April 2010
Feature Story

Anne Ford

What led Rebecca Kightlinger, DO, to direct the women’s health program for the nonprofit health care organization Remote Area Medical?

“Cancer,” she says, “and people dying of it.”

By people, she means those with no or limited access to health care, such as the impoverished residents of Guyana, a South American nation with few basic medical services. And by cancer, she means a highly preventable kind: cervical. In this setting, the Pap test is a rarely accessible exam, not a routine screening tool. If it were more widely available, says Dr. Kightlinger, assistant professor of obstetrics and gynecology at the University of Virginia Medical Center, Charlottesville, it could help lower what she has found to be an unusually high rate of high-grade dysplasia among Guyana’s indigenous women.

“A lot of people [in the United States] see Pap smears as being menial labor or something that’s low-level science,” she says. “But for our patient population, it is rocket science. It’s absolutely life-saving. It’s unattainable in Guyana.”

Unattainable, that is, except for efforts such as those of RAM, a 25-year-old charitable organization based in Knoxville, Tenn., that relies on volunteer physicians and other medical workers to provide free, badly needed health care services around the world. Founded by Stan Brock, former co-host and associate producer of the television series “Wild Kingdom,” RAM holds frequent clinics in Guyana. It also sends volunteer medical expeditions to people in countries such as the Dominican Republic, Haiti, Honduras, Nepal—and the United States, where it draws thousands of uninsured and underinsured patients. (When RAM offered eight days of free medical, dental, and vision services in Los Angeles last August, an estimated 8,000 people showed up.)

While most of the physicians who volunteer with RAM are clinicians, pathology and cytology services are badly needed as well. “We need people all over the States to process specimens for free,” Dr. Kightlinger says. “Without pathologists who read and report specimens and treat them exactly the way they do those of their own patients and are willing to take another look when we have questions, we simply would not have a program.”

John C. Neff, MD, professor emeritus of pathology at the University of Tennessee Graduate School of Medicine, Knoxville, can testify to that. Four years ago, Dr. Neff traveled to Guyana at Dr. Kightlinger’s request to evaluate the possibility of bringing RAM’s pathology services there, rather than having to bring specimens back to the United States for reading. As it happened, Guyana’s limited supplies of power and clean water, and other difficulties posed by the extremely remote locations RAM serves there, made the notion of an on-site laboratory impossible.

“Instead, we decided that the material would have to be brought back and done here” at the University of Tennessee, Dr. Neff says, “and that’s what we’ve been doing.” Now his laboratory, in partnership with LabCorp, has become one of several in the country that provide pathology services for RAM’s clinics.

“When I first began looking at that material”—Pap tests from Guyana, in this case—“it was kind of unnerving,” Dr. Neff remembers. “We’re not used to seeing that much carcinoma in situ in this country. You could look at a tray of surgical biopsies and see five or six carcinoma in situ or microinvasive cancers in a row. I’d have to get up and take a walk. I’m not used to seeing that kind of thing.”

That higher rate of cervical cancer, of course, makes RAM’s Pap testing efforts in Guyana all the more important. “We are about to publish our findings concerning 2,250 indigenous Guyanese women who were tested by RAM,” Dr. Kightlinger says, “and the prevalence of cervical cancer and high-grade dysplasia among these women is astronomical. I think part of it’s because they have certain risk factors—the older women married young and had 12, 13, 14 babies, so that’s a long time for potential exposure to HPV, and all the injury and repair to the cervix may have something to do with it. Plus they’ve never been screened, and they’ve never had the opportunity to have precancerous lesions treated. They die very difficult deaths in a very harsh environment, and it’s unnecessary.”

The prevalence of HPV in this population is also higher than in the U.S. “We’re not sure exactly why that is, but we are evaluating the prevalence of high-risk HPV infection and determining the HPV genotypes causing disease in this population,” Dr. Kightlinger says. Her group’s report, soon to be published in the American Journal of Obstetrics & Gynecology, will detail all the findings to date.

Even in the United States, where Pap tests are more widely available, the demand for them at RAM clinics is considerable. “We’re going to start seeing more and more and more women who can’t come in for their Paps [to their regular physicians] because their deductible is higher, or they’re uninsured, or they now have a higher co-pay,” Dr. Kightlinger says.

Jacqui Doran is a biomedical scientist conducting HPV research at the Royal Infirmary of Edinburgh, Scotland, who has gone on six RAM expeditions, including two to remote areas of Guyana. Her background as a cytotechnologist has given her the ability to explain cervical disease diagnoses to patients in the field through drawings of cells, the cervix, and the like. She echoes Dr. Kightlinger’s assertion of the importance of volunteer pathologists to RAM’s efforts.

“As RAM takes biological specimens that include liquid-based Pap cytology, cervical and vaginal biopsies, loop electrosurgical excision procedures, and hysterectomies, a whole range of pathology services is required,” Doran explains. “In addition to the reporting of the specimens, they need to be processed first. This is not a trivial amount of work. Laboratory staff would be dealing with samples that often have minimal mandatory data set details, including no date of birth—as our patients often don’t know theirs—and addresses that only read a village’s name. This data does not fit into what many computer systems require and can become a problem.” Any pathology performed for RAM requires a laboratory with the capacity to complete the work with a fairly quick turnaround time, she says, “to help RAM maximize the lives they save.”

One such laboratory is that of the Rochester (NY) General Hospital Department of Pathology, where pathologist Joel L. Shapiro, MD, organized a team of laboratory volunteers to process about 200 Pap tests from one of RAM’s Guyana missions. “We organized a team of volunteers that included several pathologists,” Dr. Shapiro says. “We asked our specimen management technicians to log them in and help with the paperwork and processing. We had enthusiastic support from the cytotechnologists and pathologists in our department.” Coordination was required beforehand, he remembers, such as asking BD to donate SurePath vials and asking ARUP Laboratories to provide a discount on HPV testing, which his laboratory doesn’t perform in-house.

Still, Dr. Shapiro says, it wasn’t an onerous effort. “We had to set up a mechanism to accession the Pap smears and log them into the computer system, and we exchanged e-mails and phone calls with Dr. Kightlinger,” he says. “We bought everyone pizza and finished the work in one weekend. If Dr. Kightlinger sends another 200, then we’ll schedule another weekend and gladly provide our services. I think we all feel that none of us is doing nearly enough to help out with these kinds of problems. If I can do just a little bit, maybe that’ll help somebody, somewhere.”

Pathologists and technologists who feel similarly are encouraged to contact RAM—and, if Dr. Neff’s experience is anything to go by, they will. “I know the pathology community in this country,” he says. “The cytologists and pathologists and laboratorians in this country are generous and will donate their services.”