Story of the Month
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| Gardasil® HPV Vaccine |
Cervical cancer will result in 3700 deaths in the United States in 2006. This cancer of the "mouth" of the uterus is the second largest cause of female cancer. It represents 2% of all cancer deaths in women. When I began my training in 1980, we frequently saw patients who died from this disease. Then we knew there was an association with sexual activity, but we were ignorant of the cause. Many thought it was the environment, promiscuity, lifestyle, but it's behavior was much like a sexually transmitted disease, (STD). The focus shifted to viral infections, initially felt to be herpes. During the past decade, information about human papilloma virus,(HPV), as a causal link to cervical cancer has exploded. The role of HPV infection on the development of cervical cancer far outweighs that of the known risk factors such as having many children, numerous sexual partners, young age at first intercourse, low socioeconomic status and history of cigarette smoking.
Another risk factor includes having used oral contraceptives for more than ten years. A sobering statistic is the sheer volume in our country. Approximately 70-80% of sexually active persons contract HPV in their lifetime, with acquisition occurring soon after first intercourse. Most will clear it with their own immune response, but with time, mutations of the virus occur, promoted by carcinogens such as nicotine and estrogen. There are more than 100 types of HPV. Fifteen types cause cervical cancer, however, two types are responsible for 70% of cervical cancers, types 16 and 18. In addition, 70% of genital warts are caused by types 6 and 11. Sexual contact with an infected partner is necessary for HPV transmission.
The American College of Obstetricians and Gynecologists,(ACOG), recommend that the first female adolescent health care visit take place between 13-15 years old. This visit is primarily a verbal discussion to discuss female adolescent concerns as well as educate patients and parents. Risk factors will determine if the patient requires an exam. Pap smears need only be done if there has been sexual activity for 3 years or if age 21. Pap smear screening programs have led to a decrease in cervical cancer deaths in the United States, however, there continues to be a significant population of women not receiving adequate screening. In 2003, only 67% of uninsured women aged 18-64 obtained paps within the past 3 years compared to 86% of insured women in that age group.
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In 2006, the FDA approved the first vaccine, Gardasil®, against HPV types 16, 18, 6 and 11. The FDA approval is for administration of the 3 dose vaccine to females aged 9-26 years at intervals within 6 months. This vaccine protects against these viruses 100% of the time for at least 5 years! The vaccine is 100% effective in preventing cervical dyplasia, (precancerous changes), and genital warts related to HSV 16,18,6 and 11. To be maximally effective in diminishing the incidence of cervical cancer and genital warts in Iowa and the entire USA, it must given ideally before any sexual exposure to HPV, and, it must be universal, all girls and women. If the vaccine is given after the onset of sexual activity, patients may have already been infected with HPV and develop the cascade to warts, dysplasia and cervical cancer. This recommendation was made by the FDA and seconded by the ACOG, the American Academy of Pediatrics and the Advisory Committee on Immunization Practices. Focus on the Family, a Colorado based conservative group supports widespread access and use of the vaccine.
There is now a proposition in the District of Colombia to mandate the vaccine before enrolling in the 6th grade. A female student would have to show that either she had received the vaccine against HPV or that her parents or legal guardian had chosen to opt out. An advisory committee to the CDC has recommended that girls and young women get the vaccine, and federal health programs that pay for vaccinations for uninsured youths will cover the costs. New Hampshire has announced plans to offer the vaccine free to all girls ages 11-18 as part of a state program that offers various immunizations to children at no cost. The federal government and insurance companies pay for the program. States as dissimilar as Texas and California are studying similar measures.
Abstinence from sexual activity is the most effective way to avoid STD's, including HPV infection. Now we have the tool to markedly diminish the incidence of the second largest cause of female cancers worldwide.
We, as physicians, you, as parents must educate our children, legislators and insurers. Third party payers, federal and state governmental agencies are encouraged to assist in covering the costs of HPV vaccinations to patients even if they are under insured or uninsured.
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