Dr. Annie Muir

Annie Muir is a 38 year old mother, primary care physician, and cervical cancer survivor in a rural California town. She is dedicated to building trusting relationships with her patients, who are often members of families that she grew up with. She chronicles the history of her life in parallel with the history of anti-HPV-vaccination sentiments. Throughout, she questions how to be the best physician and community member, and what to do when those roles conflict.

By Erin Spillane

The New Kid on the Block: Gardasil

The idea of community has always been important to me. The saying “it takes a village to raise a child” was a common-held fact in my small town of Groveland, California just outside of Yosemite National Park. Grandparents, cousins, neighbors, teachers, and community members were hugely influential role-models for me, often taking on many of the caretaker duties my immediate family could not. Likewise, my family contributed to the wellbeing of our community, by offering to watch the neighbors’ children when their parents worked late or supporting a local business when they knew the owner was struggling. Our humble mountain town worked together so that we could all succeed. Our family’s doctor was a part of this community symbiosis. He was trusted by all and was invested in the full health and happiness of every family. He is what first inspired me to pursue a career in medicine.

I remember vividly the first day I started seeing patients at the Mariposa Clinic, in Groveland. I was grateful to be able to give back to the place that raised me. After spending my years of medical school away from home, I was ready to get in touch with my roots and reconnect with my community. It was 2004 and I was well versed in medical protocols and passed my exams with top scores. However, there was no way I could have been fully prepared for the difficult conversations that are a necessary part of healthcare. While I expected to deliver bad news, a conversation that I did not expect to struggle with was recommending vaccinations to parents.

References

1. CDC Press Releases. (2016, January 1). CDC. https://www.cdc.gov/media/releases/2014/p0424-immunization-program.html

2. Cartmell, K. B., Young-Pierce, J., McGue, S., Alberg, A. J., Luque, J. S., Zubizarreta, M., & Brandt, H. M. (2018). Barriers, facilitators, and potential strategies for increasing HPV vaccination: A statewide assessment to inform action. Papillomavirus research (Amsterdam, Netherlands), 5, 21–31. https://doi.org/10.1016/j.pvr.2017.11.003

3.Araldi, R. P., Sant'Ana, T. A., Módolo, D. G., de Melo, T. C., Spadacci-Morena, D. D., de Cassia Stocco, R., Cerutti, J. M., & de Souza, E. B. (2018). The human papillomavirus (HPV)-related cancer biology: An overview. Biomedicine & pharmacotherapy = Biomedecine & pharmacotherapie, 106, 1537–1556. https://doi.org/10.1016/j.biopha.2018.06.149

4. Gallego, L. S., Dominguez, A., & Parmar, M. (2020). Human Papilloma Virus Vaccine. In StatPearls [Internet]. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK562186/

5. Gardasil Class Action Australia. Facebook Post. Retrieved February 5, 2021, from https://www.facebook.com/GardasilInjuryAustralia/

6.Larson, H. J. (2020). Japan’s HPV vaccine crisis: Act now to avert cervical cancer cases and deaths. The Lancet Public Health, 5(4), e184–e185. https://doi.org/10.1016/S2468-2667(20)30047-5

7. Gallego, L. S., Dominguez, A., & Parmar, M. (2020). Human Papilloma Virus Vaccine. In StatPearls [Internet]. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK562186/

8. Simms, K. T., Hanley, S. J. B., Smith, M. A., Keane, A., & Canfell, K. (2020). Impact of HPV vaccine hesitancy on cervical cancer in Japan: A modelling study. The Lancet Public Health, 5(4), e223–e234. https://doi.org/10.1016/S2468-2667(20)30010-4

Dorell, C., Yankey, D., & Strasser, S. (2011). Parent-Reported Reasons for Nonreceipt of Recommended Adolescent Vaccinations, National Immunization Survey—Teen, 2009. Clinical Pediatrics, 50(12), 1116–1124. https://doi.org/10.1177/0009922811415104

9. Simms, K. T., Hanley, S. J. B., Smith, M. A., Keane, A., & Canfell, K. (2020). Impact of HPV vaccine hesitancy on cervical cancer in Japan: A modelling study. The Lancet Public Health, 5(4), e223–e234. https://doi.org/10.1016/S2468-2667(20)30010-4

10. Dorell, C., Yankey, D., & Strasser, S. (2011). Parent-Reported Reasons for Nonreceipt of Recommended Adolescent Vaccinations, National Immunization Survey—Teen, 2009. Clinical Pediatrics, 50(12), 1116–1124. https://doi.org/10.1177/0009922811415104

11. Ferrer HB, Trotter C, Hickman M, Audrey S. Barriers and facilitators to HPV vaccination of young women in high-income countries: a qualitative systematic review and evidence synthesis. BMC Public Health. 2014 Jul 9;14:700. doi: 10.1186/1471-2458-14-700. PMID: 25004868; PMCID: PMC4100058.

Face to Face with HPV

In 2016, I attended a regular appointment with my local Gynecologist. A week later, the doctor called and told me that my test for HPV had come back positive and that my pap smear had shown abnormal cervical cells. This was a fairly common result, and she told me not to worry. Further testing would need to be done to evaluate what exactly the abnormal cervical cells meant.

Three months of tests and doctor visits later, I was diagnosed with locally advanced cervical cancer, likely as a result of a persistent HPV infection in my cervix. It was a surreal moment for me. As a young woman, I felt as though my life was just beginning and although I had to have conversations about disease and death with my patients, I had never been confronted with life-threatening sickness myself.

I immediately entered treatment and had to stop working. I first underwent surgery to remove the tumor, but because the cancer had advanced beyond what a surgeon could remove, I had to undergo radiation and chemotherapy treatment simultaneously.

Instead of being a resource for my patients, I was at the hands of many other doctors, treatments, and prescriptions. Seemingly overnight, I had become an expert in cervical cancer. At this same time, there were many new studies emerging that were strengthening the causal connection between HPV and cervical cancer, meaning that an HPV infection causes an out-of-control growth of cells in the cervix, which eventually transforms into a tumor.

References

1. Hillard, P. J. A., & Kahn, J. A. (2005). Understanding and preventing human papillomavirus infection during adolescence and young adulthood. Journal of Adolescent Health, 37(6, Supplement), S1–S2.

2. Cervical Cancer Treatment| How Is Cervical Cancer Treated? (n.d.). Retrieved March 14, 2021, from https://www.cancer.org/cancer/cervical-cancer/treating.html

3. Araldi, R. P., Sant'Ana, T. A., Módolo, D. G., de Melo, T. C., Spadacci-Morena, D. D., de Cassia Stocco, R., Cerutti, J. M., & de Souza, E. B. (2018). The human papillomavirus (HPV)-related cancer biology: An overview. Biomedicine & pharmacotherapy = Biomedecine & pharmacotherapie, 106, 1537–1556. https://doi.org/10.1016/j.biopha.2018.06.149

4. Suzuki S, Hosono A. No association between HPV vaccine and reported post-vaccination symptoms in Japanese young women: results of the Nagoya study. Papillomavirus Res. 2018;5:96–103.

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