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Linda Eckert, "Enough: Because We Can Stop Cervical Cancer" (Cambridge UP, 2024)
00:24:53
An interview with Linda Eckert
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- [00:01]
A
Welcome to the New Books Network.
- [00:05]
B
Hello, everyone, and welcome to another episode of Exchanges, a Cambridge University Press podcast, a joint production of Cambridge University Press and the New Books Network. I'm Mark Klobus and today I'm speaking with Linda Eckert, author of the book Enough Because We Can Stop Cervical Cancer. Linda, welcome to the New Books Network.
- [00:23]
A
Thank you. I'm delighted to be here.
- [00:25]
B
We're delighted to have you on our podcast. I was wondering if you could start us off by telling our listeners something about yourself.
- [00:31]
A
Well, I'm an OB GYN. I have been caring for women for over 30 years, based primarily in Seattle at the largest public hospital in the Pacific Northwest of the United States, Harperview Hospital. But I also have been working on global health policy around cervical cancer and HPV vaccine for over 15 years, internationally and nationally. And I continue to see patients. And then I, after watching so many people with cervical cancer, which is a preventable cancer, I finally decided, you know, I'm going to write a book.
- [01:07]
B
I mean, it's one of the things I found very enjoyable about your book is how you talk about the science in a very accessible way, but you also bring into it your personal experiences and show how they inform your. Your understanding and your presentation of the subject for us as readers. I was wondering if you could start perhaps about explaining something about what exactly you know, is. You know, why is cervical cancer the issue it is. And what are the effects of cervical cancer even for people who, who never are diagnosed with it themselves?
- [01:46]
A
Well, cervical cancer is what we call a preventable cancer. And if you think about it, preventable and cancer, those are two words that don't go together always. And so it's a fairly remarkable opportunity that we have. It is caused by a virus, human papillomavirus, that is a very common virus and most of the time doesn't do any harm to individuals. But if it persists, it can cause some changes that lead to pre cancer changes and eventually to cancer. And almost all of cervical cancer is caused by certain types of this human papillomavirus. And so as cervical cancer progresses, the good news is it takes a while. It goes through the infection with HPV phase, then it goes to the pre cancer phase, then it goes to the early cancer phase and then the advanced cancer phase. And all of those can have interventions for them. And so that timeline can be anywhere from five to 20 years. So we have a lot of opportunity to intervene in that timeline and make a difference and try to get rid of either the virus or the pre Cancer cells or the early cancer so that the individual with cervical cancer can go on to have, you know, a full life.
- [03:07]
B
So you describe this as a treatable cancer and that, you know, is, as you know, as you mention, is something that you don't often hear associated with the words or preventable cancer. You don't associate with that. So then what exactly what sort of damage does cervical cancer do to our society? How many people come down with it every year? How, you know, how much do we spend in having to treat what is a preventable cancer? And how does that compare with the cost that we might spend in terms of preventing it through the prevention measures that you described?
- [03:46]
A
Yeah, thank you for those questions because those are the bedrock of how you decide how you're going to spend medical funding and public health funding. Cervical cancer is a very, is very advantageous to society to prevent money, to spend money to prevent cervical cancer. Of course, when you're talking about the individual, it wreaks havoc on the individual. To treat cervical cancer almost always involves either taking out the uterus, are using radiation which confers the person infertile for the rest of their lives. And the average age to contract cervical cancer is between 35 to 50. So many individuals will not have finished their childbearing. It also can have terrible side effects of radiation damage. It can damage the vaginal tract in a way that makes normal sexual relationships very challenging for the rest of one's life. And so the individual cost and the family cost is, is really substantial. The societal cost is also huge. You know, we spend several billion dollars a year treating this preventable cancer and we're lucky we have treatment. Most of the world doesn't. And one of the unique things about cervical cancer is that 90% of the disease burden is actually in low resource settings where they really don't have prevention mechanisms or treatment mechanisms. So getting cervical cancer is a death sentence. When women die, they have children they leave behind, they have families they leave behind, they're the care providers of their parents often. And the societal impact is massive.
- [05:27]
B
I was wondering if you could perhaps elaborate a bit on some of the science of cervical cancer you described, because you discuss it in some detail in your book. You've already briefly covered the, you know, the fact, you know, it's from the human pamplonavirus that it's something that we can treat. How does one contract this virus and what are the other ways that, that, that we oftentimes imagine? And as you mentioned, you, you talked about removal of the uterus as, as, as One of the ways which is treated. What are some of the other ways in which it's treated? And, and what is the. And. And it was already. Felso could elaborate upon the, the impact of HIV infection upon the behavior of cervical cancer. Because you describe it's not simply a matter of a cancer that it's more complex than that.
- [06:18]
A
Right? Yeah. So let me start with those. I think that the human papillomavirus is extremely common virus that's sexually transmitted. By the time people have had three sexual partners, over 50% will have human papillomavirus. And 80% of adults at some point in their lives will have a human papillomavirus infection. So it is essentially a marker of sexual activity. And the good news about it is that most of the time these infections resolve on their own. For women in particular, the virus comes in, it lives right under the lining of the cervix, doesn't cause any symptoms. You don't know you have it until you get screened. And then you might have some tests that detect that human papillomavirus or you might have some pre cancer changes. And that's when you know that it's, you know, causing mischief. As I said, most human papillomaviruses resolve, but the ones that do not, there are certain types of human papillomavirus that are more likely to cause these pre cancer changes. There's 12 of those types and we call them the oncogenic or the cancer causing human papilloma virus types. And so most of the screening that we do right now for cervical pre cancer and human papillomavirus really targets those 12 high risk types to make sure that they are not the ones that are persisting and present at the level of the cervix.
- [07:52]
B
So you, so we have this challenge created by this virus which people are, as you just described, very likely to be exposed to with just a minimum of sexual activity activity. How does, and that's in that sense, growing up as I did, when I did, that's something that I also associate with hiv. And one of the things I was fascinated by was that interaction that you described between HIV and cervical cancer. How does HIV impact coming down with HPV and the development of cervical cancer?
- [08:34]
A
Yeah, thank you for that question because I think it's a really important relationship that is actually one of the biggest battles we have right now working with cervical cancer in certain parts of the world. HIV makes it much harder for the body to clear the HPV infection. So you are more likely to end up with persistent hpv. And it's really when the virus persists that it can do its mischief and cause the pre cancer to develop. And the cancer. So we actually know that women who are HIV positive have six times the rate of cervical cancer, which is a massive increase in cervical cancer. And that the cancer strikes at an early age and is more aggressive, it becomes a higher stage more quickly, and it doesn't respond as well to the pre cancer treatments that we normally use. And so the combination of HIV and HPV are, you know, they're very bad company for each other. And it's become more and more of a problem as people have their HIV treated, they're living longer from hiv, but then something like HPV that's persisting in the cervix can actually lead to more deaths. And so the as women are living longer from hiv, we're actually seeing more women dying from cervical cancer.
- [10:03]
B
Now you focus in your book upon the preventability of hpv. At what point should people be getting that intervention? At what point should they be receiving the treatment they need so as to prevent ever coming down with cervical cancer?
- [10:23]
A
Yeah, well, we actually have several opportunities to make a big difference for individuals. The first, and I think the, the bedrock opportunity is the use of the HPV vaccine. And that is typically given between the ages of 9 to 14 because you want to give it before an individual has been exposed to hpv. And also because the immune system is more robust, you get a better response to the vaccine when you give it younger, so you actually have to use fewer doses. And so if you take the HPV vaccine from between the ages of 9 to 13, then depending on the type of vaccine used, you prevent between 70 to 90% of cervical cancer from the get go just from having that vaccine on board. Not only does it prevent cervical cancer, it prevents a lot of other HPV associated cancers too, which include vaginal, vulvar, anal, throat cancers. And so the fact that we have this tool, this HPV vaccine is just amazing in the world of cancer prevention. It's mind boggling to me how good this vaccine is working actually. Then the second opportunity we have is if the person is infected with HPV and develops pre cancer, can we pick up that pre cancer and treat it? That is the whole idea behind Pap smears that have been a very successful intervention in the countries that have been able to use them. Now we also use screening for HPV DN and picking up Pap smears and HPV DNA are, you know, abnormalities with Pap smears and HPV DNA are another way that we can intervene and change the disease course. And then the third is one that also involves someone being able to be screened, which is if you pick up early cancer, cervical cancer is quite curable if it's detected at an early age. Again, that cure comes with a high price, and I prefer no one ever get to that stage. But if it is present, it can be cured, and that is also really good news. So we actually have three different tries for changing the course of cervical cancer. You did ask about the type of treatment that's used. It really depends on how advanced the cancer is. If the cancer is just confined to the cervix and hasn't really spread beyond, then surgery and lymph node dissection can often be a useful tool to lead to a cure. Sometimes you also need to do radiation of the abdomen or in the vagina. And if the tumor is spread beyond the cervix, then typically surgery is not the first course, but it's really radiation and additional chemotherapy is used. So it can be treated in a lot of different ways. But again, those treatments all come with a cost to the woman and are sometimes life altering for the rest of her life.
- [13:30]
B
And it kind of gets back that old adage about how an ounce of prevention is, is worth a pound of cure. I mean, we're talking about a cancer that is preventable rather than just merely being treatable.
- [13:42]
A
And I think that's such a great point. And for instance, the World Health Organization has really launched this global initiative to eliminate cervical cancer because it's a huge public health problem globally and it is preventable. And they did some cost analysis in 2018-2020. They looked at the idea of for every dollar spent on screening, you get $3.20 back to the economy based on keeping women in the workforce if they don't develop cervical cancer. But if you also consider the, the benefits of women to the society, from their volunteer work, from their caring for elderlies, from their community organization work, from all the other things that women do to make society work. Every dollar spent on cervical cancer screening and prevention leads to $26 coming back to the economy. So a 26 to 1 ratio on money spent to benefits gained is immense in the world of public health interventions.
- [14:52]
B
So we have all these, we have a means of prevention, we have the benefits of, you know, of early screening that are economically demonstrable. So what are the issues that are making cervical cancer so difficult to stop?
- [15:09]
A
Yeah, isn't that a good question? There are many obstacles. I can start with the vaccine. We've seen this in our country. It's been highly politicized. Hpv, because it's a sexually transmitted infection, carries a lot of stigma. And there, especially when the vaccine first rolled out in the United States, was a huge pushback from their religious right, that somehow if you gave this vaccine, it would mean that your daughters were going to be promiscuous. Globally, we've seen the same thing. When they rolled out this vaccine in Kenya, certain group of Catholic male doctors spoke out against the vaccine and it was quite harmful to the vaccine campaign. And so I think every country has had to deal with this in their own way. There's also, of course, been a lot of rumors about the vaccine, myths about side effects it can cause and so forth. And I would just say, of course I'm a vaccine advocate. But this vaccine has been studied extensively. It's been in use now for 20 years and all over the world. In any place where it's been studied, there hasn't been an association with long term or serious side effects where there is this massive cancer benefit. So to me, it's a no brainer to use the vaccine. So stigma and politicization has been one challenge. Another challenge has been global supply. Until recently, the vaccine was mostly made by one or two manufacturers. And especially right before COVID and during COVID there was a real challenge in getting enough global supply. So many of the lower resource settings where they don't pay the full market price for the vaccine had a lot more trouble getting access to the vaccine. And the price of the vaccine is still an issue for many, many countries in the world. You know, some of these countries have their whole health budget per year is $100 per person. So if you have a vaccine that costs even $5, you know, that's, that's a significant chunk of that budget. So the price and the access to the, those have all been problems. And then another challenge is this vaccine is given to pre adolescents. You know, we don't give that many vaccines to pre adolescents. Especially globally, we give a lot to infants. There's programs set up for toddlers, but there's not necessarily vaccine programs set up for this age group. So that's been an infrastructure that's had to be created and it's taken a while. We're getting a lot better at it, but it wasn't an easy go when it first started.
- [17:55]
B
So how is it that we can address these problems? How is it that we can, you know, let's Start with the, the stigma. I mean that, that's something that I, I, I, I again, you know, growing up and I did, it reminds me of, of in the 1980s when a lot of people were very dismissive of, of the need to fight HIV because again, it was seen as sexually transmitted. So therefore it was, it was sort of, and of course, you know, because of certain populations that it, you know, wasn't a big deal. It was kind of dismissible. How is it we address that stigma in both within our own country and globally?
- [18:29]
A
You know, I think one of the most powerful ways to unearth stigma is to talk about it and to provide accurate information. I mean, I think if people really understood just how common HPV was and that 8 out of 10 adults are going to have an infection at some point, it's a little harder to stigmatize it. And I think the other thing to recognize is this is a cancer. Cervical cancer strikes only women. Women are not always the most valued in cultures. They're not always viewed as the best health investment, even though data would show that they should be given what they return to the society. And so there is some, you know, long standing patriarchal attitudes about the value of women that are part of this challenge that have to be overcome. But I think talking and information are some of the best tools we have. And another is story. And that's why I wrote this book. Largely why I wrote this book is the power of stories. We all know that, you know, numbers and data don't always change policy. But if you are wanting to really help motivate people and change minds, tell them stories, tell them stories about people that they, they can relate to, that they can see themselves in. And then all of a sudden this disease is not over there. This disease is something that can strike me or someone I love or my sister. And so I really think that we use the power of story also to overcome stigma.
- [20:03]
B
I'm thinking about how if you do that, then that also helps with the, some of the issues you identified with prioritization that, how it becomes a lot more, more people are likely to devote, you know, regrettably scarce health resources, health dollars or health monies to the, the, the treatment and prevention of this disease.
- [20:29]
A
Yeah, I really hope that that is, you know, that's really one of the reasons why I wanted to, to write this book and is just to elevate the stories and to elevate the idea that, you know, these women matter and when we lose them in our culture, it really matters. I mean, we see the Generational poverty that happens when you take a maternal unit out, no matter what country you're in. You have kids that are less likely to go complete their education. They get married sooner, they have, they get less immunizations, and they go to the doctor less often. And the generational poverty and impact of losing a woman to a preventable cancer is really impacting our society in a way that we often don't see or articulate.
- [21:14]
B
And that's something else that stood out for me about your book is how it seems that so much of what you're addressing it about cervical cancer is a microcosm of the larger challenges we face with women's health more generally, both in the United States and in the world, about the degree to which it's seen as a priority, the degree to which we devote the resources to it, and the appreciation, or lack thereof, of the benefits of doing so.
- [21:45]
A
Yeah, I'm an obstetrician, gynecologist. I've dedicated my life to caring for women. I, of course, feel incredibly passionate about the value that we offer to women. And it is really hard right now to watch priorities shifting and to see that the changes that are being made in the name of reproductive health or other values, in fact, are really having impact. Women have less access to gynecologists for their fibroids or for all other reasons. And the, I think that the value of women to society and the amount we invest in them and their health is something that we should be talking about more because again, it's half the population, and it's, frankly, it's the population that does a lot of the work to keep societies going.
- [22:41]
B
And that's one of the things I, I found most valuable about your book is how you demonstrate the exact practice you, you described just a moment ago, which was how you show you don't just talk about in terms of these broad social terms, you connect it to those stories. You, you, you draw upon the experiences of individual women. And it helps to, to make these points clear about the, the benefit of such troops, the values of treatments, and how they really can change so many lives for the better.
- [23:08]
A
Well, I appreciate that and I, you know, I really tried to write this book with an eye toward elevating the voices of the individuals who were so gracious to give me their stories. There is stories from six continents of women from all means of life and who have faced all kinds of challenges with their cervical cancer treatment. And then in their lives after treatment, some family members who shared their lives of loved ones who didn't make it. And I think the message over and over again is losing these people or having them suffer the way they do with a cancer that's preventable is something that as a society, we can really move to do something about.
- [23:51]
B
Well, we appreciate the time you've taken to speak with us, but before we go, could you tell us what you're working on now?
- [23:56]
A
Well, I'm in between projects and I'm still a practicing obstetrician, gynecologist, so I see patients every week. And I am also really moving more toward into advocacy for cervical cancer. I'm hoping as this book comes out and it gets read more, I have more of a chance to work with different organizations about that and really feel the passion about enacting policies and also using STORY to help move more toward eliminating this preventable cancer.
- [24:28]
B
It sounds like incredibly noble work, and I wish you the best with it.
- [24:31]
A
It. Oh, thank you so much for this opportunity. I really appreciate it.
- [24:35]
B
You're very welcome. Dr. Eckler, thank you very much for taking some time out of your schedule to speak with us. I hope you have a wonderful day.
- [24:40]
A
Thank you so much.