Cervical cancer:
Making HPV ‘one less’ problem
As conversations go between mothers and daughters, this topic had a family tradition.
The topic was sex, and as Tahira Wilson-Guillermo, 51, a longtime schoolteacher, tells the story, her mother’s mother unknowingly started the tradition. A devoted Jehovah’s Witness, Tahira’s grandmother believed that you just did not discuss such things and would not have such talk in her house.
The lack of openness had an unintended consequence. Tahira’s mother — the grandmother’s daughter — couldn’t wait to have open and honest talks about sex with her daughter. Because of their close relationship, Tahira, in turn, couldn’t wait to pass that tradition down to her own daughter.
It was of little surprise then when Tahira and her daughter Brittany, 16, a junior at Brimmer and May School in Chestnut Hill, were watching television together and saw an advertisement for Gardasil, a vaccination designed to prevent cervical cancer.
“I want to be one less patient,” said a voice on the ad. “‘One less family turned upside down,’ ‘one less statistic,’ ‘one less sister,’ ‘one less friend whose life might be affected by cervical cancer.’”
The provocative ad prompted an almost immediate mother-daughter talk that covered some well-traveled ground on sexually transmitted diseases (STDs).
Human papillomavirus (HPV) is one of them, and while they are common and include about 100 different types — 80 percent of which are relatively harmless — a handful of the viruses are the leading cause of the majority of cervical cancer cases in the United States.
The ad “caught our attention,” Tahira said. “And Brittany seemed interested. So I asked her to talk with me about that.”
Brittany did, and took the conversation a step further. “She told me that she wanted to have the vaccine,” Tahira said, “and that she would talk with her doctor about it during her next visit.”
That’s the kind of responsibility that Tahira wanted to see in her daughter — as Tahira’s mother wanted to see in her.
Their conversation mirrored a national conversation on HPVs and what exactly should be done to combat the cancer-causing viruses. It is estimated that over 6 million people across the country are infected each year. More than 50 percent of people who have had sex will at some point have the virus, and the majority of those people will be between 15 and 25 years old.
For the most part, HPV infections are harmless and disappear within a few years. But others are not as agreeable. HPV strains 16 and 18 are responsible for 70 percent of all cervical cancers, while HPV strains 6 and 11 are the cause of 90 percent of genital warts.
Although HPV is the single most important risk factor for cervical cancer, other characteristics, such as smoking, HIV infection, and chlamydia, another STD, have an impact.
For her part, Brittany said she was aware of the link between HPV and cervical cancer from sex education classes in the ninth and 10th grades. But what had a greater immediate impact was the television ad touting Gardasil.
She has already had two of the required three shots and is scheduled to have the third in December.
Brittany said she had no reservations about receiving the vaccine. “You’re glad when you have it because you’re protected,” she said.
And that is one of the points of open discussions about sex and all of its potential consequences — protection.
Though it is possible to prevent exposure to HPVs by delaying sexual intercourse, limiting the number of sexual partners, and avoiding sex with people who have had several sexual partners, those methods are not totally foolproof. Neither is the use of condoms; the virus can spread through contact with unprotected skin.
One effective way is Gardasil, as of now the only federally approved vaccination against HPV. Studies have shown it was effective in blocking 99 percent of the transmission of HPV 16 and 18, as well as HPV 6 and 11, the strains responsible for 90 percent of genital warts.
Of note, however, is that HPV 16 and 18 account for only 70 percent of cases of cervical cancer. Roughly 30 percent are caused by HPV types not covered by the vaccine. Therefore, all women are still at risk for other HPV infections and will need to continue regular screening for cervical cancer.
So far, Gardasil has received blue-ribbon support. The Advisory Committee on Immunization Practices, a panel of experts chosen by the secretary of the Department of Health and Human Services for their expertise on vaccine-preventable diseases, recommends routine vaccination with Gardasil for females aged 11-12 and as young as nine. If not administered by the age of 12, catch-up vaccination is recommended for females aged 13-26.
The vaccine is not currently recommended for females over the age of 26.
Although the recommended young age is alarming to some, many doctors and medical experts believe that Gardasil is most effective when administered to females before they engage in sexual intercourse and exposure to HPV. National survey data indicate that 40 percent of girls in this country have had sex by the age of 16. More alarming, ten percent of sexually active ninth-graders claimed to have had more than four sex partners by that time.
Although the federal government recommends vaccination with Gardasil, the Commonwealth of Massachusetts has not as yet mandated it. However, the vaccine is available through MassHealth, the federally funded Vaccines for Children Program, and most private insurers and health maintenance organizations.
Gardasil is not a substitute for routine cervical cancer screening, as it is effective against only HPV 6, 11, 16 and 18, four of the more troublesome types. Recent studies published in September of this year suggest that the vaccine guards against additional HPVs other than 16 and 18 that can cause cervical cancer, but more research is required.
Gardasil is not without its critics. Dr. Sarah Feldman, a gynecological oncologist at Brigham and Women’s Hospital, said the vaccine is clearly promising, but it remains to be seen whether results from long-term studies on women over a wider range of ages will support its potential wonder-drug status.
Initial tests were done on only 25,000 women around the world, and on none between the ages of 9 and 12. In addition, Dr. Feldman pointed out, the vaccine protects against only some of the cancerous HPV types — not all of the estimated dozen or so.
The concern, Dr. Feldman explains, is the potential that women who receive the vaccine will have a false sense of security.
“It’s not the cure-all that people think,” Dr. Feldman cautioned. “We don’t know how safe it really is. We don’t know how long it will last. More testing is needed because many women will feel they are protected but that is not necessarily the case.”
That national debate is playing out inside the decision-making process of Rosario Sanchez. She is 26 years old and is at the edge of being too old to receive the series of Gardasil shots.
Part of the dilemma is cultural and her desire to avoid the stigma associated with a sexually transmitted disease. Sanchez didn’t want her real name to be used. But the larger problem is the medical uncertainty.
She learned about Gardasil from the “One Less” television ad — the same one that Tahira and Brittany watched together — and other promotional material posted throughout Boston subway stations.
Sanchez received further information from the Patient Navigator Program. Co-sponsored by Brigham & Women’s Hospital and Dana-Farber Cancer Institute, the program provides assistance to women with a high-risk breast or cervical finding, or a diagnosis of breast or cervical cancer.
To be honest, Sanchez says she didn’t pay that much attention at first. The one thing she didn’t want, however, was a biopsy for suspicious lesions — a procedure that some of her friends had already undergone.
“I was concerned that the research on Gardasil was still ongoing,” she said. “It made me think that the final results were not available.”
Curious, she did her own research, and received comfort when she learned that the Centers for Disease Control and Prevention had studied Gardasil for years and had recommended its usage.
She admits that it was a difficult decision, but decided to schedule an appointment this October to receive the vaccine.
“I was teetering,” she said, readily conceding that part of her anxiety was due to cultural reasons. “In Latina culture,” she explained, “things are swept under the rug. You do not talk about sex. I could never have had this conversation with my grandmother.”
And the clock was ticking. At 26, her eligibility to receive the shots ends with her next birthday. “I needed to be proactive,” she said. “This was something that I could do for my health. Getting the vaccine would give me one less thing to think about.” And when the time is right, she might start a family tradition of her own.
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| Brittany Wilson-Guillermo (right) was not shy in talking to her mother, Tahira, about Gardasil. They both agreed that the vaccination was a wise decision in preventing cervical cancer. |
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Sarah Feldman, M.D, M.P.H., is director of the Pap Smear Evaluation Center in the Division of Gynecologic Oncology at Brigham and Women’s Hospital and Dana-Farber Cancer Institute.
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