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

Mike Hixenbaugh | November 30, 2016

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.

"You should really come to the Valley with me," Schmeler told her. "Everything we're doing in Brazil is needed in our own state."

Photo: Marie D. De Jesus, Houston Chronicle

The reflection of Sonia Parra, a graduate student at Baylor College of Medicine and Rice University is seen on the screen which shows the use of the High-Resolution Microendoscope also known as HRME which is a low-cost point-of-care diagnostic for cervical cancer prevention developed Parra's mentor Dr. Rebecca Richards-Kortum. Wednesday, Oct. 19, 2016, in Houston.

Don't be fooled by the simplicity of Richard-Kortum's most promising invention. Yes, it's basically a tiny microscope connected to a Microsoft tablet - the kind you'd find at Best Buy. It might just revolutionize the way doctors diagnose some types of cancer.

"I was really excited," she said, recalling the day she dreamed up the gadget 15 years ago.

Instead of sending a cervical tissue sample off to a lab to be studied under a microscope, Richards-Kortum brings the microscope to the tissue, eliminating the need for biopsies. Her "high-resolution microendoscope" fits in a shoebox and has now been proven effective in clinical trials across the globe, but never before in a low-income setting in the U.S.

"That's what we're trying to do now in the Rio Grande Valley," said Sonia Parra, a bioengineering student studying under Richards-Kortum, while simultaneously pursuing a medical degree at Baylor College of Medicine.

In partnership with Schmeler, Parra plans to spend the next year testing the microendoscope in the Valley. Long term, their goal is to equip local clinicians with the devices.

Four days before taking her first trip to McAllen to launch the study, Parra gave a demonstration.

She propped up a tablet in her lab and rubbed an antiseptic chemical on the inside of her lip. A moment later, Parra pressed the glowing tip of the microendoscope to her mouth, and an image appeared on the screen.

"Those are my cells," she mumbled, noting that the computer program had automatically highlighted all the nuclei.

She can take a snapshot, tap the screen, and within seconds the tablet analyzes the image and spits out a diagnosis.

No need for a pathologist; if an indicator on the tablet screen turns red, the cells are cancerous.

"Instead of having to wait days or weeks for a biopsy," Parra said, "they can get the results immediately and decide a treatment right there and then.

"It's easy to see how this could be of use down in the Valley."

"Easy" might not be the right word.

Five hours after arriving at Rodriguez's free clinic in McAllen one day last month, the high-powered Rice and MD Anderson research team still hadn't screened a single patient with the microendoscope.

They'd planned ahead, flying down on a day when Rodriguez was scheduled to see at least a dozen women who'd previously had an abnormal Pap smear.

Only two showed up, and they didn't wish to participate.

"You knock one barrier down, then there's another one on the other side," Schmeler said after a few hours of waiting. "If cervical cancer rates are so high, why is this clinic so empty right now?"

In some ways, public health challenges in South Texas are more confounding than in countries where hospitals don't even have electricity or running water, Richards-Kortum said.

"I walk in the door in places like that and immediately think of 25 ideas for how to improve care with technology," she said. "It's actually more challenging to think about how to develop solutions that make a difference in the Valley because there's so much infrastructure already there; it's just not accessible."

Women without children generally are ineligible for Medicaid in Texas. Many in the Valley work part-time - if they have jobs at all - and can't afford insurance premiums in a state that has refused to accept federal funding to expand public health insurance to cover the so-called working poor. The region's many undocumented immigrants have even fewer options.

Maria Daheri, a Houston nurse who also works part-time at the free McAllen clinic, spends much of her time organizing outreach efforts in the Valley. Teams go door-to-door in neighborhoods or stand outside grocery stores, handing out packets of information. Many residents are surprised to learn of a clinic offering free medical screenings.

Just because you get a woman to show up once doesn't mean she'll come back.

"They move around, phones change," Daheri said, gesturing toward an empty exam room. "People skip appointments."

While they waited for patients, the Houston researchers killed time running through role-playing scenarios with clinic staff, simulating what would happen if a woman agreed to participate.

By the end of the first day, none had.

"We knew this wasn't going to be easy," Schmeler said as the team packed up. "It's always a challenge starting a research project in a new setting."

Photo: Marie D. De Jesus, Houston Chronicle

Maria Daheri, right, participates on a mock-up session to train McAllen UTMB Regional Maternal Child Health Program staff how to communicate effectively the purpose of High-Resolution Microendoscope to patients that are interested in participating in the study, Monday, Oct. 24, 2016, in McAllen.

The next morning, Yesenia Garza came to visit the medical staff she credits with saving her life. The 26-year-old says she's "blessed by God." How else to explain why she's alive, while so many like her are dead?

She got a Pap smear last year on a whim after skipping it for a few years. She didn't have health insurance, but the medical facility where she worked part-time had offered free screenings to employees.

The results came back abnormal. Weeks later, a biopsy taken at the free McAllen clinic confirmed her fears: She'd been diagnosed with a rare form of cervical cancer. It already had spread to her uterus. Doctors told her they needed to operate right away.

She'd hoped to harvest her eggs before having a hysterectomy, that way she and her fiance could someday have children. But doctors warned the process would take too long.

"That told me how serious this was," said Garza, who was able to qualify for a special form of Medicaid for cervical cancer patients. "If I wasn't working in a facility that provides free screenings for employees, it would have been too late for me."

If she'd gotten screened a year or two sooner, she thinks maybe she'd still be able to have kids. "Maybe something different would have happened to me," she said, tearing up in Rodriguez's office.

Down the hall, Parra and her teammates booted up their microendoscope and hurried into position.

Finally, they'd enrolled their first patient.

Photo: Marie D. De Jesus, Houston Chronicle

Dora Zuniga, left, walks away from the UTHealth Mobile Health Clinic with her daughter Ariadna Zuniga, right, after she received a pap smear, Tuesday, Oct. 25, 2016, in Brownsville. Zuniga said she prefers going the mobile unit to receive preventive care because is near her home and because is affordable.

Thirty miles away, Toscano treated women at his mobile clinic outside an elementary school a few hundred yards from the Mexico border. Want proof of the hardships people face here?

"A lot of my patients are actually teachers at the schools where we set up," Toscano said. "They have insurance, but the deductibles have become so high, they can't really afford routine screenings."

In the coming months, Parra will be training Toscano to use the microendoscope.

Eventually, the physician's assistant hopes he'll be able to diagnose cervical cancer and remove precancerous tissue in a single visit to the RV.

"We're talking about saving people's lives," he said.

He wonders how the technology might have helped the woman who didn't come back eight years ago.

Toscano remembers trying to track her down. He called the number she'd left, but it was disconnected. Sent notes in the mail, but who knows if they reached her.

Two years later, she finally got back in touch. By then, though, there was nothing he could do.

The woman had only a few months to live.

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