Vietnamese Women Face High Rates of Cervical Cancer




Audrey Magazine, News Feature, Anonymous, Posted: Feb 20, 2008

Vietnamese American women are up to five times more likely to get cervical cancer than any other American ethnic group. While a new vaccine offers hope, will it ultimately make a difference?

I sat in the doctor’s office playing with my hands; they were clammy. My ponytail tickled the small of my back, and in the sterile air the lining of my open dressing gown made my hair stand on end. She asked me to lie back, and that’s when I realized that while my experience as a reporter had not made me as personable a conversationalist as I had thought, it had turned me into someone who was curious about everything. I wanted to take a gander at that dwarf of a toilet brush she was brandishing. I wanted to cross my legs and sit at a table with her — to talk about anything.

Lying down just made me paranoid. So I counted the colored tiles on the ceiling. Green, white, green, white, green. There was greenery in Hawaii. I wished I was in Hawaii. Later I learned that that brush was actually called an Aylesbury Spatula — considered an effective tool in getting adequate samples for cervical cell screening during Pap smears. I also learned that I was a perfectly healthy specimen.

Until this time next year, I could breathe easy. But I realized that being a Vietnamese American woman, the odds weren’t in my favor from the get-go. Studies conducted in the United States consistently show that cervical cancer strikes more women of Vietnamese descent than any other ethnic population, surpassing the rate of Caucasian women five times over. But a recent breakthrough may change that statistic forever. In June of 2006, the first cancer vaccine ever was approved by the U.S. Food and Drug Administration, licensed for females between the ages of 9 and 26. And on August 28, 2006, clinical immunologist Ian Frazer got to experience something that generations of medical researchers had only dreamed of ever experiencing in their dedicated careers.

Dr. Frazer administered the first cervical cancer vaccine. “I remember it happened in Sydney in the middle of 2006, on the first day that the vaccine was made available in Australia,” says Frazer, the co-creator of Gardasil, the commercial name of the vaccine. “I gave it to a young woman who had had trouble with HPV [human papilloma virus] infection, and who wished to be the first volunteer to receive the vaccine. Clearly, the vaccine is designed to be a prophylactic, not therapeutic, but she reckoned she might still be at risk of a new HPV type. “I also, on the same day, gave a dose of the vaccine in Queensland to the daughter of one of my colleagues in a laboratory. She was a 14-year-old child at the time. She was the first schoolchild ever to receive the vaccine,” adds Frazer.

Though health and environmental factors may play small roles in putting women at risk for developing cervical cancer, the main catalyst seems to be the passing along of human papilloma virus through sexual intercourse — meaning that females who are treated with the vaccine before they become sexually active stand to receive the most benefit from it.

More than 60 types of human papilloma virus are known to exist and, according to Frazer, about 20 of those are associated with cervical cancer. Of the 60, about 15 are classified as high-risk types, including HPV 16 and HPV 18. Cumulatively, these two strands alone are responsible for 70 percent of cases of cervical cancer, though even low-risk strands can cause cancer on isolated occasions.

Though HPV infection is the main cause of cervical cancer, many women and men will be infected several times in their lifetime with little to no greater consequence. In most cases, HPV infections clear up with a boost from the body’s immune system. It is only in cases where people suffer from repeated and particularly aggressive HPV infections that they may be in immediate danger. “It [Gardasil] works because it induces what are called neutralizing antibodies to prevent infection,” says Frazer. Essentially, Gardasil contains virus-like particles (VLP) assembled from the proteins of HPVs 6, 11, 16 and 18. But because these new VLPs are not identical to the authentic strands and do not carry viral DNA, they do not cause cancer. They merely serve the purpose of revving up the body’s response against those HPV types, therefore protecting against infection. “The vaccine is 100 percent effective against HPV types 16 and 18,” says Frazer.

While the vaccine offers hope to millions of women worldwide, it came too late to help Le Thi Nguyet Yen’s mother almost three decades ago. By the time Le came of age in war-torn Vietnam in 1980, whatever precious security the middle child of seven had left was drastically shaken. Her uncle had fled to America, followed thereafter by her three older brothers. Her father became one of the thousands of political prisoners in the Communist re-education camps. And here she was, 20 years old and left with two elderly grandparents, three sisters (the youngest of whom was only 6), and a mother whose appearance began to deteriorate drastically day to day.

“She didn’t look good,” remembers Le. “She looked sick. And I would be brave and ask her if she was sick, but she would say, ‘No, I’m fine.’” The silence went on for a long time. It didn’t seem like a big deal because the Vietnamese culture is a very contemplative one — silent some would say — to an absolute fault. But one day, Le’s mother pulled her and her siblings aside. She told them she was leaving them for a while. She said, “The doctor says I have cancer in my vagina.” “She said it wasn’t serious, and so I didn’t know what to think,” says Le. “My mom was very sad, but she didn’t want to scare us by telling us she was going to die.” At that time, cervical cancer, it seemed, was basically a death sentence that not even medical experts in Vietnam could deduce.

What was worse, the hospital “treatments” were dated and were more likely to cause distress to patients than to help them. It meant being away from your family when you needed them most, but not for any reasons that would lead you to believe that you would be coming home to them anytime soon. While Le’s mother was interred in Nguyen Van Hoc Hospital in Saigon, an opportunity for Le to flee the country arose. But her mother was still hospitalized and her father was still in the Communist camps. “They told him he couldn’t leave, especially since he had been a captain,” she says.

So Le discussed it with her mother. “I told her, ‘I know you are sick and that you need me. But I hope you understand. I have to take my chance. Because if not, you know ….’” Her mother knew. “My life is over,” her mother told her. “You go take your chance.” During her last hours in Vietnam, Le decided to break hospital regulations and spend the night with her mother. “The nurse told me that cancer was unsafe for us,” says Le. “They thought it was contagious and we could catch it.” So Le hid until after hours and managed to spend one last night with her dying mother.

In May 1980, Le became one of the hundreds of thousands of Vietnamese boat people drifting at sea. She arrived in Singapore in June, and joined her brothers and uncle in Santa Ana, Calif., the following October. They received a telegram shortly before Christmas. Le’s mother had passed away from cervical cancer on December 20, 1980, at the age of 43.

Today, Le is a 47-year-old beautician in Fountain Valley, Calif., with her own family, including a daughter. “Now, I talk to my own daughter,” says Le. “We talk about her boyfriend and about my life. But that’s not how it was in Vietnam.” Perhaps Le would be surprised to find out how little things have changed. Even an ocean and a generation apart, Vietnamese American and other Asian American families seem to find it as hard as ever to openly converse about the realities of cervical cancer.

In 2003, Dr. Mai Nhung Le and Dr. Grace Yoo of San Francisco State University conducted a study of 400 college-aged women of Vietnamese, Korean and Filipina descent and their respective knowledge about cervical cancer and receptiveness to preventative care in comparison to each other and to their Caucasian counterparts. The study (funded by the Asian American Network for Cancer Awareness, Research, and Training’s Special Populations Initiative under the National Cancer Institute) found that, even though these young women were acculturated into American society and were attending American universities, their level of practical knowledge about cervical cancer was drastically lower than that of their Caucasian peers. Consequently, they were also less likely to seek preventative care.

The lack of communication and knowledge today about cervical cancer is more tragic considering that, even before the creation of Gardasil, cervical cancer has always been a very preventable disease, says Dr. Le, an assistant professor of Asian American studies at San Francisco State University. “It can be treated relatively quickly early on.” But even if Asian American women were aware that preventative care can virtually diminish their chances of suffering through cervical cancer — a terrifying disease where bone fractures, swollen legs, heavy vaginal bleeding, and leaking of urine and feces from the vagina are common symptoms — there is still a whole variety of cultural pressures and emotions that Asian women have to deal with before they even are able to pick up the phone and set that first screening appointment.

There are a million things telling them no. “We recruited young women through some universities throughout California, and found out that there was a lot of stigma within the Asian American community toward Pap smears and the issue of cervical cancer,” says Le. “Awareness of HPV is very low, and there is an unwillingness to get Pap smears due to social and cultural reasons. They don’t want parents to see them as sexually active even though they are.”

Cervical cancer is often labeled a sexually transmitted disease because males and females who engage in sexual intercourse at an early age and those who have had many sex partners are at higher risk of getting and transmitting HPV. “If you get breast cancer, it’s not your fault because there are a host of factors,” says Le, but “the main risk factor for cervical cancer is sex. “Sex is such a taboo subject in our [Vietnamese] culture,” Le continues. “People talk about it, they’ve heard of it, but as far as knowing details about it, they don’t want anybody to know or think of them as sexual. Friends and family construe that they might be promiscuous. Plus, parents don’t talk to their children about sexual issues.” However, unknown to many is the fact that HPV, including the high-risk types, can be transmitted in a number of ways, including skin-to-skin contact with infected areas.

Condoms, therefore, do not necessarily prevent transmission. “For those who find out they have abnormalities and don’t go back, things can get much worse,” says Le. “Some get even more scared by letting time pass, and soon get to that point where they have to have a cone biopsy.” In a cone biopsy, a less intensive procedure than the other option of a hysterectomy, a surgeon attempts to remove the cancerous part of a woman’s cervix and preserve her uterus and ovaries (and fertility) at the same time. It is a procedure that is only worth trying if the cancer has not yet spread. Of course, for some, going back may not be an option due to the lack of health care. “Korean American women belong to an ethnicity that has the highest percentage of uninsured in the U.S.,” said Dr. Yoo, an assistant professor of Asian American studies at San Francisco State University. “In a study that I did with a colleague at Cal State Long Beach, we found that 30 percent of Korean Americans were uninsured. Not having health insurance prevents access to preventative cancer screenings.”

While Le and Yoo’s 2003 study also found that Korean American women were less likely to have had a Pap smear than Vietnamese American women, with Filipino American women more likely than both groups to have had a Pap smear, the study also revealed that foreign-born Vietnamese, Filipino and Korean American women were even less likely to have a Pap smear than American-born Vietnamese, Filipino and Korean American women. Indeed, more than 80 percent of cervical cancer cases are estimated to occur in the poorer countries of the world — areas like sub-Saharan Africa, South America, India and China. “We know [the number of women worldwide who suffer from cervical cancer] to be approximately a quarter of a million, but that’s probably an underestimate,” says Frazer. “Perhaps it would be better to say that it is somewhere near half a million. “There seems to be a particular problem in Southeast Asia,” Frazer continues. “I don’t think there’s any particular genetic predisposition to cervical cancer, but women who come to a new country from overseas tend not to take part in the public health measures that are available to help prevent disease — and that, of course, includes screening programs for cervical cancer.”

Frazer goes regularly to Asia because of his collaboration with colleagues in Wenzhou Medical College in the Zhejiang Province of China. Since Gardasil’s co-creator, Dr. Jian Zhou, passed away at the age of 42 in 1999, Frazer has been left alone to carry on the work. For the last five years, he has been traveling throughout Zhou’s native China — to remote places like Chengdu and Xinjiang Provinces — and also to Japan, Thailand and Malaysia to speak to everyone from senior politicians to women’s groups. Frazer reasons that vaccination is the most effective way to deal with cervical cancer in developing areas because treatment options are simply not available and so screening becomes pointless. And part of getting this vaccine to the women who need it most is to make it as affordable as possible. Frazer has worked with the Bill & Melinda Gates Foundation and the World Health Organization’s Expanded Vaccine Initiative in an effort to make Gardasil more accessible on a global scale, though it remains unclear, he says, what the plan will be from here on out.

“Discussions are still going on in that area, but I’m committed absolutely to the concept of promoting the idea of the vaccine becoming available in the developing world,” says Frazer. And while Gardasil is currently being marketed as a cancer vaccine, at $360 for the three-series injections, the price is too steep for many American families. Merck and CSL Limited, the companies involved in making the vaccine, have voiced their interest in working with a fixed rate to make Gardasil more affordable worldwide, and have also suggested that the vaccinations be made mandatory for public school attendance in the U.S. But this has not been without controversy, provoking groups who fear the drug will give young women a fast pass toward promiscuity.

“Clearly it’s a matter of education,” says Frazer. “But the education has to be targeted at explaining what viruses are about, what vaccines are about, and how viruses can cause cancer so that people can understand that a vaccine that can prevent infection can, in due course, reduce their risk of cancer.”