Guest Column: Who is Cancer Charlie, and how do we stop him?
Who is Cancer Charlie, and how do we stop him?
By Robert Hatcher, MD, MPH
Professor, Gynecology and Obstetrics
Emory University School of Medicine
It is now widely accepted that cancer of the cervix is caused by infection with the human papillomavirus (HPV). The infectious etiology of cervical cancer was first suggested when the second wives of some HPV-infected men whose first wives died of cervical cancer also developed the disease.
Cancer Charlie is an actual man. Decades ago, he came to the attention of one of the leaders in obstetrics and gynecology who helped elucidate the story of HPV as the primary cause of cervical cancer. Cancer Charlie caused cervical cancer in four women. He looked like any other man. None of the four women who were infected by him with the human papillomavirus could tell by looking at him that he was potentially a threat to them.
It is worth saying this again: Cervical cancer is the result of an infection. Health care providers now have an effective tool to prevent such disease in Gardasil, a vaccine that prevents infections by four types of genital HPV (6, 11, 16, and 18). Infections by these four HPV types are now being prevented in millions of women by this vaccine. Large multicenter studies in young women indicate that the vaccine is nearly 100% effective in preventing infection with these HPV types and importantly, in preventing associated cervical cancer.1,2 The Advisory Committee on Immunization Practices (ACIP) now recommends that the vaccine be routinely given to girls when they are 11 to 12 years old, with the recommendation allowing for vaccination of girls beginning at age 9, as well as vaccination of females ages 13 to 26.3 In the best-case scenario, the vaccine is provided to young women before they ever have intercourse.
Stop Cancer Charlie!
It is soon going to be possible to stop Cancer Charlie! Gardasil might be available for men by the end of 2009, if the vaccine is approved for such use by the Food and Drug Administration (FDA). If Cancer Charlie had received Gardasil as he entered the teen years, he would have been immunized against the two strains of the HPV virus (16 and 18) that cause about 80% of cases of cervical cancer in women and also can cause penile cancer in men. If he had been immunized with the Gardasil vaccine, Cancer Charlie most likely would not have caused cancer in those four women, and the spread of infection would have been stemmed.
Once the vaccine is available to men and women, it will be important to remember that not all the cancer-causing serotypes of the human papillomavirus virus will be prevented. Sexually transmitted, high-risk HPVs include types 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66, 68, and 73.4 Women and men will need to use condoms to prevent the other HPV types that cause cervical cancer. Use of condoms also will prevent infection from other noncancerous HPV types. Types 6 and 11 usually cause visible genital warts (condyloma). Genital warts might be on the rise. Statistics from the National Health and Nutrition Examination 1999-2004 survey indicate 5.6% (95% CI: 4.9-6.4) of sexually active 18- to 59-year-olds self-reported a history of a genital wart diagnosis.5
Data underscore safety
The question young men and women will ask of the HPV vaccine is "Is it safe?" Since the vaccine was approved, the FDA and the Centers for Disease Control and Prevention (CDC) have monitored its use. Three systems are in place to oversee the safety of all vaccines:
- Vaccine Adverse Event Reporting System (VAERS), which helps the CDC and the FDA detect possible side effects or adverse events following vaccination.
- Vaccine Safety Datalink Project, a joint project that calls on the CDC and eight health care organizations to study patterns in reports detected by VAERS and determine if a vaccine is causing a side effect.
- Clinical Immunization Safety Assessment Network, a project coordinated by six U.S. academic centers that researches adverse events that might be caused by vaccines.6
According to the CDC, more than 24 million doses of Gardasil were distributed in the United States as of May 1, 2009. As of that same date, there were 13,758 VAERS reports of adverse events following Gardasil vaccination in the United States. Of those reports, 93% were regarding events considered to be nonserious, and 7% were reports of events considered to be serious.6 As of May 1, 2009, the CDC says there been 39 U.S. reports of death among females who have received the vaccine. Twenty-six of those reports have been confirmed, six still are under investigation, and seven remain unconfirmed due to no identifiable patient information in the report (such as a name and contact information to confirm the report).6 In the 26 reports that have been confirmed, there was no unusual pattern or clustering to the deaths that would suggest that they were caused by the vaccine, says the CDC.6
- Ault KA, Future II Study Group. Effect of prophylactic human papillomavirus L1 virus-like-particle vaccine on risk of cervical intraepithelial neoplasia grade 2, grade 3, and adenocarcinoma in situ: A combined analysis of four randomised clinical trials. Lancet 2007; 369(9,576):1,861-1,868.
- FUTURE II Study Group. Quadrivalent vaccine against human papillomavirus to prevent high-grade cervical lesions. N Engl J Med 2007; 356:1,915-1,927.
- Markowitz LE, Dunne EF, Saraiya M, et al. Quadrivalent human papillomavirus vaccine: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 2007; 56(RR-2):1-24.
- Munoz N, Bosch FX, Castellsague X, et al. Against which human papillomavirus types shall we vaccinate and screen? The international perspective. Int J Cancer 2004; 111:278-285.
- Dinh TH, Sternberg M, Dunne EF, et al. Genital warts among 18- to 59-year-olds in the United States, national health and nutrition examination survey, 1999-2004. Sex Transm Dis 2008; 35:357-360.
- Centers for Disease Control and Prevention. Reports of Health Concerns Following HPV Vaccination. Accessed at www.cdc.gov/vaccinesafety/vaers/gardasil.htm.
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