Breaking Barriers to Earlier Cervical Cancer Detection in Vulnerable Populations

Self-possessed and ambitious from a young age, Associate Research Scientist Lauren Johnson, PhD, believes she didn’t choose nursing; it chose her.

Now, she can’t imagine any other career for herself, having received her bachelor’s degree in nursing in 2014, followed by her PhD in 2017. Despite originally being a premed student, Johnson realized, through shadowing experiences, being a doctor wasn’t what she wanted as a career—that it lacked a core holistic care component—and transferred to her school’s nursing program. Johnson recognized that nurse-led, patient-centered care treated patients as people first: respecting and reflecting their dignity; staying closer to their besides; and being more directly involved in their care and comfort. Her research interests in cervical cancer epidemiology and screening techniques, inspired by her work as a registered nurse (RN)—and the memory of her sister who died of ovarian cancer—brought her to Botswana and South Africa and to underserved patient populations. Johnson looks forward to discovering ways to better detect cervical cancer early in limited resource settings, as it remains the deadliest form of cancer for women in many low- and middle- income countries.

What made you want to become a nurse?

I entered college as a premedical student and spent the first two years completing the required coursework. However, through shadowing and mentoring experiences, I learned being a doctor wasn’t what I had imagined. I was interested in more direct care and wanted to be closer to the bedside, so I transferred into my college’s nursing program. 

Although my family was very supportive of my decision, I initially felt unsettled with the transfer because of others’ perception that I was giving up on medical school. Despite my ambivalence, the holistic approach to patient care distinguished nursing education from medical training and solidified my decision. I have been an RN for four years now and regard my career change as one of the best decisions of my life. That’s why I always say that I didn’t choose nursing; it chose me.

Why did you pursue a PhD in nursing and a research career in this field?

My purpose was to obtain the necessary knowledge base to address disparities in cancer care. From my perspective, research is a tool to help advocate on behalf of vulnerable populations and increase access to evidenced-based, patient-centered care, which everyone deserves.    

While I was an undergraduate, a new initiative—anticipating a shortage of PhD-prepared nursing faculty—was started to streamline the entry of high-achieving undergraduate students into PhD nursing programs. Students completed their undergraduate degree and then began their nursing PhD coursework. At the time, I was conducting an undergraduate research project looking at maternal mortality in Ghana. I enjoyed the experience and was enthusiastic about exploring nursing research as a potential career. As a PhD student, I focused my research on using implementation strategies to improve cervical cancer screening in Botswana.

I came to Columbia University to pursue my postdoctoral training in cancer epidemiology, first at the Mailman School of Public Health as a T32 Postdoctoral Fellow in Cancer Epidemiology. It was a perfect fit, given that my postdoctoral mentor, Louise Kuhn, PhD, a professor there, was conducting cervical cancer research in South Africa. During my two years of training, I was able to expand my expertise in cervical cancer prevention from an epidemiological perspective. 

While you were a PhD student, you were an inpatient clinical nurse, providing care to antepartum, postpartum, and gynecologic oncology patients. What did you learn from your work, and how did it contribute to your research interests? 

After completing my undergraduate studies, I participated in the program’s optional clinical immersion fellowship. We were given the opportunity to practice as an RN for six months before starting the PhD program. I chose to conduct my fellowship on an inpatient women’s health unit at a hospital in Philadelphia, where I cared for high-risk antepartum and postpartum women, as well as women dealing with gynecologic cancers. Working as an RN was invaluable for my research career. I gained a deeper understanding of the clinical experiences of the patient population that I study. I also gained insight into the workforce realities of nursing and the inner workings of the health care system. I continued practicing through my pre- and postdoctoral training and am still practicing as an RN on a per diem basis in the same unit.

Up until now, my research training has focused on global disparities in gynecologic oncology, particularly for cervical cancer. Through my new role at Columbia Nursing as an Associate Research Scientist, I am developing an independent program of research that will focus more on domestic disparities in gynecologic oncology care. My global experiences, together with my clinical work, has underscored for me that certain marginalized U.S. populations experience challenges in care that mimic those in limited resource settings. I have taken care of many patients that were not diagnosed until their diseases had reached advanced stages when curative treatment options are limited. Despite seeking medical attention for symptoms, these late diagnoses and treatment delays are often due to health system barriers.

Cancer has also become a personal passion of mine. I lost my sister in 2018 after a courageous battle with ovarian cancer. Sadly, she was misdiagnosed for two years and suffered a great deal before she died. I am pursuing this work to honor her memory.

Cervical cancer prevention in Botswana figures prominently in your current research agenda, doctoral dissertation, and past and in-progress scholarship. Can you walk us through some of your key findings and why you selected Botswana?

My graduate work primarily focused on cervical cancer, which exhibits a striking global disparity in disease burden. High-income countries have shown significant reductions in incidence and mortality since the introduction of Pap testing. Yet, cervical cancer remains the deadliest cancer for women in many low- and middle- income countries. My dissertation sought to better understand how to support implementation of screening programs with limited resources, using Botswana as a case study.

I worked closely with a faculty member at the University of Botswana, which was instrumental in implementing and scaling up cervical cancer screening there, using an innovative method called visual inspection with acetic acid (VIA). VIA is a less expensive, simpler screening method compared with the Pap smear. Through my dissertation, I showed that implementation strategies are effective in supporting nurses’ competence and guideline adherence in conducting VIA.

My postdoctoral work has expanded my expertise in cervical cancer prevention in limited resource settings. Under the mentorship of my advisor, I worked closely with a global partnership between ICAP at Mailman and the University of Cape Town. This research focused on another important aspect of cervical cancer screening: human papillomavirus (HPV). HPV is regarded as the primary cause of cervical cancer, and screening initiatives are increasingly focusing on including HPV DNA testing in their programs. We looked at the feasibility and acceptability of point-of-care HPV DNA testing, which can be conducted in the clinical setting. I analyzed how we could improve specificity (i.e., reduce false negatives) of a particular point-of-care device via restricting the HPV genotypes tested.

You are currently engaged internationally in oncology nursing capacity building in Nigeria. Can you elaborate on these two projects?

As an Associate Research Scientist, I am jointly appointed at Columbia Nursing and Memorial Sloan Kettering Cancer Center (MSKCC), serving as part of MSKCC’s Global Cancer Disparities Initiative. This initiative predominantly focuses on improving colorectal and breast cancer care in Nigeria. In April, I traveled to Nigeria to participate in the 6th Annual African Research Oncology Group conference at Obafemi Awolowo University (OAU). It was a truly interdisciplinary effort between nurses, surgeons, radiologists, pathologists, and pharmacists. In addition to MSKCC co-hosting the conference, we held educational sessions to teach chemotherapy safe handling and administration. I hope to continue my involvement and assist in making OAU an exemplar oncology center in limited resource environments.