Women’s health, cancer screening and Papanicolaou

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Healthcare suffers from male dominance. At the beginning of 20th century, most doctors were men. Maternal care, commonest women’s health concern, was more of a tradition rather than part of a profession. Midwives and later nurses were flag bearers of health issues affecting women. In this context, it is no surprise that in comparison to other diseases, cancers of breast and uterine cervix, two commonest malignancies in women have a scant references in medical history. Turn-around for women’s health started only in 1960s when we also started screening for cancers in women. It is indeed remarkable, that today we have a vaccine to prevent cancer of the cervix, and in 2022, European Union has embarked on an ambitious goal of eliminating cancer of the cervix altogether.

Where did it all start ?

If left to human discomfort, all cancers will grow big enough, before they are detected. Large cancers are difficult to remove. Even with heroic surgeries, recurrence is a struggle. So, today the focus is on screening for cancer, before we have any discomfort. George Papanicolaou, was the first person who discovered how to do it. His story, is indeed inspiring.

George (b1883)was born to a prominent doctor father. He studied medicine in Athens, and in 1904 was all set to inherit his father’s practice. However, as soon as he completed his medical education, he was conscripted in army for next two years. In 1907, he found little appeal in either continuing in army, or his father’s practice. For next three years, he studied Zoology in Germany, and learned various microscopic methods. On his way back to Greece in 1910, he met Andromache Mavroyeni (a colonel’s daughter), fell in love, and married.

George had little interest in returning back to his native town of Kymi in Greece. Sponsored by his father-in-law, he spent another year on an oceanographic ship expedition in Monaco, and again joined armed forces in 1912. A year later in 1913, and against wishes of his father, George and Andromache migrated to US. Couple landed in New York, with only a little knowledge of English, and no definite plan in mind. After initial errand jobs as a salesman, and a tailor the couple found employment in department of Anatomy at Cornell Medical College New York- George as a technician, and his wife Andromache as his assistant. Since Andromache was difficult to pronounce, she thereafter called herself Mary.

George and Mary’s tryst with a microscope

In 1916, George was doing animal research, that required him to retrieve guinea-pig ova. He stumbled upon an idea, to look at vaginal smears of guinea pigs, to predict when would she ovulate. These were the first cervical smears, where he discovered that cells changed in shape and size, on different days of menstrual cycle. His wife Mary volunteered to be his “human-subject.” He was excited, to report in 1917, that even human cells shed from uterine cervix had a cyclic pattern. Recognition of this cyclic pattern formed the basis of more discoveries.

Discovery of Sex-hormones

In 1923, Edgar Allen and Edward Doisy discovered oestrogen. Five years later, in 1928 Willard M. Allen and George W. Corner identified other ovarian hormone progesterone, and by 1933 they could extract it in a crystalline form. Meanwhile three zoologists Fevold, Hisaw and Leonard, in 1931 identified that these sex-hormones are regulated by LH and FSH from the pituitary gland located in the brain. None of the above discoveries got a Nobel. Meanwhile discovery of testosterone – male sex hormone in 1935, won Adolf Butenandt a Nobel in 1939.

Pap smear comes of age

Coming back to George and Mary, after 1917, they engaged in more systematic research. In 1928 he described cervical smear patterns in a lady with an early cancer. He proposed, that it is possible to detect cancer of uterine cervix early, by looking at cells in the smear. With no serious takers for this idea, George and Mary teamed up with Herbert Traut, a pathologist. Together, they proved value of cervical smear in early detection of cancer. They first published their work in 1941. Between 1948 and 1959, Papanicolaou was nominated five times for a Nobel. However he was never awarded one.

Value of his work, was really known after 1960s, when American Cancer Society advocated universal screening for cervical cancer, using smears. These smears, were named after Papanicolaou. We all know it as a Pap smear. Screening of cancer of cervix by Pap smear, saved millions of lives, and deaths due to cervical cancer had plateaued by 1970s.

Screening for cancers of Cervix and Breast

Basic premise of screening is to detect early, so that we can make a difference. For a cancer to be screened, it should be common, and method of screening should be simple. Today most common cancers in women are of of Breast and Cervix.

Between 1960-1990, European countries introduced universal screening for cancer of the cervix. Pap smears, could detect cancer early. This also promoted early treatment and hence less deaths. Countries such as India, however have very low screening rates. In 1980, we discovered that cancer of cervix occurs because of human papilloma virus. This Nobel Prize winning discovery, led to development of a HPV vaccine in 2006 (Ian Frazer and Jian Zhou, University of Queensland, Australia).

Screening for Breast cancer, however started much later. It was first included in the Canadian Guidelines in 1976, and later in the US guidelines in 1984. However, it has remained controversial. Breast being superficial, is easily accessible. Self or a physician based breast examination, can detect lumps, some of which can be due to a cancer. While this is a low cost technique, but often lumps become big-enough when detected. An alternate is screening mammography – a process where we obtain annual X-rays of breast for early detection. Exposure to radiation, need for an equipment, discomfort and loss of privacy are concerns. Benefits of screening mammography are best seen between age of 50-69 years. In coming years, ultrasound may replace X-rays in such screening. Last words on either cause or prevention of breast cancer, are yet to come.

A push for Women’s health

Screening and treatment for cancers of cervix and breast is only one dimensions of Women’s health. However, both these screenings have brought non-maternity women’s health to a forefront. 28th May is International day for action on Women’s health. A day to celebrate our successes, and to be aware of its challenges.