As a mother of a young daughter, the new vaccine for cervical cancer has been at the top of my mind. On one hand, I am not wildly enthusiastic about vaccines. Personal experience with the older child has shown that some immune systems just can’t deal with the onslaught of vaccines that we seem to be subjecting young bodies to these days. On the other hand, cervical cancer, caused by the Human Pappilomavirus(HPV), is the second leading cancer in women (worldwide – in India it is the leading cancer) and is responsible for about 250,000 deaths worldwide.
When the vaccine (Gardasil, by Merck) was introduced a couple of years ago, it created a storm of controversy. This was because while the cancer is generally considered to be a sexually transmitted disease, the vaccine is administered when the child is 11 or 12, sometimes even as young as 9. Parents could not come to terms with the fact that their young daughters could be sexually active one day and resisted the vaccine. Then there was the issue of the newness of the vaccine and its potential side effects and the cost of the vaccine, which is very high (about $360 for the three doses required.)
Dr. Shobha Krishnan, a gynecologist based at Columbia University, set out to educate parents about the cancer and the vaccine and its risks and benefits. I spoke with her about her well-researched tome, “The HPV Vaccine Controversy Book-: Sex, Cancer, God and Politics.”
Why did you feel there was a need for this book?
SK: This is a vaccine for a cancer that is sexually transmitted and parents have to get their daughters vaccinated at 11 or 12. They have doubts and doctors can sometimes fall short at informing and reassuring parents. I think this book answers all questions about HPV and cervical cancer. It empowers parents who are going to be faced with this decision.
What does the book cover?
SK: The first 5 chapters tell parents what the controversy is about; what the risk factors are; the different kinds of disease that HPV causes. One chapter that has never been dealt with anywhere else is the emotional aspect of the disease. A young person may be infected with the HPV virus for years before it develops in to a cancer for which there is no cure. They have to make important decisions like what to tell their partners if they are infected with this dormant virus. Then I go into vaccines. There are two at present for cervical cancer. Both cover the two strains of the virus which are responsible for 70% of all cervical cancers.
The conclusions I came to were that should the studies show that men could benefit from the vaccine, then boys should be vaccinated too and that women should still go for pap smears because of the 30% of viruses that cannot be vaccinated against.
Given that regular pap smears in the US make for early detection of the precancerous lesions that signal cervical cancer, is this vaccine really necessary?
SK: Prevention is still better than a cure. In the US, regular pap smears detect any precancerous lesions in the cervix, which can then be treated. But it still makes financial sense to prevent that from happening. Elsewhere in the world, where regular health checkups for women are not the norm, this vaccine takes on a greater significance.
The other problem is that unless this vaccine reaches the same group of women who can’t afford pap smears in the first place, the mortality won’t go down. The cost of the vaccine must come down. In India the Bill Gates foundation is working on this. GAVI, a global alliance for vaccination in poor countries, is working with the pharmaceutical companies to bring the costs down.
How safe is this vaccine?
SK: This is a fairly new vaccine. Last year, I wrote an article about the side effects of the vaccine. There have some cases of fainting spells and some vaccinated people have complained of muscle weakness. But between 2.5 to 8 million doses have been given and the incidence of side effects has been very low. For the number of doses that were given, the percentage was thee same as any other vaccine. The main side effects are pain at the site of injection and redness and swelling. As of now the FDA and CDC do not believe that the vaccine is responsible for muscle weakness. I think this vaccine is as safe as any other vaccine.
It has only been 2.5 years since the vaccine was introduced so it is hard to gauge long term effects. The reason I am comfortable with it is that lots of doses have been given and had there been some concerns I believe something would have come up.
What would your recommendations to parent of daughters?
SK: There is no substitute for knowledge and proper parental guidance. In this age of premarital sex, we want to do everything we can to protect our children. When we teach our children to ride a bicycle, we make them wear a helmet not because we want them to have an accident but as insurance. Because this vaccine it is preventive it makes sense to give it at a time when the antibodies can be produced. At that age children normally go to the doctor for booster shots.
How long is the vaccine effective for?
SK: At this time we know that both vaccines are good for 6 years. Vaccines are a breakthrough technology so no one knows if they could have a longer effectiveness.
How do we know the vaccine is really working?
SK: That is a good question. Unfortunately, we don’t have a registry for precancerous lesions so we don’t know if the incidence of these lesions has come down. We need this registry so we can track the effectiveness of the vaccine. Cervical cancer is a very slow growing disease. We will not see any effects in one or two years, only in the next generation.