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During my first year in practice, I met Eileen, a delightful woman who wanted children but sacrificed her fertility by having a radical hysterectomy to cure her cervical cancer. Sometimes I wonder where she is, whether she ever married, if she has adopted children. I hope so, because she would be a wonderful mother. Had she been diagnosed today, she might be a candidate for a fertility-sparing radical trachelectomy, like my current patient, Crystal. Her 5-year-old son was the first child conceived at Duke after fertility-sparing surgery for stage IB cervical cancer.
And I will never forget Sandra, who presented in labor with a 7-cm-dilated cervix that contained a large cancer. A cesarean-radical hysterectomy yielded a healthy baby boy, but the pathology report showed that the cancer had spread to her lymph nodes. Even with chemoradiation, her prognosis was uncertain, and the follow-up visits were agonizing as we held our breath desperately hoping that Sandra was cured. She beat the odds and her son is now in elementary school.
I remember, too, the patients with recurrent cervical cancer who have undergone pelvic exenteration as a last act of desperation and been willing to live with a colostomy and urinary conduit. There was the young African-American woman who developed an incurable recurrence after exenteration. On Vivian's last hospital admission, I was called to discharge her urgently because the bus that provides transportation for patients lacking other means was about to leave. That day was the first anniversary of 9/11. The outpouring of sympathy for those lost in the terrorist attacks was understandably great, but in stark contrast to the barely noticed death of my indigent young patient in rural North Carolina several days later.
In the future, perhaps, women won't have to suffer as did the patients I've described. Not only is the incidence of cervical cancer continuing to fall with advances in screening, but there is a new vaccine against HPV 16 and 18 that has the potential to prevent most cases. I hope it will be widely adopted and prove as effective as predicted, but it will be many years before we can judge the success of this approach. Let's hope, too, that women who are vaccinated will not neglect cervical screening out of a false sense of security. There are other potential pitfalls along the way. It is possible that prevention of HPV 16 and 18 may allow other subtypes to emerge as a major cause of cervical cancer. And will the vaccine's efficacy be compromised if only women are vaccinated?
I say bring on the cervical cancer vaccine in the hope that cervical cancer can become a rare medical curiosity, like polio, smallpox, and other formerly devastating viral infectious diseases!