But some experts remain unconvinced, saying policy makers rushed into a pricey immunization program when there is no epidemic of cervical cancer, which can already be screened through regular Pap smears.
In a Canadian Medical Association Journal article last year, four researchers led by epidemiologist Abby Lippman of McGill University urged a more prudent course.
The New England Journal of Medicine echoed similar feelings in an editorial two weeks ago. "With so many essential questions still unanswered, there is good reason to be cautious about introducing large-scale vaccination programs," it said.
Says the reader:
This study on its own won't change your mind, but maybe the drip, drip of these findings will eventually give you pause.
Let's think about this. Effect of allergic reactions:
The allergic reactions included nausea, itchy red rash, difficulty breathing and other symptoms.
Now let's talk about what happens when you get an abnormal pap. First, they test for HPV. If that comes back positive, they microscopically examine your cervix for cancer. If they decide you're in danger, here are your treatment options:
- Total hysterectomy: Surgery to remove the uterus, including the cervix. If the uterus and cervix are taken out through the vagina, the operation is called a vaginal hysterectomy. If the uterus and cervix are taken out through a large incision (cut) in the abdomen, the operation is called a total abdominal hysterectomy. If the uterus and cervix are taken out through a small incision in the abdomen using a laparoscope, the operation is called a total laparoscopic hysterectomy.
- Bilateral salpingo-oophorectomy: Surgery to remove both ovaries and both fallopian tubes.
- Radical hysterectomy: Surgery to remove the uterus, cervix, and part of the vagina. The ovaries, fallopian tubes, or nearby lymph nodes may also be removed.
- Pelvic exenteration: Surgery to remove the lower colon, rectum, and bladder. In women, the cervix, vagina, ovaries, and nearby lymph nodes are also removed. Artificial openings (stoma) are made for urine and stool to flow from the body to a collection bag. Plastic surgery may be needed to make an artificial vagina after this operation.
- Cryosurgery: A treatment that uses an instrument to freeze and destroy abnormal tissue, such as carcinoma in situ. This type of treatment is also called cryotherapy.
- Laser surgery: A surgical procedure that uses a laser beam (a narrow beam of intense light) as a knife to make bloodless cuts in tissue or to remove a surface lesion such as a tumor.
- Loop electrosurgical excision procedure (LEEP): A treatment that uses electrical current passed through a thin wire loop as a knife to remove abnormal tissue or cancer.
If they don't do any of these procedures, what they do is watch you, with an eye to doing one of them in the future if there are any changes.
Nausea and/or a rash, or hysterectomy? We report, you decide.
Thanks, Megan, your report on this is so much more important than the government pointing assault rifles at potential protesters in Minneapolis-St. Paul.
I love libertarians. They gotta defend some crazy VP pick of the Republicans against attacks no one is making before they can even talk about civil rights abuses.
I love libertarians. They gotta defend some crazy VP pick of the Republicans against attacks no one is making before they can even talk about civil rights abuses.
Well, I love the firemeganmcardle crowd. They gotta bring up all sorts of irrelevant crap in a thread about HPV vaccines.
And "potential" protesters? Who are they? People who might, at some unknown future date, protest something?
I find Megan's argument about comparative severity interesting. However, a more complete argument would look at the frequency of complications from the vaccine with the frequency the cancer occurs. If they are similar, than the severity of the cancer and its treatment argues for the vaccine. If the side effects of the vaccine are much more common, perhaps they aren't worth the risk.
My primary concern, Megan, is that the HPV vaccine will encourage riskier behavior. Not just sexual behavior, mind you, but decreased compliance with screening protocols. The approval process was fast-tracked, so we quite simply lack good long-term data on the duration of immunity conferred by the vaccine. (Not to mention that it doesn't extend to all strains of the virus). It's being sold with the promise of providing permanent protection, and it may lead to a false sense of security.
I think much of the problem can be traced to the privatization of the process. Allowing drug companies to launch lobbying and advertising campaigns on behalf of a vaccine is a terrible idea. It's led to overstated claims, over-dramatic hype, and a foreshortened timeline. It would have been far better if public health agencies had been in charge of the education and awareness campaigns.
It's important to know what markets are good at, and what they're not. Government isn't as good at developing cures as profit-driven corporations that are properly incentivized. But those same corporations are incapable of weighing, assessing, and balancing the complex costs and benefits that determine public health policy - they will always, instead, try to maximize their own profits, whatever the public costs. So private development and public marketing is a perfect strategy. In this case, it sure looks like a promising vaccine was rushed to market a little too quickly. We haven't been able to develop data on when/if booster shots will be needed; on how the immunity from HPV translates to lower rates of cervical cancer; on certain side effects; and on a host of other troubling questions.
I'm a fan of vaccines, and understand your frustration. But in this case, it probably would have made sense to require a full-length study, and then to require universal vaccination.
I want to know why Megan hasn't been posting about the reporters that have been arrested at both the Republican and Democratic conventions.
Oh, they've only arrested reporters at the DNC?
That must be an oversight. The week is yet young.
Whoops, looks like Amy Goodman was arrested.
So I take that back.
Cynic has nailed a portion of this down for everybody. Yes this vaccine is so widespread due to a successful marketing campaign. Its been on rush delivery, so it seems untested (the testing has only been less thorough, it still cleared federal regulators, remember companies tend to actually double up on experimentation to avoid the class-action lawsuit). But the "encouraging riskier behavior" bit, oh that is the juice of the argument. Because its allowed it suddenly becomes preferred? Its funny but people have been talking about the sexual habits of teenagers for over 50 years. Yet it is still shocking that yes your daughter may have waived bye-bye to her virginity before she turned 17.
I would say that if you're worried about her sexual behavior then don't let her leave the house. My father did that to my sister and she hated the double standard, but he was pretty simple about it "18." Unfair or not that was the way it worked.
But I'm going off topic; the main logical problem with the "encourages riskier behavior" thought process is that it means instead of hedging your bets your going all in on black. With the only real reason being a subjective judgment about your daughter's behavior. And thats it, on a personal level you either trust your daughter or you don't.
You may say that the removal of parental decision making is whats really at stake, but they did it for Smallpox. And they've virtually done it for Typhoid, Yellow fever, Whooping cought, Measles, Mumps, Rubella, Etc. (your child will not be allowed to attend most public schools if he/she does not have a standard vaccine regimen). The only reason this seems to be different is it involves sex. Apparently once sex is involved myopia sets in as well.
My wife had cryosurgery a year ago for HPV, and it wasn't a big deal. I don't recall how long a "no sex" rule was in effect afterwards, but I'm pretty sure it was less than six weeks. Two maybe?
Of course it was a bigger deal, and more expensive, than an HPV vaccine. But still, as surgeries go, it's pretty minor.
There is a small but non-zero collection of cases where the HPV vaccine is the most likely cause of death for immunized women. If these are caused by the vaccine, then you can restate the problem:
There is this disease HPV. If I do not participate in risky behavior, then my chance of contracting this disease is very low. My chances of dying from the vaccine is non-zero, but the vaccine prevents significant problems. Is the risk of getting the disease higher than the risk of the vaccine itself? If it is, get the vaccine, or lower your risk. Either one is valid.
The metric is the same as people who are not vaccinating their kids with polio. Here in the US, as many unvaccinated people die with polio as who die from the polio vaccine. Since polio is almost non-existent in the US, you can make a judgement that it's safer to not vaccinate.
Cynic-
The problem with leaving it entirely up to the FDA and their preferred timeline is simple: Incentives.
The FDA has a HUGE incentive to avoid letting out a single product that turns out to be unsafe. They have ZERO incentive to release a product just because it will safe lots of lives.
Over 75% of all adults will, at some point in their lives, contract HPV. What is the "risky behavior?" Not saving yourself for marriage? Or rather, having sex with someone who didn't save themselves for marriage? Because your darling daughter may have sex with only one person, and if he had sex with someone who ever had sex with anyone else, there's a good chance he'll give it to her. This is not AIDS--it's very easy to get, and rampant in the heterosexual population. That's a pretty chancy bet.
Overall I agree with notion that large scale HPV vaccination is a good idea and even mandatory immunization is a good idea, but there are a couple of minor points that need to be raised or clarified.
1) It's too early to know if large scale HPV vaccination will reduce the rate of cervical cancer or preinvasive disease. Most studies currently are just models and projections. Medical models are just as inaccurate as other models in other fields. There is a significant percentage of patients who develop cervical cancer because they don't get healthcare. If you don't reach those who don't usually go get treated, you're vaccinating the wrong people and those projections can be thrown out the window. Those who do get care and still get cancer often have HPV types (or non HPV etiologies) that aren't covered by the current vaccines.
2) You don't have to have a bilateral salpingo-oophorectomy because you have cervical cancer.
3) Pelvic exenteration is extremely rare and only occurs in recurrent centrally located cervical cancer.
4) You forgot the radiation and chemotherapy for cervical cancer.
5) Laser therapy often is better for the patient than the LEEP or cryotherapy. It is technically difficult and a pain to use in the OR.
6) I do not know completely the history behind the HPV vaccine, but a vaccine that is advertised on television is worrisome from my perspective. Drugs on TV is a worrisome proposition as it creates a problem that might not be a problem. Drug companies dictating what is or is not a public health problem is a road I'm not sure any society should walk down.
People are not really worried about getting an itchy rash. They're worried about the long-term effects, which are pretty much an unknown.
Megan McArdle writes:
Now let's talk about what happens when you get an abnormal pap. First, they test for HPV. If that comes back positive, they microscopically examine your cervix for cancer. If they decide you're in danger, here are your treatment options:
Now let's talk about what happens when you do not get a pap:
The large majority of people cure themselves (usually without ever knowing that they had been infected).(Rutgers health education website)
McArdle ends with:
Nausea and/or a rash, or hysterectomy? We report, you decide.
Frankly, only a fool would decide to be vaccinated on the basis of the evidence provided by McArdle.
It seems to me that the worry is that the symptoms of a reaction look like those of anaphylaxis, so even if they're mild or moderate in some cases, people are worried about the severe cases.
ndm:
There's hundreds of different strains of HPV. There are 2 major strains that cause most cervical cancer cases; two major strains that cause most genital warts cases; and the rest of the strains do nothing, or they are rare strains that cause cancer or warts. The vaccine protects against the 4 strains I mentioned.
If a doctor determines that they need to a hysterectomy or LEEP or other surgery it isn't because you simply tested positive for HPV. It's because there is clearly some kind of pre-cancerous or cancerous tissue.
Police in Minneapolis raided multiple homes of people who were going to (ie had not yet) protest the RNC. These people broke no laws and yet were handcuffed for almost an hour with machine guns pointed at their heads.
How is that not the first thing an alleged "libertarian" would blog about? Oh, because it's MM and she's not really a libertarian, she's just a Republican hack who doesn't want to be called a Republican.
k -
I have no reason to doubt your comment and believe it to be consistent with mine. Both point to the naivete of Megan McArdle's comment: "Nausea and/or a rash, or hysterectomy? We report, you decide."
Megan:
I agree it is quite a high dollar bet. The only issue I do have with the HPV vaccine is that they are short on the long-term research. But that is small beans compared to what seems to be a very foolish method of deciding health issues. I think as a parent if you have a daughter it would be smart to look and learn at least.
Megan,
I'm not sure how your post is responsive to my comment. I had in mind two sorts of risky behavior. (And I can't believe that, after writing about seatbelts last week, you don't understand my claim that an elevated sense of protection can lead to riskier behavior that actually negates the gains in safety.)
The first is unprotected intercourse. People are notoriously bad at evaluating risk. The campaign to promote the HPV vaccine has focused on protection. It does, in fact, grant a degree of protection - but not the same degree that the use of condoms, or for that matter, monogamous relationships might provide. I worry about skewing the calculation. (And I'm not principally worried about adolescents. The point is that the vaccine needs to be administered prior to exposure in order to be effective. So, fine - vaccinate 12-year-olds - but what happens when they grow into adult women, and, like most Americans, have multiple sexual partners?) But that, of course, is a critique of the advertising campaign, and not of the vaccine. There's no question, as you write, that the population as a whole is better off being vaccinated. We just need to drive home the message that they're still unsafe.
More worrisome is the impact on screening and diagnosis. The HPV vaccine is targeted at just a few strains of the virus, albeit those that presently account for most cases of cervical cancer. Most, but not all. How will the virus respond to vaccinations? Will strains that are currently more rare spread more widely, limiting its benefits? Will the protection conferred by the vaccine last a lifetime? Will it require booster shots? And here's where it gets a little sticky. We've had a very successful public health campaign, spanning decades, that has convinced most women to get annual pap smears. Those tests have gotten progressively more sensitive and accurate with the introduction of liquid-based pap testing. Obviously, an ounce of prevention is worth a pound of diagnosis. But even the most ardent supporters of the vaccine don't claim it can eliminate cervical cancer, just dramatically reduce its incidence. So we're going to need to go on screening, whether that involves Paps or HPV tests or some combination of the approaches. But that message is getting lost in the euphoria over the vaccine.
My nightmare is that, after a dramatic decline, the incidence of cervical cancer spikes a decade or two from now. That the vaccine turns out not to confer permanent immunity. That just as women are starting to get the message that unprotected sex can lead to cancer, they suddenly have a false sense of protection. That testing and screening decline as the imminence of the threat recedes, and as a result, mortality increases.
None of these are arguments against the vaccine, which is an incontestable force for good in the world. But they are arguments for more research. We don't know how effective this vaccine is, how long its immunity lasts, how the virus will respond, or what its longterm impacts may be. Those are eminently reasonable questions, and I fear that fast-tracking a preventative approach has short-circuited the normal process of careful consideration. It's one thing to fast-track a treatment, something else again to fast-track a vaccine. My hope is that the FDA will ban corporate advertising and lobbying campaigns on behalf of vaccines. That will reduce much of the hype, and most of the risk stems from the hype. I hope that women will embrace the vaccine, but with due caution. And I hope that the long-term studies will confirm its effectiveness. But until they do, making these vaccinations mandatory is much more of an iffy-proposition than you suggest. It's reasonable to impose risk across a population when the rewards are clear. It's less reasonable to do so when they are not.
ndm-
Doh. I see now. I misread yours.
Because I own ADRs in SNY.
Megan-
The last line of your post is unfortunately reductive and not up to the standard of your better posts. You need to quantitatively examine the risk reduction for each of the outcomes being prevented (ranging from anxiety over a pap smear showing dysplasia through to pelvic exenteration), versus the risk increase from the vaccination and also versus the financial costs (whether paid communally or indivudally). For each element multiply risk reduction/increase by the severity, *factoring in personal preferences* (i.e. no single expert panel can decide this) and also factoring in the herd effects of the immunization program.
As a libertarian and a doctor, I will allow that vaccination programs and antibiotic use are rare examples of true network externalities in medicine, and perhaps the only areas in which a roomful of eggheads making decisions for the rest of us has some moral validity. Those eggheads cannot of course know or compute individual preferences for risk (allergic reactions) or financial costs or for risks of not having the vaccination. But in the areas of vaccination and antibiotics there is at least some rationale for allowing the planners to have their way with us, despite the knowledge problem.
Anyway, I think that is why it is reasonable to continue to do centralized cost-benefit-risk analyses in this area at least, and not shoot from the hip with rash versus hysterectomy assessments. If it was a cost of 25 cents per person and a 1% chance of a mild rash to completely prevent a 5% chance of hysterectomy you'd say sure, let's get vaccinated. If it was a 50% chance of a horrible pustulating rash that could get infected, and a cost of $800 per person, in order to reduce the risk of hysterectomy from 0.05% to 0.0499% then you might think it is not worth it. These numbers are all fictitious and extreme of course.
Best, Paris.
Megan:
I agree it is quite a high dollar bet. The only issue I do have with the HPV vaccine is that they are short on the long-term research. But that is small beans compared to what seems to be a very foolish method of deciding health issues. I think as a parent if you have a daughter it would be smart to look and learn at least.
Why not learn about what I'm talking about before criticizing.
Why not provide a link so that I don't wander around news sites wondering what the hell you're talking about (which I did)?
Megan, you are out of your depth and possibly irresponsible for opining on matters you are not qualified to have an opinion on, considering the very real that some women may implicitly trust you and take your post for what would amount to medical advice. You should stick to things that you at least purport to know something about.
As I watched Evita this weekend, I couldn't help but wonder how different Argentina might be today if the HPV vaccine had been available to Eva Peron when she was 12.
Totally unrelated to HPV, but today I got the Kindle I ordered and it better be flippin' awesome or I'm blaming you Megan!
But I'm pretty excited!
I'm very much in favor of the HPV vaccine and have actually searched for, and found, a doctor who is willing to give it to a 32-year-old. However, I've also had a severe allergic reaction to a perscription drug. (An antibiotic called Septra.)
The rash and fever alerted me in time to make it to the ER before my breathing problems hit critical. But I can testify that "breathing difficulty" can be an understatement in that warning.
The warning wouldn't keep me from wanting my child to receive the vacination, nor does it stop me from urging my friends and family to consider the option. But it does raise some red flags that can't be lightly brushed off because I believe in the vaccine.
Fair enough. Funny that you never ask your muse to provide a link.
http://www.salon.com/opinion/greenwald/2008/08/31/raids/index.html
Over 75% of all adults will, at some point in their lives, contract HPV.
Three-quarters of the women in the country will end up with genital warts? Are you sure of your sources here?
There are lots of strains of HPV. Some cause cancer, others cause warts. If you're going to get HPV, the warty one is the one to get, since those DON'T cause cancer.
I think the big issue is that people don't like the government telling them they have to get their daughters vaccinated, particularly with a vaccine that has essentially no long-term testing.
I find it interesting how many people who use "choice," "bodily integrity" and "autonomy" as reasons to support abortion rights no longer care about such things when the issue of getting vaccinated for HPV comes up.
The most effective push for the HPV vaccine has been the pharma companies. I assume you've read the various drug studies and checked to see where the pharma donations went (have you?).
Look at your politicians (BOTH SIDES! ! ! !) and follow the money. The pig-snouts reach deeply into the pharma donation and lobbying feed-bag.
Its pitiful to see the people pointing at the various interest groups ("it's the lubruls" . . .. . "it's the bible-thumpers . . . ".
Helloooooo? These people don't pass laws. Look to the lobbyists and the politicians, and follow the river of money back to the pharma companies
We report, you decide.
Which is precisely what is at issue. People should indeed be free to choose the vaccine or not choose it, but in many jurisdictions, the vaccine is required for public school children.
I'm not necessarily disagreeing with your risk calculus, but it seems to only apply to someone sexually active with people who are infected or whose status is unknown. Someone who is not sexually active, or is monogamous with an uninfected person, suffers all the risk of taking the vaccine and enjoys none of the benefits.
I have two daughters, 13 and 15, and I am not having them vaccinated. Yet. Why should I make my (as yet sexually inactive) kids be the beta test rats for a drug company?
What is telling is what I'm hearing from them about these shots in their peers. Kids fainting, literally crashing to the ground in a dead faint an hour or two after the shots. Some doctors now keep kids for observation after administration of the shots. Their arms are *extremely* sore for days after the shot.
Needs more study. In computing I never install the upgrade till I've heard from a lot of other users that there's a good reason to do it other than nagging by the software producer, and few/no bugs.
With my kids I have time to wait to make sure it's safe.
Oh, and to Ben above, your casual mention of your sister's ordeal with your father chilled me.
"I would say that if you're worried about her sexual behavior then don't let her leave the house. My father did that to my sister and she hated the double standard, but he was pretty simple about it "18." Unfair or not that was the way it worked."
You do know that this is child abuse, don't you?
Just asking. Your sister must still be in therapy, and you're a jerk for being so blase about it.
Oh, and to Ben above, your casual mention of your sister's ordeal with your father chilled me.
"I would say that if you're worried about her sexual behavior then don't let her leave the house. My father did that to my sister and she hated the double standard, but he was pretty simple about it "18." Unfair or not that was the way it worked."
You do know that this is child abuse, don't you?
Just asking. Your sister must still be in therapy, and you're a jerk for being so blase about it.
There are lots of strains of HPV. Some cause cancer, others cause warts. If you're going to get HPV, the warty one is the one to get, since those DON'T cause cancer.
Actually, if you're going to get HPV the one to get are most kinds, which cause neither warts, nor cancer.
Anaphylaxis is not a laughing matter, and I'm surprised that Megan makes fun. Especially since the incidence of cervical cancer is so low.
My major issue is the $/life saved of the HPV vaccine. The same money could be spent for much greater reductions in death, but not in as compelling a manner. The HPV stampede is exactly why cynics and libertarians hate "it's for the children" statements with the fury of a thousand suns. Megan's usually one of those people.
We don't know if the "major" strains of HPV are more likely to cause problems or if they just out compete other strains. The vaccine just could clear the field for other strains (which could be even more dangerous). Some of the most deadly side effects of antibiotics come from the after effects of killing off the typical flora in a patient's body. Less successful but more dangerous bacteria then colonize the skin or GI tract leading to unpleasant to horrific effects.
Some jurisdictions are justifying the vaccine as a way of treating "hard to serve communities" who are uncompliant with screening. Of course these are the least likely to get vaccinated and the most likely to be at risk for HPV. Errr...
Thanks to the narrow effect, people who are vaccinated still must get the annual smear, which has a really scary false positive rate. The vaccine is saving very, very few lives, no money, and won't save any woman from the stress and unnecessary surgery of a false positive.
With better long term data, I'd still be get my hypothetical daughter vaccinated as early as practicable. If my hypothetical daughter ever manifests herself, there will have bee sufficient information to make that decision. But right now we are getting buffaloed by a hysterical panic over "our daughters". The irony is bountiful! But cervical cancer is just not such a huge societal issue that we should have made these decisions. The vaccine is making the anti-vaccine people look sane, and the pro jabbers nuts, while other existing and possible vaccines deal with much more dangerous issues and provide much better benefits in terms of lives and money.
Meg, this is about the only post in the last week that makes any sense.
Whats up with you lately?
Over 75% of all adults will, at some point in their lives, contract HPV.
What percentage contract the HPV strains that the vaccine will actually protect against, or the strains that actually cause warts or cancer?
That would be the relevant statistic.
Megan, at age 22 I had one of those procedures named above because of a Dalkon Shield. I got "lucky" - only needed a total hysterectomy, instead of what my doctors referred to as a "pelvic evacuation." But, going into menopause at that age, not to mention never being able to have biological children, I did not feel hugely fortunate.
I raise this because I was told that the Shield was safe and effective and a wonderful way to not have to worry about pregnancy. Boy; were they right!
While the vaccine for HPV may be exactly what you tout it to be, please excuse some of us for being more cautious and even a bit apprehensive. I know what it is like to be assured by the medical community that something is completely safe - only to find myself close to death and only saved by having half of my insides removed.
Maybe before every girl gets this, we should study what happens to the girls who do get it 10-15-20 years down the road?