Must not have been a squamous histology.
I wonder if it was a cut-through hysterectomy.
Why don’t people get Paps?
My inner dialogue emerged amid the monotonous job of chart review on a large retrospective study of cervical cancer outcomes. I could see the importance of prognostic factors for the poor outcomes that we were studying in the charts I was reviewing. But something about you made me pause.
As I opened your chart, my first observation was your last name: Cardinal.
Then your year of birth: 1986.
I then read the referral letter.
“Presented with vaginal bleeding after sexual assault. On examination, mass seen on the cervix.”
Horrific. Sexual assault as the instigating factor for presentation to a health care facility, and then the discovery of a cervical cancer. My mind quickly did the math to when you must have acquired the human papillomavirus infection that led to your cancer, and I had to wonder what the circumstances were.
On to the pathology — what type of tumour was it? Were the margins positive? Did you get adjuvant treatment? Shoot, maybe it was laparoscopic …
Squamous histology. No lymphovascular space invasion. Tumour size 1.3 cm. Negative margins. Not a minimally invasive approach. Adequate lymph node sampling.
Final stage: 1B1 squamous cell carcinoma, with no risk factors to suggest need for adjuvant treatment.
I then searched through your chart for the date of recurrence. We have so much to learn about tumour biology: Why did this tumour behave so badly despite the favourable pathologic features?
… But there was no recurrence. Just a series of scanned diagnostic imaging reports. Computed tomography scan of the chest, abdomen, pelvis. CT brain, clinical history: “trauma.”
Another few months pass and more diagnostic imaging reports — clinical history: “blunt trauma.”
Then your chart ended. No recurrence. Only trauma upon trauma upon trauma, ending with the heading “Deceased.”
I sat for a moment, taking in your story. We were the same age and sex and I couldn’t help but place myself in your position. Yet somehow I could not. Acutely aware of my privilege as a White woman, so much separating us. A young Indigenous woman with cervical cancer. You presented with a trauma. We found your cancer; we cured your cancer; but your chart did not end there. You presented again with a trauma, and again with a trauma. What else did we not see?
In oncology, we are guided by the prognostic features of a patient and their tumour, which informs evidence-based recommendations with the aim of curing cancer, and we did that. But it was not enough. We failed you because we did not see all of you. We failed to see the complexity of your circumstance, and ultimately you lost your life. I cannot help but wonder what needed to happen for your chart not to end here. The greatest tragedy is that your situation is not unique. How many other people are we not seeing?
Would things have been different if you were a White woman? Would we have been more outraged at the violence? Would your story have ended up on the news? Would we have recognized your situation and intervened?
I often tell patients that “cancer does not discriminate,” but this is actually not true. Indigenous women have a higher incidence of cervical cancer,1 and an increased risk of health inequity.2 And in this lies a reflection of our institutional and societal discrimination.
Why did I pause this time? What was it about you? Maybe it was not about you. Maybe it was the circumstances of this encounter; with all the context stripped away, I could for once see the trajectory from diagnosis to treatment to cure and to death for what it was: a reflection of our … of my failure. We cured your cancer, but this was not what took your life.
Footnotes
This article has been peer reviewed.
This article is based on a chart review of almost 500 patients spanning 10 years. All information that could identify the individual portrayed here has been changed to protect her identity.
This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY-NC-ND 4.0) licence, which permits use, distribution and reproduction in any medium, provided that the original publication is properly cited, the use is noncommercial (i.e., research or educational use), and no modifications or adaptations are made. See: https://creativecommons.org/licenses/by-nc-nd/4.0/