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I have worn many labels (Not in any particular order): Catholic, Wife, Mom,Gramma, Doctor, Major, Soccer Mom, Military Wife, Professor, Fellow.

All of these filter my views of the world. I hope that like St. Monica, I can through prayer, words and example, lead my children and others to Faith.
"The important thing is that we do not let a single day go by in vain without putting it to good use for eternity"--Blessed Franz J├Ągerst├Ątter

Tuesday, July 17, 2012

HPV vaccine revisited

My post yesterday mentioned some of the many changes that have occurred in my life since I started this blog in 2006. Because you asked for it, Barb, let's chat about what has happened with the HPV vaccine in that time. I have a whole series of posts on this that you can read here

First of all, there are now two vaccines to choose from instead of just one. Gardasil is manufactured by Merck. Cervarix is manufactured by GlaxoSmithKline. Instead of being marketed just to girls and women. The vaccine can now be given to boys and men ages 9 to 26. For males, the indication is the prevention of genital warts. For females, the indication is the prevention of infection with two of the subtypes of HPV (16 and  18) that cause cervical cancer. The cost of the vaccine is just under $400 for a three shot series. Some insurance plans cover the cost of vaccination. Women who are vaccinated still need to have regular pap smears because the vaccine does not cover the types of HPV that account for 30% of all cervical cancers. The safety profile for both vaccines looks pretty good.

When Gardasil was introduced six years ago, I was appalled at the rush to make it mandatory. We did not have enough clinical experience to be sure of the safety. Numerous drugs are licensed and withdrawn due to adverse effects that are only discovered once the drug is in general clinical use. Merck was pouring huge amounts of money and energy to push the mandates. Look at my old blog posts and you can see that they were even stalking lowly bloggers like me and planting "doctors" to comment on my blog posts. Merck knew that Cervarix was coming down the pike and they wanted the mandates to go into effect while they were still the only show in town.

Six years later I am satisfied with the safety. My opinion is that these are reasonable vaccines to offer to patients. They are not essential. I still oppose making these vaccines mandatory. The public health risk of HPV infection does not rise to the level necessary to take this decision out of the hands of parents. So why would a parent choose to get the vaccine for her child? The $400 upfront cost of vaccination does not lower any costs for preventive care. Women who are vaccinated still have to get the same routine pap smears as women who are not vaccinated. The vaccine is not going to save any lives in women who get regular pap smears because these routine exams will detect early changes that can be treated and prevent the progression to cervical cancer. The Center for Disease Control (CDC) admits as much

Regular cervical cancer screening and follow-up can prevent most cases of cervical cancer. The Pap test can detect cell changes in the cervix before they turn into cancer. Pap tests can also detect most, but not all, cervical cancers at an early, treatable stage. Most women diagnosed with cervical cancer in the U.S. have either never had a Pap test, or have not had a Pap test in the last 5 years.

Remember that the vast majority of women who contract HPV, including subtypes 16 and 18, clear the virus on their own with no treatment. So what your $400 dollars in vaccine cost is buying you is insurance against having to have the cryotherapy or other treatment to eliminate pre-cancerous cervical changes because you are one of the few who contracted these specific types of HPV and your immune system did not take care of it. 

The case for vaccinating boys is even shakier. The vaccine has not been shown to prevent penile cancer. It has not been shown to decrease HPV transmission to women. There is evidence it reduces the incidence of genital warts, an embarrassing and annoying condition that is not life threatening. If you really want to decrease HPV and penile cancer in your sons, you should circumcise them.

The push to vaccinate young girls as early as age nine comes from the desire to reach them before they are sexually active. Early sexual activity and multiple sexual partners increase the risk of HPV infection and subsequent cervical cancer. I think that it is probably very reasonable to encourage vaccination for those girls who seem very likely to become sexually active early. I don't think it will hurt to vaccinate other girls as well--I am just not so sure it will help much either. So if you, as a parent, want to feel like you have addressed every sort of cancer prevention no matter how small the risk of cancer or how small the potential benefit, then go for it. If you decide that the risk for your daughter is low enough that you feel comfortable with the routine cancer screening pap smears alone, then that is perfectly reasonable too. 

I do not believe any physician should be pushing this vaccine as clearly essential for all patients. It is an option. Parents need to be informed of exactly what the vaccine does and does not do. Then the choice is theirs.


RAnn said...

Amazing that a doctor thinks parents are smart enough to make healthcare decisions for their kids, especially when those decisions have anything to do with sex. What's the world coming to?

Barb, ofs said...

I am SO on the fence on this issue, with my 16-year-old daughter. I appreciate your perspective and my husband and I will consider it carefully. I just have the feeling, with this vaccine, that there is "playing with fire" involved.
Now if there were a vaccine against strep throat, I'd be the first to line up my kids.

Denise said...

Barb, just to put things in perspective, you cannot make a bad decision. If you choose not to vaccinate, your daughter should have regular pap smears. Those will detect precancerous changes. If that were to happen to her, she gets treated and life goes on. If you choose to vaccinate, your daughter should have regular pap smears. She still may get precancerous changes because 30% of cervical cancers are caused by HPV not covered by the vaccine. If that happens, she gets treated and life goes on. What you are changing with your decision, assuming your daughter gets regular pap smears (as in every 2-3 years--not necessarily yearly) is the chance she will have pre-cancerous changes. You are not really changing the chance she will get cancer.

Michelle said...

Thanks for this, Denise. The doc didn't talk about this vaccine during my daughters' recent physicals (my oldest is almost 11). I figured I had a few more years before I needed to weigh the pros and cons. My biggest concern was the immediate health risks associated with the vaccine. Now it seems more like a flu shot: lessening, but not guaranteeing, you won't get sick.

Ebeth said...

Denise!!! Thanks so much for talking about this, with two teen daughters I have been advised for both to have this vaccination....I declined six years ago and will continue to decline now.

Emm T. Nester said...

Thanks for this post.

What about getting the vaccine solely to prevent genital warts?

Sorry if I missed your answer.