I support giving girls the new vaccine to prevent infections by some strains of the Human Papilloma virus (AKA Warts) that is associated with cervical cancer in women.

But at the time the vaccine was released, it’s use almost became a crusade: Some states even mandated young girls receive the very expensive vaccine, and parents who hesitated were widely ridiculed in the press.

Now, however, there are questions if the expensive vaccine is worth it in all girls, and if the hype encouraged by the drug company was mirrored by a similar hype in the press.

The press called the vaccine a “cancer vaccine”; few reports noted that it was actually an anti wart vaccine, and that women exposed to the wart virus had a small risk of cancer, but that the vaccine could really lower that risk a lot, but not completely.

So who is questioning the spin about this wonderful vaccine? No, not a paranoid right wing webpage, but  the NYTimes and  the esteemed New England Journal of Medicine.

One big reason for the questions is that doctors now realize that exposure to the HP virus may cause “precancerous” changes on the pap smear, but that in most women, the body’s own immune system will clear the virus and the pap smear will come back to normal. This is changing how doctors treat mildly abnormal pap smears (what we used to call Class II: showing non cancerous changes): No more hurried culposcopy and treatment, just recheck in six to 12 months, and make sure it goes back to normal.

And in most cases, it does return to normal.

This should not be a surprise: like kids with warts on the hand, most clear up without treatment if you leave them alone for awhile.

The danger is that if girls get the vaccine, they will stop getting pap smears. If they already caught the virus, or if they get an infection by one of the milder cancer causing viruses that are not in the vaccine, they won’t be picked up if they don’t get checked. So the end result might be finding these cancers later, when they are harder to treat.
Another question is: how long does the shot last?

Will we be eliminating cervical cancer in younger women, only to have older women start getting the infection?

Then there is a question on when to start, and the definition of “sex”. Remember, this is a wart virus: so you could theoretically catch it without going “all the way”.

Finally, there is a question about “catch up” vaccinations. What about the 17 year old, who had sex a few times with her boyfriend, but is now going to college. She might have been exposed, but you can’t tell; but if you don’t give it to her, she might catch it in college, where the risks of STD from strangers is higher.

Then there is the problem of the “minor” strains. If a lot of women are now immune to the major virus strains that cause cancer,will we start seeing cancers from the milder viruses that can cause cancer but at a lower rate?

Then there is the cost: The way this is measured is for each year of life saved.

On the assumption that the vaccine provided lifelong immunity, the cost-effectiveness ratio of vaccination of 12-year-old girls was $43,600 per quality-adjusted life-year (QALY) gained, as compared with the current screening practice. Under baseline assumptions, the cost-effectiveness ratio for extending a temporary catch-up program for girls to 18 years of age was $97,300 per QALY; the cost of extending vaccination of girls and women to the age of 21 years was $120,400 per QALY

And remember: A lot of vaccines don’t last forever, so booster shots every ten years might be needed.

Most experts think that vaccinating early teens, before sexual experience, would be the way to go.

immunization of preteens before sexual exposure makes the best economic sense. Vaccinating older teens and young-adult females who have not had sexual exposure would also seem to be cost-effective, although the optimal cutoff age is unclear.

So what should you do for your daughters?

I’d give my own daughter the vaccine. It’s not perfect, and like other vaccines, she might have to get booster shots in the future, but it’s the best we have right now.

I’ve seen women die of cervical cancer.

Anything that lowers the number of women dying of this terrible disease is worth it.


Nancy Reyes is a retired physician living in the rural Philippines. Her website is Finest Kind Clinic and Fishmarket, and she writes about medicine at HeyDoc Xanga Blog.


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