The Cancer Vaccine

By James Hamblin
Artists enact the passing of Jade Goody, who died of cervical cancer at age 27. (Stefan Wermuth/Reuters)

If you haven't yet seen Captain Phillips, I won't spoil it. Since it's a biopic based on events recently in the news, though, I think it's fair to mention that the U.S. Navy deployed a destroyer and a SEAL team to thwart the abduction of a middle-aged guy from Massachusetts.

The cost of days spent tracking and disarming four Somali pirates was enormous financially, but the display of  authority and American idealism had value, as the story goes. People in my theater applauded. I didn't hear whispers that his rescue wasn't worthwhile. It probably wouldn't have been necessary if Phillips' ship had been armed with more than fire hoses.

His life was saved in a very public, American way. In some other, quieter realm are the 4,000 women in the states who die from cervical cancer every year. (On a global scale, cervical cancer kills hundreds of thousands.) Our best data says that 70 to 90 percent of those deaths are preventable by getting vaccinated against one virus. It's a vaccine that's available, that other countries have implemented effectively, and that requires zero confrontations with pirates.

There are also more than 7,000 cancers of the head and neck in the U.S. every year deemed "potentially HPV-associated," according to the CDC. Around 5,700 of those are in men. That's in addition to 3,000 HPV-associated anal cancers (1,100 in men), 2,300 new cases of vulvar cancer, 800 penile, and 600 vaginal. The vaccine could prevent many, though an unclear number, of these cases.

HPV is a sort of piracy, an insidious thing. Once it gets in, it either chooses to leave us intact or does not. We can't cure it. When it causes cancer, it takes the best of modern medicine to beat it back. But we can keep it out. What's striking and immediately actionable is how few people get vaccinated.

The FDA approved the quadrivalent HPV vaccine for girls in 2006, and for boys in 2011. As of 2010, in numbers widely circulated this spring, 75 percent of teenage girls in the U.S. were not up to date on their vaccine. 44 percent of parents said they didn't plan to get their daughters vaccinated, which was up from 40 percent two years earlier. CDC data in August was similarly unnerving: as of 2012, only 33.4 percent of American girls had received all  three doses of the HPV vaccine.

In March of this year, Oklahoma pediatrician Paul Darden wrote in the journal Pediatrics, "Despite doctors increasingly recommending adolescent vaccines, parents increasingly intend not to vaccinate female teens with [the] HPV [vaccine]." 

"Our coverage is not moving forward with the HPV vaccine for girls, and coverage is low for the HPV vaccine for boys," Dr. Melinda Wharton, deputy director of the CDC's National Center for Immunizations and Respiratory Diseases, said in August of the lack of increase between 2011 and 2012.

Meanwhile in Australia the boys are 70 to 80 percent, and girls approach 100. In Rwanda more than 80 percent of teenage girls are vaccinated.

If the United States could reach the same vaccination rates as Rwanda, according to the CDC, it would prevent 50,000 girls alive today from getting cervical cancer.

In media coverage the HPV-unvaccinated are often lumped together with the measles-unvaccinated, Jenny McCarthy-hysteria crowd. It's an oversimplification, though, fortunately and unfortunately, to say that ignorance the primary burden. Other vaccination rates are on the rise where HPV is not taking. The HPV vaccine is expensive, stigmatized, and, still too-often, not mentioned by doctors.

In research out this week, a team at the University of Texas Medical Branch at Galveston Department of Obstetrics and Gynecology led by Mahbubur Rahman reported some interesting trends in why people don't get vaccinated. They saw that vaccination initiation and completion correlated with age, marital status, education, income, routine medical check-up during the past year, flu vaccination, and health care coverage.

"Women with lower incomes were less likely to initiate the HPV vaccine," Rahman wrote in the medical journal Vaccine, "which has been reported as a common trend." The same was true for women without healthcare coverage. Lack of insurance was a "major barrier ... due to the high cost of the vaccine."

Vaccination programs, though, have been shown to overcome socioeconomic disparities. Rahman writes that "assistance for low-income adults could eliminate disparities in HPV uptake among this population."

His primary observation was that young adult women in the American South—where there's more poverty and more cervical cancer—had the lowest HPV vaccine uptake rates, by a significant margin.

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(CDC)

Comparing data from sample states in the Northeast, Midwest, West, and South, the Northeast has the highest rates. There, 37 percent of girls started (and 23 percent completed) the vaccine series at some point during the three years of data collection. In the South, those numbers were 14 and 6 percent, respectively.

"It would not be an overstatement," they write, "that the HPV vaccine uptake is the lowest in the U.S. where it is needed the most ... Thus, there is a need to design strategies to improve the HPV vaccine uptake in the South, to lower the burden of HPV-related diseases and cancers in the long run."

"Moreover, it needs to be examined whether regional or state level policies contribute to this regional variation." That is, some states have championed policies that would require HPV vaccination as part of standard public-school requirement. Should that be the norm? Is distrust of the medical establishment so ingrained in some communities that this would only further seed distrust, of schools, by association?

Rahman told me that school-oriented legislation is a reasonable place to start, with appropriately tempered expectations. Since 2006, legislators in at least 42 states and territories have introduced legislation that would require, fund, or promote public-school education about the HPV vaccine. Most were not enacted. New Hampshire, an outlier, was quick to announce in 2006 that it would provide the vaccine at no cost to girls under 18. In 2007 the governor of Texas mandated that all girls entering sixth grade receive the vaccine, but that was overridden by legislature. The District of Columbia does have a requirement for girls entering school, as does Vermont, though exemptions are allowed on the basis of "moral or religious beliefs." (When is it morally defensible not to vaccinate a kid against cancer?) 

In the U.K., a British National Health service program lets teenagers get the vaccine without parental consent. They have even incentivized it with shopping vouchers. Even factoring in the vouchers, it costs the system much less than chemotherapy. In the United States, meanwhile, only 45 percent of adults are in favor of allowing teenagers to get vaccinated without parental consent, much less baiting them with gift-certificates or imposing law.

Solutions, Rahman says, must address the multifactorial nature of the disparities. They begin with perception and end with access. In between are focused education initiatives and awareness campaigns, especially in places most deprived. Appreciating the grand potential of this vaccine, in terms of money saved and lives lost, should guide its incorporation into American culture. What's needed, Rahman says, is consensus.

In the 2009 rescue of Captain Richard Phillips, Navy SEALs managed to simultaneously execute three pirates on a moving platform at sea in the dead of night. Look what we can do. We've also created a multimillion dollar robot that can excise pelvic tumors. Look how high-tech our hospital is. The more impressive thing is rendering it unnecessary.

This article available online at:

http://www.theatlantic.com/health/archive/2013/11/the-cancer-vaccine/281365/