Why Every Girl Ought To Have The Cervical Cancer Vaccine
The introduction of the Human Papilloma Virus (HPV) vaccine (in the form of Gardasil® and Cervarix®) against cervical cancer was generally well received but there was a small and quite vocal discordant note from a few sections of society. A couple of years on, it is important to re-visit the subject, to take a dispassionate look at the facts and for those of us on the frontline and in the pro-vaccine camp, to reiterate the reasons for our enthusiasm for this development.
Cervical cancer statistics
First the backdrop: Cervical cancer remains the single most commonly diagnosed malignancy among women in Latin America, Asia and sub-Saharan Africa. Globally, it is estimated to kill well over a quarter of a million women every year.
In the United States, in 2007, over 12,000 women were diagnosed with cervical cancer and the disease claimed 4021 lives that year. In the same year, in the UK (with a population which is a fifth that of the USA), 2,828 women were diagnosed with the disease and 957 women died from it. The rate of diagnosis and mortality is therefore roughly similar. In developing countries the problem is much worse. In India alone, it was estimated that the annual death toll from cervical cancer was to be around 79,000 in the year 2010. That would be a quarter of all worldwide expected deaths from the disease. Overall 1 in 11 (9%) of all cancer deaths among women worldwide are due to this single type of cancer.
Cervical (Pap) smear
In the United States, like in the rest of the developed world, cervical cancer cases diagnosed every year and deaths from the disease have fallen steadily over the last 40 years or so, mainly as a result of introduction and establishment of regular cervical smears (Pap smears) for screening. This has enabled pre-malignant changes to the cervix to be detected early and treated. Roughly 3 million abnormal smears are detected every year in the United States and all these have to be acted upon. Such schemes are unavailable to the majority of women who live in resource-poor developing countries. In those countries, the morbidity and mortality toll from the disease remains truly appalling. The statistics shown above for the UK give a cervical cancer mortality rate of 2.4 per 100,000 which is actually an impressive 70% lower than it was 30 years ago. There is no doubt that screening programs are responsible for this improvement. However, such programs, impressively successful as they have been, are a case of damage limitation. They address a problem that has already occurred and their running costs are high. In countries where this service is funded by the state, figures speak for themselves. In England alone, the cervical smear program costs around £157 million (approx. $250 million) every year. It is regarded as a success but it does not and cannot be expected to prevent those hundreds of deaths every year. A three-yearly smear for a woman in her late 20s or 30s has around 41% effectiveness in preventing cervical cancer. Effectiveness goes up with age. It is therefore aimed at reducing but cannot be expected to eliminate risk of cervical cancer. It is also the case that such expenditure is clearly beyond the means of most developing countries. The £157 million spent in England every year for this program is more than 50% of the entire annual health budget for Kenya, a country of 40 million people. Kenya’s health budget in 2010 was KShs 39.9 billion (about £291 million), effectively meaning every individual is allocated less than £8 ($13) for the whole year. That is the stark reality.
Impact of Cervical Cancer
Not all cancers are created equal. Cervical cancer is a devastating disease. Caught early, the cancer is treatable through surgery, radiotherapy or a combination of the two. However, whichever form of treatment is adopted, the woman is almost certain to lose her ability to have children. There is only a very small window in the diagnosis whereby a fertility preserving surgery could be deemed suitable and adequate to achieve a cure. The vast majority of patients cannot have this. Even though cervical cancer is largely a disease of middle age and later, there is a significant minority who are diagnosed with the condition at a relatively young age. In fact, around 7% (1 in 14) of those who die from cervical cancer are under 35 years of age.
When cervical cancer is diagnosed late, the chances of complete cure are reduced significantly. Moreover, when the cancer spreads to adjacent structures such as the urinary bladder, bowel or the lower spine, the impact on the quality of life for the dying patient can be quite distressing. You have got to understand also that the quite effective palliative options available to women in developed countries, to lessen the pain and distress in the final months of life, are simply not available to affected women in poorer developing countries. They have to go through the agony of the slow incredibly painful death over weeks and months and nothing can be done about it.
The Role of HPV Infection
Many people are usually surprised to learn that Human Papilloma Virus (HPV) infection is the commonest sexually transmitted infection in the United States and probably the world. The fact that it is almost always symptom-free is responsible for this ignorance. There are well over 100 sub-types of HPV and only about a third of these are sexually transmitted. A fewer still are responsible for the cervical changes that lead to cervical cancer. The HPV sub-types are named in numbers. Sub-types 16 and 18 are responsible for 70% of all cervical cancer cases. When we talk about 280,000 women dying every year from cervical cancer, these two HPV sub-types are directly responsible for at least 196,000 of those deaths. These are the 196,000 deaths that we can prevent EVERY YEAR in the future by vaccinating girls before they become sexually active.
Sexual activity and cervical cancer
As stated above, HPV is transmitted through sexual activity.
For decades it has been known that, early age of sexual debut and number of
sexual partners, are risk factors for cervical cancer. If HPV infection is
acquired early, the cells on the cervix are likely to be more vulnerable. Also,
the higher the number of sexual partners a girl has, the higher the possibility
of getting the infection. It is usually a combination of these factors that
determines whether the pathological changes that might lead to cervical cancer
will occur as well as its timing. It is estimated that it takes at least 10 years,
usually longer; from the time the infection is acquired to the time the early
pre-malignant changes can be detected. This is why in the UK and many
other countries, cervical (Pap) smears are not routinely offered to women under
25 years of age. In the United States, Pap smears are offered from age of 21 and two yearly thereafter until age of 30. If consistently normal, the intervals are increased to three yearly as practised elsewhere in the world.
Adolescent sexual behaviour
Studies have shown that in the UK, 1 in 10 (10%) of all girls are sexually active at the age of 14. At 15, almost 50% are. A study published in the Contraception Journal in April 2009 reported that, even though there are significant racial differences, in the United States, roughly 50-80% of all adolescents are already sexually active by their 17th birthday. Bluntly put, it is a reality of life that adolescents have sex. Living in denial is no substitute for effective strategy. Alongside continuing sexual education to enlighten them on avoiding risky sexual behaviour, it is the society’s moral responsibility to apply all means at our disposal to protect these members of the future generations. If it is right to vaccinate people against measles, it is equally right to vaccinate them against possible cervical cancer and all its consequences.
So far, those vehemently opposed against HPV vaccination have done so on the principle that this type of action encourages young people to be promiscuous. I have always found this type of twisted logic so profoundly frustrating and, I believe, so have most fellow professionals. It follows the same line of argument given by those who have campaigned against the use of condoms for the purpose of reducing the transmission of such deadly infections as HIV and other STDs. That is despite the solid scientific evidence of the effectiveness of such measures. For me, this reasoning is akin to dissuading young drivers from wearing a seatbelt because “it encourages speeding”. It is important that we do not allow despair at such irrational ‘reasoning’ to rob our future generations of the freedom from this disease.
Why girls should be vaccinated
I am pro-vaccination and this is why: Young girls do grow into adolescent girls who, sooner or later, become sexually active. This may be undesirable to some but it is a fact of life. As we have seen on the figures above, the majority of them are sexually active by their mid-teens. Sexual activity usually involves another individual, meaning the girl is not in complete control of the consequences. This is a stage of life where human beings are wired to be reckless. It is part of the growing up process. However well intentioned, no one can guarantee that if the girl decides to become sexually active, she will ensure she uses barrier methods which will protect her against HPV and other potential STDs. As such, having a measure in place which eliminates this risk, which can devastate her life and that of her family, is not only desirable but a moral obligation. What’s more, we should resist the temptation to be parochial. We should encourage the powers that be to facilitate the availability of this vaccine to all the young girls across the globe, regardless of their individual means, to liberate the future generations from this terrible scourge.
Why not boys?
Finally; the question of boys. In most countries which have introduced the HPV vaccination program, boys have been excluded. Many have questioned this. Apart from the economics, it is actually logical. HPV, like all STDs that affect heterosexual individuals, is passed among sexual partners. If one half of the equation is rendered free of this infection, in the course of time, the infection will die out. Since the vaccines are currently still quite expensive, it makes sense to approach it this way. However, this is not perfect. These HPV sub-types are also responsible for anal cancer among men and women. Admittedly, this is a much less common type of cancer. It, nonetheless, leaves open the question of whether boys who are gay are left unprotected. That will need to be addressed.