cervical cancer

As a sexual health researcher, I have followed the saga of HPV (human papillomavirus) vaccination since the early 2000s. I’m posting this month’s column early to address three news stories that recently caught my attention – both for what they reported and also for what they left out:

March 26, 2012: PRNewswire report on Harold zur Hausen’s remarks at the annual meeting of the Society of Gynecologic Oncology. Having won the 2008 Nobel Prize in Medicine for discovering the link between HPV and cervical cancer, zur Hausen kept the spotlight on cervical cancer when he advocated for HPV vaccination of young females and males in order to “eradicate cervical cancer.” While I advocated for non-sexist HPV vaccination policies back in a 2010 Ms. Magazine article, I was surprised by reports that zur Hausen favored male vaccination: “…if society were to vaccinate just one gender to prevent the spread of cervical-cancer causing HPV, it would be more effective to vaccinate just males.”  I found myself asking two questions: (1) Why base medical recommendations on heterosexist assumptions that girls/women only contract cancer-causing strains of HPV from male partners? (2) Why continue to narrowly focus on HPV as a cause of cervical cancer, when a growing body of research documents its role in a range of genital cancers as well as often fatal oral-throat cancers?

April 2, 2012: The New York Times offers a summary of a study published in the March issue of the British Medical Journal: the findings suggest that HPV vaccination “can significantly cut the likelihood of virus-related disease even among women who have had surgery for cervical cancer caused by HPV.” The strongest prevention effect – 64% reduction in risk – was for women who had the most serious kinds of cervical cancer. The article quotes Dr. Elmar A. Joura, associate professor of gynecology at the Medical University of Vienna: “Regardless of your age or your history, a vaccination can prevent new disease.” Key question not addressed by this article: why does the CDC have an upper-age limit of 26 years old for HPV vaccination? Last year, Canada raised their upper-age limit to 45 – how much longer will ‘older’ Americans have to wait?

April 4, 2012: Forbes article on “The Gardasil Problem” fails to address the full scope of HPV vaccination ‘problems.’ First, the author misleads readers into thinking that HPV-related oral-throat cancers are “a new form” – again, see not only the 2010 Ms. Magazine article but also the Oral Cancer Foundation’s thorough summary of the decades of research linking sexually-transmitted HPV to serious oral cancers.

The author also misstates the focus/bias of Merck’s original years of marketing Gardasil: “When it was introduced in 2006…Merck began an advertising push to raise awareness of the risks of HPV.” What ads did he see? I and other consumers of mainstream media were exposed to a series of commercials that referred to Gardasil as “the cervical cancer vaccine” and strategically obscured message about “HPV-related diseases”, never clarifying for viewers that HPV was, in fact, sexually transmitted.  While I offered a feminist critique of the branding and marketing of Gardasil in my 2008 book and several blog posts – trying to get the public to understand that “You don’t need to have a cervix to benefit from the cervical cancer vaccine” – Merck did not change to a focus on Gardasil as a STD vaccine until it received FDA approval for male vaccination…until profits depended upon bursting the bubble of the mythical cervical cancer vaccine.

Next, the author not only makes a heterosexist assumption but also unnecessarily demonizes oral sex on women as the ‘usual’ mode of transmission: “Usually transmitted when men perform oral sex on women, it can also spread through other forms of contact, perhaps even just kissing.”  If kissing can transmit the virus, the why is he so sure that most of men with HPV-related oral-throat cancers skipped ‘first base’ and went straight to ‘third base’? If, and this is a big ‘if’, clinical studies can verify unprotected oral sex as the primary mode of transmission, then why not offer readers a brief education on the vaccine-free ways to practice safer oral sex? 

Finally, the author unnecessarily dashes readers’ hopes for the near future: “tests that might well prove that [Gardasil] can prevent the new throat cancer strain would take at least 20 years, until the boys sampled actually became sexually active and then contracted the disease.” Why would these tests take 20 years? Does this author think that a boy who is vaccinated at age 12 will not perform oral sex until he’s 20+ years old? Where is the data to show it would take another ten years for HPV-related oral and throat cancers to develop?  In addition, the author fails to point readers towards the likely source of delay: a lack of interest by the makers of the two FDA-approved HPV vaccines.   

A 2010 article in the Journal of the National Cancer Institute not only clarifies the challenges of developing effective screening for oral HPV infections but also reports the truth about Merck’s failure to move forward with testing HPV vaccination as prevention of oral and throat cancers. Maura Gillison, M.D., Ph.D., a leading researcher on HPV-related head and neck cancers at Ohio State University in Columbus, explained why clinical trial plans were derailed in 2010: “We were 6 weeks from enrolling the first patient when I got an e-mail saying it was no longer in the interest of Merck to conduct the trial.” The article also quotes Pam Eisele, a Merck spokeswoman:

“The link between HPV infection and head and neck cancers continues to be an area of scientific interest for Merck; however, we currently do not have any plans to study the potential of Gardasil to prevent HPV-related oropharyngeal cancers. In 2008, we did conduct a small pilot study to assess our ability to obtain adequate and valid oropharyngeal samples. While the results of the pilot study were promising, due to competing research and business priorities we ultimately decided not to move ahead with an efficacy study at this time.”

Why is Forbes not asking for a more complete explanation of those “competing research and business priorities”?  We, the American public, should demand more funding find out how to prevent cancers which research shows to be on the rise and more fatal than cervical cancer in the U.S.

The one section of this Forbes article that some readers might find valuable is its summary of the data on the safety record of HPV vaccination.  However, as I’ve said before, I am not advocating that vaccination is the only way to reduce one’s risk of contracting cancer-causing strains of HPV.  Those who decide not to vaccinate themselves and/or their children need to learn the facts about HPV prevention, testing, diagnosis, and treatment: check out the American Social Health Association’s online HPV and Cervical Cancer Prevention Resource Center.

Coco Chanel has often been quoted as saying, “A woman who doesn’t wear perfume has no future.” If perfume staves off doom, then perhaps that’s what inspired this otherwise-inexplicable new ad by GlaxoSmithKline for its HPV vaccine:

As you can see, it leads with a blue-eyed, fair-skinned, made-up (and apparently affluent) young woman lounging on an antique sofa on the first floor of a mansion. But softly shimmering lights and fairy-like chimes distract the waif from her book. She dreamily follows the golden twinkling lights up an impressive staircase, where she gazes with a beatific smile upon a champagne-colored perfume bottle magically floating in mid-air. As the bottle rotates to reveal the words “CERVICAL CANCER“, the young woman’s expression switches from bliss to frowning concern. Enter the narrator’s voice:

Maybe it’s unfair to get your attention this way, but nothing’s fair about cervical cancer. Every 47 minutes, another woman in the U.S. is diagnosed. But, there are ways to prevent it. Talk to your doctor.

Unfair? I would have said “insulting.” As in, maybe it’s insulting to assume that the best way to attract a young woman’s attention to a serious health issue is to dupe her into thinking she’s watching a perfume commercial? But, if you want to talk ‘unfair’…Maybe it’s unfair that there hasn’t been a public health campaign to educate teens, women and men about sexually-transmitted HPV (human papillomavirus), which can cause not only cervical cancer but also other serious cancers in men and women? Maybe it’s unfair that the only public “education” about the HPV epidemic has come in the form of pharmaceutical ads that continue to narrowly brand and market HPV vaccines as “cervical cancer” vaccines?

The ad finishes by presenting a GlaxoSmithKline website — which troubles me, as a sexual health researcher, because it does not offer visitors a comprehensive HPV education. But that may have been too much to hope for, given that their HPV vaccine (Cervarix) received FDA approval for use in girls and women (ages 9 to 26) just this past October.

So, skip this ad and website if you’re looking for a more neutral source of information about HPV vaccine options, and visit the CDC instead. And those who’d like a more thorough STD/STI education should check out the American Social Health Association and other website resources which are not funding by pharmaceutical companies.

Note: while GSK has disabled adding comments to their series of new ads, you may rate not only this ‘perfume’ ad but also their ‘front porch‘ and ‘night out‘ ads with the start-ratings you feel they deserve. And, for more on the mis-marketing of HPV vaccines, read my article, “Why Men’s Health is a Feminist Issue,” in the Winter issue of Ms., on newsstands now.

(Originally posted on Ms. blog, cross-posted at Sociological Images and AdinaNack.com)

January is Cervical Health Awareness Month, making it the perfect time to post a follow-up to Part I which featured my concerns about potential unintended consequences of new Pap test guidelines (from ACOG, the American College of Obstetricians and Gynecologists). To recap, it is vital that we do not confuse a recommendation of less frequent Pap tests with the unchanged recommendation of annual pelvic/sexual health exams (see the National Cancer Institute for explanations of both).

So, let’s look back at a letter dated November 20, 2009, in which the President of ACOG clarified:

Cervical cancer screening should begin at age 21 years (regardless of sexual history). Screening before age 21 should be avoided because women less than 21 years old are at very low risk of cancer. Screening these women may lead to unnecessary and harmful evaluation and treatment.

Medically speaking, why should this recommendation disregard an individual woman’s sexual history? His letter continues on to state:

Cervical cytology screening is recommended every 2 years for women between the ages of 21 years and 29 years. Evidence shows that screening women every year has little benefit over screening every other year.

Doesn’t this depend on how many new sexual partners a woman has in a given year? Are the revised guidelines assuming monogamy (or at least long-term, serial monogamous relationships) which decrease odds of a woman contracting a new cancer-causing strain of HPV in less than a 2-year period? Where are the conclusive findings of large-scale sexual-behavior surveys to support this assumption?

ACOG’s November 2009 press release featured these quotes from Alan Waxman, M.D.:

Adolescents have most of their childbearing years ahead of them, so it’s important to avoid unnecessary procedures that negatively affect the cervix. Screening for cervical cancer in adolescents only serves to increase their anxiety and has led to overuse of follow-up procedures for something that usually resolves on its own.

I agree with GWP reader anniegirl1138 who commented on my previous post that over-treatment is no joke. However, we have not been presented with data that a Pap test — the test, itself, not over-treatment based on test findings — is directly linked to significant increases of any negative health outcome.

Cervical HPV infections can be detected by Pap tests: ACOG acknowledges that, “the rate of HPV infection is high among sexually active adolescents, but counters with, “the large majority of cervical dysplasias in adolescents resolve on their own without treatment.”

Why should that smaller group of girls and young women (whose pre-cancerous lesions do not resolve without treatment) miss the annual opportunity to receive an early diagnosis? Early-stages of cervical HPV infection can often be resolved with less-invasive treatment options.

More-invasive treatment options, such as the “excisional procedures for dysplasia” that have been linked to increased risk of premature births, are one of several medical treatments for cervical HPV.

And, what about the possibility that an increased risk of premature births may not be the paramount concern for every female patient? Not all women want to or can biologically become mothers. What if an individual female patient would rather seek medical treatment for a HPV infection that has resulted in cervical dysplasia so that she has greater peace of mind in knowing that she has reduced her risk of cervical cancer and reduced the likelihood of transmitting HPV to her sexual partner(s) and/or future babies?

Call me a feminist, but I still believe that knowledge is power and that every sexually-active girl and woman should be encouraged to consider the benefits of annual Pap tests. When Pap smear results show “abnormal” cellular changs, then healthcare practitioners should explain the potential for false-positives and discuss the pro’s and con’s of moving forward with different diagnostic and treatment options.  

ACOG acknowledges that, “HPV also causes genital and anal warts, as well as oral and anal cancer.” A Pap test may be a girl/woman’s first chance to learn of a cervical HPV infection, which can result in her having a colposcopy exam. This procedure helps a practitioner find HPV-infected cells not only on the cervix but also in other anogenital areas (the vaginal canal, the labia, the perineum). Beyond the cervix, a Pap test that is positive for HPV may be a wake-up call to get a thorough oral screening for serious oral cancers which have been linked to sexually transmitted HPV.

In addition, my research and others’ studies have found that STI diagnoses can lead to attitudinal and behavioral changes which can decrease risks of contracting other STIs, including HIV. For all of these reasons, a Pap test that leads to a diagnosis of a sexually transmitted cervical HPV infection can bring unintended positive consequences.

In light of the new Pap smear guidelines, I hope that U.S. girls and women who get less frequent Pap tests will more frequently ask their healthcare practitioners to educate them about cervical cancer, about the full range of STIs, and about FDA-approved vaccines against viruses that can be sexually transmitted (HPV and Hepatitis B).

For the medical facts about HPV and HPV vaccines, check out the book The HPV Vaccine Controversy by Shobha Krishnan, M.D., a member of the Medical Advisory Board of the National Cervical Cancer Coalition. 

The Bottom Line: a recommendation for less frequent Pap tests does not mean you should forgo your annual pelvic exam. In our busy lives, e-reminders can make the difference:  PromiseToMe.com allows you to schedule an annual email reminder. [Note for boys/men: make sure to get an annual sexual health exam, too!]

On this national day of gratitude, I find myself giving thanks for many things — including my family, my friends, and my health. I owe my sexual health to the now outdated norm of getting annual gynecological exams, with Pap smears, from the time I became sexually active. As a 20-year-old, in the mid-1990’s, I benefited from U.S. medical guidelines that supported my gynecologist in recommending cryosurgery (application of liquid nitrogen) to kill/remove the HPV-infected cells on my cervix. Early detection and early treatment afforded me a quick recovery from a potentially cancer-causing and highly contagious sexually transmitted infection. Following that treatment, I never had another abnormal Pap test result, got pregnant the first time I tried, and gave birth to a healthy baby. For all of those outcomes, I give thanks.

Today, many teen girls and women may not benefit from the level of medical care that I received. Last week, the American College of Obstetricians and Gynecologists (ACOG) issued new guidelines for pap smear and cervical cancer screening, and this may prove to have unintended, negative consequences for sexually-active Americans.

Until 2008, ACOG had recommended annual screening for women under 30. This month, ACOG summed up their revised recommendations:

…women should have their first cancer screening at age 21 and can be rescreened less frequently than previously recommended. 

Media coverage of this latest revision has not done as good a job distinguishing that a Pap test is just one aspect of a pelvic/sexual health exam. How many girls and women will interpret the new guideline of “No need for an annual pap tes,” as, “No need to get an annual pelvic exam”?

ACOG admits that the Pap test has been the reason for falling rates of cervical cancer in the U.S.

Cervical cancer rates have fallen more than 50% in the past 30 years in the US due to the widespread use of the Pap test. The incidence of cervical cancer fell from 14.8 per 100,000 women in 1975 to 6.5 per 100,000 women in 2006. The American Cancer Society estimates that there will be 11,270 new cases of cervical cancer and 4,070 deaths from it in the US in 2009. The majority of deaths from cervical cancer in the US are among women who are screened infrequently or not at all.

So, why revise the guidelines such that we are likely to see an increase in the number of U.S. women “who are screened infrequently or not at all”?

And, it’s not just teen girls and young women that are the focus of these revisions. ACOG also recommends that older women stop being screened for cervical cancer:

It is reasonable to stop cervical cancer screening at age 65 or 70 among women who have three or more negative cytology results in a row and no abnormal test results in the past 10 years.

How much of this rationale depends upon women over 65 years old being sexually inactive or monogamous? This argument seems predicated upon ageist assumptions about older women’s sex drives and sexual behaviors (or lack thereof).

As the tryptophan from my Thanksgiving feast begins to dampen my ire, I’ll bring this post to a close. These are just a few of the problematic aspects of this new policy recommendation — stay tuned for “Part II” of this post in the near future.

Welcome to the first official post for Bedside Manners. As a sexual health researcher and book author, I receive a lot of emails from women and men who are dealing with sexually transmitted diseases. Yesterday, I replied to Liza, a 25 year-old married, monogamous woman who had just been diagnosed with a serious cervical HPV infection and treated via LEEP. She could not understand how this had happened, since she had been getting pap smears during her annual gynecological exams for the past 10 years, and her husband had never been diagnosed with genital warts. Her doctor told her it was “bad luck,” and now she is worried about the possibility of having an oral HPV infection, wondering whether her cervical infection is cured, and trying to figure out how to this will affect her marriage.

By getting annual pap smear exams, Liza has been doing the right thing. Unfortunately, most medical practitioners don’t explain that pap smears only sample a small area of a woman’s cervix. So, it is possible to receive a “normal” pap smear result when there are HPV-infected/abnormal cell changes in other portions of the cervix.

With Liza’s husband as her only sexual partner, it’s key for him to get thoroughly examined for HPV/genital warts. If HPV-infected cells are found, then he should have them removed via one of several treatment options. Once both of their bodies have healed from treatments, the couple should strongly consider using condoms during sex (note: condoms reduce but do not eliminate the risk of HPV transmission).

Given Liza’s concern about oral HPV, a ‘HPV test’ can determine the specific strain of the virus. HPV 16 has been linked to cervical cancer and to oral/head/neck cancers. So, an important follow-up exam after receiving a genital HPV diagnosis is to see a dentist: I encouraged her to share that she’s been exposed to HPV orally and request a thorough exam.

As I concluded my reply to Liza, I realized that I needed to address the stress that she was clearly experiencing. Medical sociologists have often written about how disease can cause dis-ease, an illness often causes a patient to lose her sense of wellbeing. In the case of socially stigmatizing and medically incurable infections, like HPV, stress is almost unavoidable for newly diagnosed patients. In my book, Damaged Goods?, I detail specific strategies for handling the variety of stressors that come with a genital HPV or herpes infection, but I’ve decided to wrap up today’s post with a general note about stress.

I was fortunate to attend a talk last night by the authors of a new book, The Inner Game of Stress. Tim Gallwey has teamed up with two physicians, who practice a patient-centered approach to integrative medicine, to combine medical research with his executive coaching techniques. The result is a thoughtful self-help approach to stress management that encourages readers to be assertive patients. As a medical sociologist, I have written about the health impacts of practitioner-patient interactions and was familiar with the body of research showing how stress can weaken a person’s immune system.

For people, like Liza, who are battling a virus, it is important to not only empower yourself with knowledge about your particular illness but also to strategize how to strengthen your immune system. In addition to the obvious recommendations of decreasing unhealthy behaviors and increasing healthy ones, I encouraged her to find sources of emotional and social support. Some who are facing a stigmatizing illness may find comfort by talking with trusted friends, while others may prefer the neutrality of a therapist, and many may find empowerment in a book. 

Here today is Adina Nack with a fantastic guest post on how STD stereotypes have led to the mismarketing of the HPV vaccine as a cervical cancer vaccine. An associate professor of sociology, who has directed California Lutheran University’s Center for Equality and Justice and their Gender and Women’s Studies Program, and author of Damaged Goods?, Adina asks some provocative questions about the consequences this gendered mislabeling will have for public health awareness. –Kristen

The “Cervical Cancer” Vaccine, STD Stigma & the Truth about HPVby Adina Nack

You’ve probably seen one of Merck‘s ads which promote GARDASIL as the first cervical cancer vaccine. Last year, their commercials featured teenage girls telling us they want to be “one less” woman with cervical cancer. GARDASIL’s website features new TV spots which say the vaccine helps prevent “other HPV diseases,” too, and end with, “You have the power to choose,” but do you, the viewer, know what you are choosing?

A clue that this is a STD vaccine appears briefly at the bottom of the screen: “HPV is Human Papillomavirus.” Merck’s goal may have been to appeal to parents who are squeamish about vaccinating their daughters against 4 types of virus which are almost always sexually transmitted. This marketing strategy means that the U.S. public, currently undereducated about HPV, is none the wiser about this family of viruses which infect millions in the U.S. and worldwide each year. When the ads briefly mention “other HPV diseases,” how many realize they’re talking about genital/anal warts and that recent studies link HPV with oral/throat cancers? [You don’t need to have a cervix (or even a vagina) to contract any of these “other” HPV diseases.] Why don’t they want us to know the whole truth about the vaccine?

Branding GARDASIL as a cervical cancer vaccine was aimed at winning public support. But, what are the consequences of a campaign built on half-truths? Today, only females, ages 9-26, can be protected against strains of a virus that may have serious consequences for boys/men and women past their mid-20s. If public health is the goal, then let’s question how our STD attitudes shaped a marketing plan which has, in turn, influenced drug policy.

Marketing a “cervical cancer” vaccine may have appeased some social conservatives who don’t want their daughters vaccinated against any STD, fearing it might promote premarital sex. But, the vaccine will likely soon be available to males, and their anatomy does not include a cervix — will girls get a “cervical cancer” vaccine and boys get a HPV vaccine? The current gender-biased policy supports a centuries old double-standard of sexual morality. Most view STD infections as more damaging to women than to men. Many believe that STDs result from promiscuity — girls/women deserve what they get. So, are we ready to embrace any STD vaccine (including a future HIV vaccine) as a preventive health measure?

Having studied women with HPV, I know that a person can contract the virus from nonconsensual sex or from their first sexual partner — you could still be a ‘technical’ virgin since skin-to-skin contact, not penetration, is the route of transmission. In my new book, Damaged Goods?, I take readers inside the lives of 43 women who have struggled to negotiate the stigma of having a chronic STD. One chapter delves into stereotypes about the types of people who get STDs: these beliefs not only skew our perceptions of STD risk (bad things only happen to bad people) but also can psychologically scar us if we contract one of those diseases. Merck’s branding of GARDASIL makes sense: a typical U.S. teenage girl or young woman has good reason to fear others’ judgments of her — thinking her to be promiscuous, dirty, naïve, and irresponsible — if they knew she’d sought out a STD vaccine. Whereas, getting a “cervical cancer” vaccine feels more like something that a responsible girl/woman would do.

Unfortunately, with GARDASIL taking the easy way out, the U.S. public misses a prime opportunity to learn about this prevalent, easily transmitted disease that is unfortunately difficult to test for. We’ve also lost a chance to take on STD stigma and challenge the population to view sexually transmitted infections as medical problems rather than as blemishes of moral character.

No vaccine is 100% effective and neither are the treatment options for HPV infections. STD stereotypes (particularly negative about infected women) come back to haunt those of us who become infected with diseases like HPV and herpes, which are treatable but not curable. Until there’s a ‘magic bullet’ cure, we should educate ourselves not only about medical facts but also about STD stigma — the anxiety, fear, shame and guilt — that often proves more damaging to the lives of those infected than the viruses, themselves.