Could anyone forget the beautiful music of Evita, or even more compelling the black and white photos of Eva Peron, her cheeks becoming more and more hollowed as cervix cancer siphoned away her legendary vitality, causing her death at age 33? What is lesser known is that Juan Peron's first wife (Aurelia) died of the same disease-- at age 28. Knowing the likely cause reveals this to be less than tragically coincidental. President Peron was twice widowed before widespread Pap smear screening was promoted, and certainly long before the nature of the virus responsible: HPV (Human Papilloma Virus) was understood.
I recall the haunting youth of the cervix cancer patients I cared for on my oncology rotations as a resident. Unlike the more common older cancer patients, these women were my contemporaries, some even younger than I at the time. In the field of gynecology we were aware of the connection of cervix cancer and precancers to HPV, but it was not yet part of conventional wisdom. Despite the lack of HPV awareness in the late 80's, the fear of HIV and herpes was helping promote safe sex and routine gynecologic screening.
Unfortunately most women (and men) are not aware that condoms do not offer complete protection from HPV, in fact penetration of any orifice is not required for infection. Simple genital skin-to-skin contact can accomplish transmission. Contrary to popular assumption, most women who contact anal HPV have not had anal penetration. The skin of the scrotum need only come into contact with the anus for transmission of the virus (contact that commonly occurs with vaginal intercourse). It is the ease of transmission that contributes significantly to the fact that an estimated 6 million persons are affected by genital HPV every year. It is the most common sexually transmitted disease in our country. While it is true that the great majority of those affected will not require treatment (most mild forms of the virus will be eliminated by the host's immune system), the American Cancer Society (ACS) estimates 11,270 new diagnoses of cervix cancer in the US in 2009. Anal cancer (now felt to also be caused in large part by genital HPV) is growing at a rapid pace, and the ACS estimates approximately 3,200 cases of anal cancer will occur in women this year. There is good evidence that the HPV vaccine may not only offer protection for cervix, vaginal, vulvar and anal cancer, but also some head and neck and oral cancers as well. The vaccine also protects against genital warts, which affect approximately 500,000 people per year in the US.
While some of my eligible patients have declined the HPV vaccine, feeling that it isn't necessary for them, I am reminded that one of my dear patients, a rape victim, lost her uterus at a very young age due to cervix cancer contracted from sexual assault. Monogamy is a safe and wise practice; however, sexual assault victims remind us we are not always in complete control of our sexual exposure.
The protection of the vaccine is not perfect; there are at least 13 types that are known to be associated with genital cancer or precancer, and the vaccine covers 4 types. Two of the covered types are felt to cause the majority of aggressive cancers, and the other two prevent most genital warts. It is pretty remarkable for a vaccine to give protection for 4 different subtypes of a virus, and literally historic to offer protection against cancer. One drawback is that it takes almost a full year after the first injection (in a series of three) for the protection to completely establish. Many patients are inclined to assume protection from the initial shot, only to get a call from the doctor about an abnormal pap before immunity has set up.
In my practice, since it became available, we have administered thousands of Gardasil
injections--with no serious side effects. Though all vaccines have inherent risks, the Vaccine Adverse Event Reporting System (VAERS)---reports only very rare serious complications. The vaccine is somewhat expensive; it requires time and may not offer lifetime immunity (a booster may be needed in the future), but it will save lives, save embarrassment, save marriages, reduce painful and expensive tests and treatments...and had my generation had it, it might have saved Farrah.
Facts about Gardasil®, the HPV vaccine:
• The vaccine is administered by intramuscular injection, and the recommended schedule is a 3-dose series with the second and third doses administered 2 and 6 months after the first dose.
• The recommended age for vaccination of females is 11-12 years. Vaccines can be administered to those as young as age 9 years.
• While it is only approved for women ages 9-26, many individuals have requested and been given the vaccine who are older than 26. It is estimated that several thousand men have requested and received the vaccine.
Two nights ago my daughter and I drove away from the high school she will be attending this fall after she learned she did not make the volleyball team. She was trying to fight back her tears when I bit my tongue as the cliché slipped out, "things could be worse." I fought back my own tears of frustration knowing I can't fight her battles for her, but I can make sure she gets her third Gardasil shot-- due in 2 more months.