Cervical Cancer

CENTER OF GRAVITY By Rony V. Diaz Cervical cancer
THE New England Journal of Medicine (NEJM) published on August 21, two articles and an editorial that were critical of the vaccines against the human papilloma­virus (HPV) that Merck and GlaxoSmithKline had put on the market.
HPV is sexually transmitted. It has no symptoms in the early stages but genital warts may appear in time. It does not trigger the immune system. When it becomes chronic—which is relatively rare—it may cause cervical cancer.
Gardasil and Cervarix are the brand names of, respectively, Merck’s and GlaxoSmithKline’s vaccines. According to the articles in the NEJM, the evidence that they are effective is not “sufficient.” It’s also not clear, NEJM continued, that immunity would last a lifetime. The vaccines are expensive; 3 shots cost from US$400 to $1000.
The last point is important because almost 80 percent of cervical cancer occurs in poor countries, according to the World Health Organization (WHO). It’s the second most common cancer, after breast cancer, in women all over the world.
I did not find any official statistics on the number of cervical cancer cases in the Philippines. By extrapolating from WHO’s numbers—500,000 new cases each year; 274,000 mortality in 2006, nearly 95 percent in developing countries and so forth—my guess would be between 50 and 100 cases every year. The Journal of the National Cancer Institute in the US estimates the risk at less than 1 woman in 1000 younger than 50 of dying in the next decade from cervical cancer. It would be interesting also to find out the rate of HPV infection but because the Department of Health (DOH) has no Pap screening program, one might have to fall back on the Population Commission’s (Popcom) estimate of sexual activity among young persons between the ages of 18 and 40.
Charlotte Haug, the editor of The Journal of the Norwegian Medical Association and the author of the editorial in the NEJM, wrote: “Despite great expectations and promising results of clinical trials, we still lack sufficient evidence of an effective vaccine against cervical cancer… With so many essential questions still unanswered, there is good reason to be cautious.”
She also thought that six-and-a-half years of clinical trials were not enough for the vaccines to have been approved in 2006 by the US Food and Drug Administration (FDA) for general use.
Among the unanswered questions were those that relate to whether eliminating the 2 strains of the HPV that cause genital warts and cervical cancer would affect the ability of the immune system to respond to the other strains of the HPV.
Her most telling point was since cervical cancer develops only after years of chronic HPV infection, there was no clear proof that protection against 2 of its strains would also reduce the rates of cervical cancer.
In answer, Richard Haupt, the medical director of Merck, told The New York Times (August 21, 2008): “You can only study a vaccine for so long before you license and use it in a population… This is a remarkable vaccine that will have a huge impact on women.”
He added that Haug’s points were “very theoretical”; continuing research indicates that immunity is “long lasting” and that the vaccine “would not lead to problems with other strains.”
Unless the government pays for or subsidizes them, these vaccines are not affordable by poor people.
In rich countries, the cost of mandatory vaccination is charged to public health budgets.
Health economists estimate that depending on how the vaccines are used, the cost to society could be between $30,000 and $70,000, “for each year of life they save.”
Dr. Abby Lippman, the policy director of the Canadian Women’s Health Network, was quoted by The New York Times, as saying, “This kind of money could be better used to solve so many other problems in women’s health. I’m not against vaccines, but in Canada and in the US, women are not dying in the streets of cervical cancer.”
It’s only a matter of time before these pharmaceutical giants will start to market these vaccines in middle-income countries like the Philippines.
Cancer prevention and women’s health are powerful marketing messages. The DOH is well-advised to begin thinking of a policy response.
The choice is between mandatory vaccination and a Pap smear program. Until the medical benefits of mandatory vaccination are clearly established, a policy of Pap screening is the better option. The WHO said that in countries where Pap smear programs are available, few women died of cervical cancer.