Reflections on work in Africa: Cervical cancer prevention in the U.S. and Rwanda

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This month, the latest guidelines for appropriate cervical screening will be published by the American Society for Cervical Pathology and Colposcopy (ASCPC). Experts developed these guideliens in an effort to maximize our ability to detect, and thus, treat, pre-cancerous cervical changes while also minimizing over-intervention and unnecessary procedures.  The guidelines are based on sound scientific studies of the human papilloma virus, better known as HPV, the causal agent in the development of cervical cancer, and the behavior of abnormal cervical cell changes – also called dysplasia – over time.

rwanda doctors colpscopySince the adoption of routine Pap screenings in the US in the 1950s, cervical cancer rates in this country have plummeted by more than 70 percent.  Pap screening has been very successful; it represents screening at its best.  We have been able to detect abnormal cells through Paps, evaluate the cells through colposcopy, and remove the pre-cancerous cells through an in-office procedure called LEEP, thereby hindering the progression to cervical cancer.

As I leave the small African country of Rwanda after participating in a two-week ASCCP training course to teach colposcopy and LEEP, I am struck by the contrast between the United States and Rwanda relating to cervical cancer.  Cervical cancer is the most frequent cancer killer of women in Rwanda.  Screening is not widely available in this resource-poor country.  Women are dying unnecessarily, often in their 40s, at a time when they are working to support their families and community and raising children.  The Ministry of Health in conjunction with Partners in Health has devised a practical screening program with the potential to make a significant impact on the rates of cervical cancer.  The physicians I trained were enthusiastic to use the new tools.  I am optimistic that if the protocol is widely adopted, it will save many Rwandan women from an untimely cervical cancer death.

Now I return home, where I will try to convince my colleagues and patients that less screening–not more– is the appropriate, scientifically sound approach in this community. We American women have been encouraged to get our yearly Pap, and this is a testament to the success of cervical screening in the US. Supplied with new information and the benefit of (appropriately used) HPV testing, we can safely extend screening to every 3 or even 5 years. The new recommendations are rational and not, as some skeptics have questioned, the result of insurance companies attempting to provide less coverage. My challenge in Rwanda was to teach physicians how to effectively screen and treat as many women as possible. My challenge at home is to reassure women that less testing does not equate to less care.

For more on my recent trip and cervical cancer treatment in Rwanda, take a look at the following articles: Twelve doctors trained to steer cervical cancer fight;  Rwanda’s Historic Health Recovery: What the U.S. Might Learn; and Pap Tests For Cervical Cancer Are Often Wasted


About the Author:

Dr. Lepine earned her medical degree from the University of California at San Diego and completed her residency at the same institution in 1994. After residency, she pursued her interests in public health and international medicine through a fellowship in the Epidemic Intelligence Service at the Centers for Disease Control and Prevention. Education and advocacy for women, particularly the under-served, has always been at the heart of her work. She has participated in both public health and clinical work in the developing world, including Rwanda, Kenya, Mexico, Bangladesh, Honduras, and Nicaragua.

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