Famous Patients, Famous Operations, 2002 - Part 6: The Case of the Politician's Wife

Albert B. Lowenfels, MD

Disclosures

December 05, 2002

Introduction

A 30-year-old female who complained of weakness and abdominal pain noted progressive weakness for several months before admission to a hospital, culminating in a fainting episode a few days prior to hospitalization. The week following the fainting episode, she underwent appendectomy. Her recovery was uncomplicated, but she remained fatigued after discharge from the hospital.

She had generally good health except for frequent coughs and attacks of bronchitis. Her mother died at age 77 from cancer of the cervix. She was born in a rural area, but spent most of her life in a large city. She traveled extensively. Alcohol consumption was moderate and smoking history is unknown. She was married without children.

Her weakness progressed, becoming pronounced several months after her appendectomy, and she continued to complain of abdominal pain as well as vaginal bleeding. Ten months following the onset of her initial symptoms, hysterectomy with lymph node dissection was performed. She recovered and was discharged from the hospital.

Three months later, because of recurrence of abdominal pain, a pelvic examination and biopsy were performed, followed by radiotherapy. Within a few months she developed cough and shortness of breath, which were treated with chemotherapy (nitrogen mustard).

She rapidly lost weight (final weight only 36 kg), became comatose, and died at 33 years of age, 2 1/2 years after the onset of disease.

Who is this mystery patient?

The mystery patient whose illness is described above was the Argentinean, Eva (Evita) Duarte Perón (Figure 1), hated by the aristocracy, beloved by the poor and members of the Peronist party, who became Juan Perón's second wife. She died from aggressive, widespread cervical cancer in her early 30s.

Evita speaking from La Casa Rosada to the people of Argentina.

Evita Perón, born in 1919 an illegitimate child of destitute Argentine farmers, grew up in Los Toldos, a small village located 150 miles west of Buenos Aires. At age 15, she left home for Buenos Aires, aspiring to become an actress. Men were attracted to her, and she eventually met and married Juan Perón. Together they led the Peronist party, ruling Argentina jointly from 1946 until her death in 1952. At the time of her death, because of her genuine interest in the poor, she was greatly loved and respected by large numbers of the working class. When authorities announced her demise, the entire country went into mourning. The few businesses that remained open included flower shops that quickly were sold out. After her death, thousands of people stood in line to view her body.

Was the diagnosis of cervical cancer missed, or was there a cover-up?

Cervical cancer is rarely confused with appendicitis, so we must assume that either there was a serious misdiagnosis or, for political reasons, the diagnosis of cervical cancer was kept secret. But within a year, because of progressive symptoms, she was re-operated on for cervical cancer. The tumor must have been extremely aggressive, judging by the early age of onset and the rapid clinical course. This time her operative team included a famous American surgeon, George Pack, who secretly flew to Argentina to perform the hysterectomy. Neither Evita Perón nor the Argentinean people knew that Dr. Pack had examined her and then performed the operation. Indeed, Evita Perón never was told and presumably never knew that she had cancer, although she subsequently received radiotherapy and chemotherapy.

What has been the impact of Pap smears?

Since the 1950s, there have been tremendous advances in diagnosis, management, and prevention of cervical cancer. Cervical cancer used to be one of the most common female tumors, but as shown in Figure 2, survival statistics have dramatically improved over the past several decades.[1] Currently, in the United States, for all races, there are only about 13,000 new cases of cervical cancer per year and only about 4000 annual deaths from this tumor. By contrast, about 66,000 women die from lung cancer and 40,000 women die from breast cancer each year.[1]

The graph shows a dramatic improvement in survival from cervical cancer, presumably related to widespread screening.[1]

The main reason for the decline in cervical cancer has been the widespread acceptance and use of "Pap" smears for the early detection of cervical cancer. Dr. George Papanicolaou, a physician trained in Greece, came to the United States after World War I. Initially, he supported himself by playing the violin, until finding employment at the New York Hospital. In 1928, Papanicolaou first described cancer cells in cervical smears, but his breakthrough discovery was not widely accepted, perhaps because initially it was published in an obscure journal. Only after 1941, when a more detailed report appeared in the American Journal of Obstetrics and Gynecology, did the technique became popular.[2] In 1950, Pap smears were not widely used in Argentina, nor was there much evidence that they were effective.

Was Evita's tumor operable?

It is probable that at the time of Evita Perón's hysterectomy, she already had advanced disease. She received preoperative radiotherapy to stop the bleeding and to reduce the tumor burden, but George Pack, the operating surgeon, was not convinced that he had removed all the cancer.[3] Today, a similar patient with a large, bulky, invasive tumor would receive more aggressive radiotherapy both externally and internally, as well as chemotherapy. A combination of cisplatin plus other chemotherapeutic agents might be used.

What caused Evita's cancer?

Evita Perón had several risk factors that led to the eventual development of cervical cancer. Sexual activity presumably began at an early age. She married a man who had had multiple sexual partners. Even more important, Juan Perón's first wife, Aurelia Tizon, died from cervical cancer when she was only 28 years old. We now know that infection with human papillomavirus (HPV), a common sexually transmitted disease, is the main cause of cervical cancer. Cervical cancer resembles various nonmalignant venereal diseases in that it is associated with promiscuity. In addition, there was another possible risk factor; Evita's mother died of cervical cancer at age 77.

Since the time of Evita's death in the 1950s, there has been a rapid rise of information about the association between viruses and cancer. In addition to the link between HPV and cervical cancer, there is evidence that HPV might be linked to squamous cancers of the head and neck.[4] Also, viruses are suspected to be major causative agents for other tumors such as liver cancer (hepatitis B and C), Burkitt's lymphoma, nasopharyngeal cancer (Epstein-Barr virus), and Kaposi's sarcoma. Immunization of hepatitis B virus can prevent liver cancer, and there is exciting recent evidence that a vaccine against HPV type 16 may be capable of preventing cervical cancer.[5,6,7]

Was Evita a victim of the "VIP" syndrome?

Evita Perón is an excellent example of a "VIP" (very important person) with a major health problem. Probably for political reasons, neither she nor the Argentinean public ever knew about her diagnosis of cancer. Indeed, in the middle of the last century, it was uncommon to tell patients that they had cancer; now we usually do. If the patient is a VIP, there is often widespread discussion of the disease and its implications by the news media. New York City Mayor Rudy Giuliani's recent bout with prostate cancer is a good example. Often, the publicity connected with cancer in a famous person leads to greater public awareness. As an illustration, there was widespread publicity about President Ford's wife's breast cancer, which led to a measurable increase in mammography screening.

What happened to Evita's body?

Juan Perón planned to build a mausoleum for Evita's body, which had been carefully embalmed by Dr. Pedro Ara, a Spanish pathologist. But a revolution forced Juan Perón to flee the country before the mausoleum could be constructed. To prevent the body from being recovered, the coffin was buried under a false name in an Italian cemetery. Even after her death, Evita played a role in Argentinean politics. Her body was exhumed so that it could accompany Perón who, after 17 years of exile, returned to Argentina at age 76 with a new wife to again become President.

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