Houston doctors determined to reduce cervical cancer deaths in Rio Grande Valley

Mike Hixenbaugh | November 30, 2016

http://www.houstonchronicle.com/news/houston-texas/houston/article/Houston-doctors-take-mobile-clinic-to-Rio-Grande-10636122.php?t=f0a7670540438d9cbb&cmpid=twitter-premium

McALLEN - Many of the patients who come to Paul Toscano's free mobile clinic are jobless. Uninsured. Undocumented. Desperate.

Photo: Marie D. De Jesus, Houston Chronicle

Dora Zuniga is examined by UT Health doctor, Tuesday, Oct. 25, 2016, in McAllen. Zuniga said she prefers going the mobile unit to receive preventive care because is near her home and because is affordable.

The physician's assistant treats so many inside this retrofitted RV that it's impossible to remember them all. Some he'll never forget.

He closes his eyes and thinks of a woman who knocked on the door eight years ago. She'd wanted a Pap smear, a routine screening to check for signs of cervical cancer. But he'd turned her away; told her to come back when she wasn't menstruating.

She never did.

"That happens here," Toscano said one afternoon last month. "Patients disappear."

Welcome to the Rio Grande Valley, where women are nearly twice as likely to die from cervical cancer compared to the rest of the country. The disease is now relatively rare in the U.S. but flourishes here in a section of Texas where half the population has no health insurance.

Toscano and another medical assistant travel along the Mexico border in UTHealth's mobile clinic, parking outside schools and treating as many people as possible, many of them women. But an abnormal Pap requires up to two return visits, an added burden for those without steady jobs or reliable transportation.

"That's hopefully where we come in," said Dr. Kathleen Schmeler, a gynecologic oncologist at MD Anderson Cancer Center in Houston.

For years, Schmeler and renowned Rice University bioengineering professor Rebecca Richards-Kortum have been studying ways to combat cervical cancer in the poorest sections of Latin America. The work centers on a portable, pen-sized device Richards-Kortum invented that allows medical technicians to diagnose cancer in real-time.

By deploying the low-cost tool inside clinics like Toscano's, Schmeler and Richards-Kortum found they could diagnose and treat women in a single visit, saving lives in places like Brazil and El Salvador.

Now, remarkably, they've found a need far closer to home.

The first time Schmeler visited a clinic along the border, she couldn't believe what she saw. "Are we really in the United States?" she'd said.

Health outcomes in Texas' four southernmost counties are among the worst in the country. Schmeler was horrified by stories of women showing up at emergency rooms with vaginal bleeding, only to be turned away because they couldn't afford cancer treatments.

The percentage of women diagnosed with cervical cancer has steadily fallen across Texas, by 20 percent over the past decade, primarily because more women are getting the Pap test, which can find changes in the cervix before cancer develops.

Over that same period, the cervical cancer rate has gone up 6 percent in Cameron County. Here, in the state's southernmost county, 4.3 out of every 100,000 women die of cervical cancer each year - nearly double the national average.

"Initially, I was outraged," Schmeler said. "No one should be dying from cervical cancer in the United States. But I also thought, 'We can do something about this.'"

Since 2014, Schmeler and MD Anderson have been working to educate women in the Valley about the need for cancer screenings and the HPV vaccine, which blocks transmission of the HPV virus, the primary cause of cervical cancer. The effort also includes teaching local providers non-invasive techniques to remove precancerous cervical tissue. But too often, Schmeler found, women fail to follow up after the initial examination.

"There are too many ways for women to fall through the cracks here," said Dr. Ana Rodriguez, a University of Texas Medical Branch gynecologist who travels from Galveston to McAllen once a month to run a free women's clinic. Women travel from up to an hour away for treatment there.

If one of Rodriguez's patients has an abnormal Pap, she has to return for a colposcopy. If that test reveals areas of concern, Rodriguez then performs a biopsy - taking a tissue sample and sending it to a lab. If those results come back positive, the patient then must return for a third visit, weeks later, to have any cancerous tissue removed.

Rodriguez recalled a patient who seemingly fell off the grid for nearly a year after an abnormal Pap. She was fortunate. Rodriguez said: "Some women don't come back until it's too late."

Every year, some two dozen women die of cervical cancer in the Rio Grande Valley, according to data compiled by the Texas Cancer Registry. The figure doesn't include immigrants who return to Mexico to be with family before they die.

"That happens a lot," Schmeler said.

Last year, during an unrelated research trip abroad, she told Richards-Kortum about the staggering problems she'd found only a few hours south of Houston and its world-class medical center.