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Vaccine Against Cervical Cancer: Worth It?
The recently launched HPV vaccine aimed at preventing cervical cancer has provoked a lot of debate. Debate is good because it is the catalyst of mass information and information is the truest form of empowerment.
The Facts:
Cervical cancer accounts for 1% of all cancers in the UK causing over 1100 deaths every year. In the United States in 2002,
over 12,000 women were diagnosed with cervical cancer and nearly 4000 women died of the disease that year. About 3700 women were expected to die of the disease in 2006.
World-wide, over 270,000 women die of cervical cancer each year and it accounts for 9% of all female cancer deaths annually with women in the developing world bearing the brunt of this disease. Cervical cancer is the commonest diagnosed cancer among women in Central America and Southern Africa.
With the introduction of regular cervical cancer screening using smears, the rate of the disease and death from it in western countries has fallen steadily over the years. In the United States, the annual rate of fall has been around 4.5% but it is still a significant cause of morbidity and mortality among women of all age groups.
The HPV Vaccine
The Human Papilloma Virus (HPV) infection is known to be the leading predisposing factor to cervical changes which lead to cervical cancer. The infection accounts for almost all cervical cancers. It is also responsible for genital warts.
HPV is the commonest sexually transmitted infection in the United States and quite possibly the world. Crucially it is almost always symptom-less at the time of transmission.
There are over 100 strains or subtypes of the Human Papilloma Virus (HPV), a third of which are sexually transmitted. The other non-sexually transmitted strains are dubbed low-risk and possibly clinically insignificant.
The strains that are known to predispose to cervical cancer are subtypes 16, 18, 31, 33 and a few others.
Subtypes 16 and 18 are by far the most important accounting for 70% of cervical cancers.
Subtypes 6 and 11 are the strains most responsible for genital warts (90%).
The newly introduced HPV vaccine (Gardasil ) protects against subtypes 6, 11, 16 and 18. These as shown above, are responsible for the vast majority of genital warts and cervical cancer cases. What s more, studies have shown the vaccine to be almost 100% effective in preventing cervical cancer and other diseases, including dysplasia (pre-cancer) of the cervix, vulva and vagina, and genital warts, caused by the four HPV strains . That is so if given to girls and women who have not been exposed to the virus. With that logic, it has been recommended that it be made available to girls and young women from the age of 9 to 26 years. With universal coverage, such a program has the potential of dramatically cutting down the rate of cervical cancer and save millions of lives.
In the United States, Indiana became the first state in January 2007 to legislate for this vaccine. The bill requires girls to be vaccinated against HPV before the start of sixth grade. Texas followed soon after, via an executive order in February 2007, launching the vaccination program starting with girls entering the 6th grade in 2008. The order also makes the vaccine available free to uninsured girls aged 9 to 18. This is an example of bold political foresight and decision making. Other states are almost certain to follow suit.
In Britain, where such a program would fall under the auspices of the National Health Service (and therefore significant long term budgetary implications), it is under active consideration. It is, however, already available privately at a total cost of about 450 for the full course (three doses). This is significant for the individual who might feel impatient with the grinding of the state machinery towards decision making.
The Age
It is clear why the recommended start age is 9 years. It is to ensure girls are protected well before they become sexually active. HPV is largely sexually transmitted and the whole process starts there. For some, that process inexorably leads to pre-cancer (dysplasia) changes and then cancer. This is a very distressing disease which might eliminate the woman s fertility, lead to premature menopause and for some, tragically, death. The issue of age has exercised many a mind and has been one of the main areas of contention in this debate.
There is a school of thought that argues that giving this vaccine to such young girls is giving them a greenlight to be sexually active without worrying about consequences. Personally, this is a track of reasoning that I find absurd. This is similar to the mainly religious lobby which frowns upon the availability of condoms. Only it is worse. Unfortunately, this anti-vaccine lobby is quite powerful and voluble and sadly the most vulnerable members of our societies are the most susceptible to this self-righteous pious posturing. Encouragingly, in a recent study by Cancer Research UK, most (75%) mothers were in favour of having their daughters vaccinated and 80% of them felt 10-14 years will be the appropriate age.
Young girls grow into young women and most young women, sooner or later, become sexually active. The sexual activity involves another individual (usually) which means it removes the absolute control the individual might want to have about its consequences. This is regardless of whether the sexual activity is in a religiously acceptable context or not. It follows, therefore, that any reasonable individual will applaud the availability of this protection for our children and young women against one of these perennial scourges.
The HPV vaccine is a very important milestone in our fight against cancer. I put its advent, not quite, but almost at par with the discovery of Aspirin and Penicillin. Unsung and shrugged shoulders at launch but now responsible for saved lives and wellbeing of billions of people across the world over the intervening decades. It is incumbent upon those in the know to spread the word.
By: Joe Kabyemela -
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Dr Joe Kabyemela, MD, MRCOG. Obstetrician & Gynaecologist: ACWH, University Hospital Aintree and Liverpool Women s Hospital. www.hpv-centre.co.uk: Information on vaccine availability in UK. www.pregnancy-bliss.co.uk: Portal for comprehensive information on Pregnancy and Childbirth
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