On October 12th, 2020, I underwent a LEEP procedure to remove the distal portion of my cervix. In the wake of COVID-19, with PPE and willing staff in short supply to complete Pap smears in clinic, a colleague and I were trialing self-swab HPV testing – a technique pioneered in countries like Australia that is likely to become the eventual standard of care for cervical cancer screening. Since my last Pap was somewhat longer ago than the guidelines suggest, I volunteered to try out this protocol on myself. We achieved proof-of-concept (right materials, correct order sets) when my self-swab came back positive for a cancer-causing strain of the HPV virus.
A Pap and colposcopy turned back contradictory results – the biopsies were normal, but the Pap read out an ASC-H classification: atypical squamous cells, cannot rule-out high-grade squamous intraepithelial lesion. With this discordant data in hand, the gynecologist offered to recheck in a year, or to go ahead and remove the end of the cervix via electrocautery under local anesthetic in the office.
I weighed risks and I weighed benefits. I am 45 years old, and my age group alone is a risk for the progression of squamous cell abnormalities of the cervix. A close relative underwent a LEEP almost two decades ago when she was pregnant with her fourth child – the lesion had advanced so far that her providers deemed the risk of losing the pregnancy justifiable to prevent progression to cervical cancer. I know that cervical carcinoma is almost universally caused by the HPV virus, and I know that the tendency for HPV to persist and transform normal tissue malignant runs loosely in families. I know that my close relative held that pregnancy and two more to term after the LEEP; I also know that a pregnancy at my age with a shortened cervix would be an unacceptably high-risk experience, such that a LEEP would effectively end my reproductive years. I weighed the best advice I could find and the most relevant literature I could identify but still felt ambiguous on how to proceed.
On October 12th, 2020, the U.S. Senate began confirmation hearings on Supreme Court nominee Amy Coney Barrett, whose nomination falls on a platform of removing the Affordable Care Act’s protections, including injunctions on excluding coverage for pre-existing conditions. On that same date, I put my feet up in stirrups, felt the yank of the gynecologist pulling out my IUD, the burning pinch of a paracervical block, a tugging pain from the electrocautery loop, and finally the reverse pressure of a new IUD being inserted. In the end, I made this decision not on the preponderance of scientific evidence, but on the weight of knowing that when that year mark came around, without the ACA protections on pre-existing conditions, I would be uninsurable and possibly facing a precancerous condition with no coverage for a LEEP, an IUD removal and reinsertion, or any further interventions that might be necessary by then.
No person should ever be forced to make a medical decision on the vagaries of congressional hearings or the winds of political whim. But as a family medicine physician with ten years’ primary care experience, that is exactly what I was forced to do: Weigh best evidence and best practices, and come to an invasive, uncomfortable conclusion driven by the fight over the future of the Supreme Court.
America is the last standing developed country that fails to ensure universal health care to its people; indeed, most developing countries have patched together some kind of solution to this challenge. Whether this arrives as incremental reform of the ACA or revolutionary strides like Medicare for all, universal health care is core to America’s security and its future. Without it, we risk becoming a nation that not only refuses to take care of its own, but fades into a feudal state of medical practice based on untenable risk and fear rather than the evidence, guidelines, and protocols that should define modern health care.
The author is an anonymous physician.
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