, Gachupin F, Caporaso JG, Herbst-Kralovetz M, Lee N. Designing Inclusive HPV Cancer Vaccines and Increasing Uptake Among Native Americans- A Cultural Perspective Review. Current Oncology 2021 Oct;28 (5) 3705-3716.
4. SGO Task Force for the Elimination of Cervical Cancer.
5. Wright T, Stolor M, Behrens C, Sharma A, Zhang G, Wright T. Primary Cervical Cancer Screening with Human Papillomavirus: End of Study results from the ATHENA Study using HPV as the First-line Screening test. Gynecologic Oncology136 (2015) 189-197.
6. Peabody, F. The Care of the Patient. JAMA 1927;88(12):877-882.