Viral Debate – The Facts Behind HPV, Cervical Cancer, and a Controversial Vaccine

But one might not realize that, judging by some parents’ reaction to the current recommendations for the human papilloma virus (HPV) vaccine.

Specifically, the medical community recommends that girls and women between the ages of 9 and 26 get vaccinated against HPV — a virus exclusively spread through skin-to-skin sexual contact.

“The reason they begin so young is that the vaccine is most effective when the child has had no exposure to HPV,” said Katharine White, chief of the Division of General Obstetrics and Gynecology at Baystate Medical Center, adding that it’s easy to see where the controversy comes from.

“The vaccine has to do with sex, and we don’t want to talk about kids having sex,” she said. “And if a vaccine can protect minors during sexual activity, you don’t have to be incredibly conservative to have mixed feelings about that.

“Doctors see it as a way of protecting your kids and young women from cancer,” she continued, “but it’s also seen as a way of protecting kids from the consequences of sex, and whenever morality gets mixed up with healthcare, the facts often get lost in the emotions. To doctors, it’s a slam dunk; there is zero controversy about this in the medical community.”

There are some unanswered questions — for instance, whether there’s a need for a booster shot after a certain amoint of time. “But the questions are not about the safety of basic efficacy,” she said.

The concern over HPV is clear, as it is virtually the only cause of cervical cancer in women — one of the less-dangerous cancers in terms of mortality rate, with a five-year survival rate of 68{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5}, but a killer nonetheless. In 2012, there were 12,170 new cases of cervical cancer, and 4,220 deaths from the disease.

“It’s not a huge problem in the U.S. compared to other other countries that don’t have regular screening or with the vaccine,” said Kathryn Sharpless, a general ob/gyn at Baystate.

Dr. Marc Zerbe, an ob/gyn at Holyoke Medical Center, doesn’t see the problem with vaccinating, either.

“The risks are very minor — local irritation, redness, fever, vomiting — but I think a lot of parents have the false impression that, if you give kids the vaccine, it’s as if you’re giving them the green light to start engaging in sexual activity,” he told HCN. “But it can decrease the risk of cervical cancer.”

It’s helpful to first note, however, exactly what HPV is. In short, it’s the most common sexually transmitted infection — so common, in fact, that about 80{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} of men and women will contract it in their lifetimes.

Most of the known strains are benign, cause no symptoms, and clear on their own, but HPV can cause genital warts and — more seriously — cervical cancer.

“HPV is a relatively new discovery,” White said, noting that, when she started working as an ob/gyn in 1998, few had heard of it. Today, HPV-specific tests are recommended only for women over 30 and can be costly, but for younger women, the common pap test, or pap smear — which detects signs of cancer by looking for abnormal changes in the cervix — is a highly effective way to catch pre-cancers before they turn serious.

“It’s very powerful at detecting problems well before they lead to cancer — so much that, if it’s negative, you can be screened every five years,” White said. “We still think it’s good to go to your ob/gyn every year though, because you are more than a cervix to us, and all this does is look for cervical disease.”

She noted that more than half the women who die of cervical cancer have never had a pap smear, or had inadequate screening. “Women can be assured that, if they go get their paps as suggested, the chance of dying from cervical cancer is very low.”

Although the virus is always sexually transmitted, other risk factors, like immunodeficiency diseases and smoking, can increase susceptibility, Zerbe said.

“Pap smears are the most important method of prevention and detection,” Zerbe said, noting that pap-test recommendations have evolved to the current guidelines, which are no testing before age 21, once every three years from age 21 to 65 — or once every five years if done in conjunction with HPV screenings — and no testing after age 65, or after a hysterectomy.

“You can come up with anywhere form a mild pre-cancer that can be eradicated by the immune system to a pre-cancer that can persist or progress into cancer if untreated,” he said. “Eighty percent of women, in their lifetime, get an HPV infection, and most clear away within two years. Most infections are asymptomatic, especially in men.”

“Men rarely have any symptoms or cancer,” White added. “There’s no equivalent pre-cancerous stage and no test for men, so the most well-meaning man can be spreading HPV without knowing it.”

Sharpless noted that it’s impossible to tell when an HPV infection was contracted, as the progression from being exposed to the emergence of symptoms is usually a very long period of time — often more than a decade.

“So if you test positive for HPV at the gynecologist, don’t kill your husband or boyfriend,” White added with a laugh. “It can take years to show up, and we can never tell you how long you’ve had it.”

Sharpless said 70{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} of new HPV infections resolve within one year, and 90{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} resolve within two years — longer for women who smoke or have immunodeficiency issues. Even many symptomatic strains aren’t dangerous, but they carry their own burdens.

“Low-risk strains cause cervical warts, and while those won’t kill you, they can be irritating and embarrassing, and the treatments are often painful,” White said.

Enter the HPV vaccine, which was approved in the U.S. less than a decade ago.

There are actually two vaccines in use. Cervarix protects against the two most common carcinogenic strains of HPV, while Gardasil targets the same two strains, plus the two most common strains that cause genital warts. As a rule, both girls and boys can be given either vaccine beginning in their preteen years.

However, “the U.S. is fairly poor at vaccinating young women and girls against HPV,” Sharpless said, with about one-third of age-eligible girls and women currently having received the vaccine, compared to countries like Rwanda, where 80{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} are vaccinated. Still, “interestingly, even though the vaccination rate is 30-something percent here, it’s having an effect already because of herd immunity; the two high-risk types are definitely reducing in prevalence because of it.”

White cited “benign neglect” as one reason parents don’t have their children vaccinated, tying it to a broader anti-vaccination culture in the U.S. that most doctors say has contributed to resurgent pockets of deadly childhood illnesses. Meanwhile, she added, many pediatricians see their patients as children and are simply uncomfortable bringing up a vaccine so closely associated with potential sexual activity.

“Some parents don’t want it because of a moral stance, or they just have a lot going on in their lives,” she added, noting, however, that cost is not a factor, as insurance coverage for the HPV vaccines are very common.

While studies conducted before widespread HPV vaccination show that nearly 10{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} of American girls were infected by age 15, and nearly 20{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} by age 17, qualms persist, even among some medical professionals.

Among the most notable is Dr. Diane Harper, a professor at the University of Missouri-Kansas City School of Medicine, and one of the doctors who worked on the studies that got the vaccines approved. She said she changed her mind when the vaccine makers started lobbying state legislatures to require schoolchildren to get vaccinated — efforts that have never gained much traction.

“Ninety-five percent of women who are infected with HPV never, ever get cervical cancer,” she notes in an National Public Radio report, maintaining that regular pap smears are a more effective way of preventing cervical cancer. “It seemed very odd to be mandating something for which 95{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} of infections never amount to anything.”

Other groups claim the vaccine itself is dangerous, citing at least two children who died of a rare neurological disorder after getting the vaccine. But the independent Institute of Medicine has found no evidence that that these deaths, or any other serious side effects, were caused by the vaccine.

In addition, the Centers for Disease Control and Prevention has examined 35 deaths that occurred among 35 million young people who received the vaccine, and concluded there is no evidence of cause and effect. White told HCN that serious reactions to the vaccine are “ridiculously rare.”

“There’s a general controversy in some circles about how many vaccinations kids are getting, and most focus on the first two years of life,” she noted. “But that anti-vaccination sentiment is starting to pervade the conversation about older kids, too. It’s similar to the other vaccines — people don’t remember what it was like; they’re too young to remember when a lot of women died of cervical cancer.”

“These are young deaths,” Sharpless added — “women in their 40s with children.”

The idea behind the vaccine, Zerbe said, is to eradicate most HPV within 15 to 20 years — and thus put a stop to cervical cancer.

For women who are met with an abnormal pap smear — about 7{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} of women in the U.S. each year — the experience can be frightening, Sharpless said.

“There are a lot of panicked phone calls from women worried they have cancer,” White added. “While a pap smear could pick up cancer, much more often it picks up a pre-cancerous lesion, and we have to figure out whether it will relieve on its own or if you need to undergo procedures to make sure it goes away.”

Those steps might include a colposcopy, which uses a magnifying device to look more closely at the cervix, and possibly a biopsy.

White said these procedures can strike fear into women, but the truth is, catching a potential problem at this stage allows plenty of room to deal with the issue. “That’s the beauty of this lag time between the infection and when cancer happens. You have a lot of time before you have to hear the words, ‘you have cancer.’”

If cancer is detected, “treatment can be anywhere from a hysterectomy to radiation or chemotherapy,” Zerbe said, adding that early detection makes a big difference in how difficult the cancer is to treat. “The earlier the pre-cancer, the higher the regression rate and the less risk of progression.”

To reduce the risk, all the doctors who spoke with HCN stressed the importance of safe sex and keeping up with the recommended pap tests.

Oral and anal sex carry the same risk as vaginal intercourse, White noted, so it’s important to practice safe sex in those activities as well. “The bottom line is, always wear a condom, but it’s not 100{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} effective, and go get tested.”

She stressed that a previous infection is not a green light to risky behavior. “HPV is not like chicken pox; it’s not like you get a strain, and then you’re immune to it.”

Looking forward, she envisions a day when women may be able to test themselves for HPV — not such a farfetched concept, given the rise of home pregnancy tests, HIV cheek swabs, and self-testing for blood sugar among diabetics.

“The other thing in the future might be vaccines that cover more high-risk types of HPV,” Sharpless added. “Gardasil and Cervarix now protect against 70{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} of all pre-cancers and cancers, and 90{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} of the ones that cause warts.”

“The bottom line,” Zerbe concluded, “is to get vaccinated, practice safe sex, don’t smoke, and get your pap smear regularly, and you’ll lower your chances of getting cervical cancer by a huge amount.”