The challenges facing the cervical cancer vaccine

Gardasil offers nearly 100% protection against the two most common cancer-causing HPV strains, as well as two others that cause genital warts. But at $360 for three shots given over six months, the vaccine, which was developed by Merck, is among the most expensive on the market. The price tag alone probably puts it out of reach for many uninsured women in the U.S. (as well as those whose insurance companies balk at the cost), not to mention millions of poor women in the developing world, where cervical cancer is a leading cause of death.

Comments

Samson Isberg
There is a cheaper way to avoid cervical cancer, you know…
Anonymous
What is that cheaper way Dr. Isberg?….Total abstinence? As in never in your life have sex? Because any woman that has ever had sex is at risk for HPV infection. I have lived through this so I know how it works.
I was a virgin when I met my husband at 18 years of age. He was 8 years older than I and had previously been married and divorced with 2 small children. We married when I was 20.
After 10 years of clean PAP tests I was low-risk and gave up having them. I had never been with another man. It was more than 10 years before I had another PAP test and I was diagnosed with cervical cancer with angiolymphatic invasion.
The bottom line is that my husbands first wife had received a hyst. years before for having pre-cancer dysplasia caused by HPV.
Was this somehow my fault that I got this disease? Was it his first wife’s fault for passing the virus to him years earlier? Is there even a way to know that it started with her?
They were kids, he had sex before her, maybe he gave her HPV? Maybe her prior boyfriend gave it to her. WHO KNOWS? The options are many and varied and it does no good to point a finger. I got lax in having a preventative test that I thought I no longer needed, so if any of us are to blame, I must take the blame. My body, my responsibility to take care of it.
People have sex, and anyone that has sex with anyone could be at risk for HPV.
ipanema
Tests are under way in older women and in males, who can carry HPV and transmit it to women or develop penile and other cancers.

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There’s an acute need of this vaccine in developing world where local health systems do not support routine Pap smears.
Currently, there’s a plan to run pilot schemes in four countries, care of Bill Gates, the major sponsor. Too expensive for $360/3 shots, I don’t know if the same people can afford.
ipanema
True Anon 9.49. At the moment they are still going to decide on the age of those who will receive the vaccine, it’s 9-26 y.o. as per last press release. Before it was even recommended for approval, there were mixed reviews on this, it’s more on the moralists and its implication to young girls.
Well, Merck is very happy indeed earning billions from this, what with the Vioxx scandal they’ve suffered. At the moment, that’s the price. We can watch another player in the market once GlaxoSmithKline Plc’s rival HPV will be approved. In the meantime, Merck is grinning.
Anonymous
I am mixed on this, but as someone who just had LEEP, and pathology came back as carcinoma in situ, at least there IS a vaccine. I told my frined who has a 9 year old daughter that I will start saving and when I have the money, will treat her daughter to the vaccine.
Now that it’s here, we just need to keep fighting to get it cheaper. I HATE the moral arguments.
As well, I did not even know about HPV until my pap came back abnormal. For me, if nothing else, that has opened up awareness on the std and dialogue.
So Merk is making money, this still can save lives.
Anonymous
I am mixed on this, but as someone who just had LEEP, and pathology came back as carcinoma in situ, at least there IS a vaccine. I told my friend who has a 9 year old daughter that I will start saving and when I have the money, will treat her daughter to the vaccine.
Now that it’s here, we just need to keep fighting to get it cheaper. I HATE the moral arguments.
As well, I did not even know about HPV until my pap came back abnormal. For me, if nothing else, that has opened up awareness on the std and dialogue.
So Merk is making money, this still can save lives.
ipanema
Yes, it’s Gardasil or nothing at the moment.
diora
Currently women in the US are advised to have yearly PAP tests.
This is not correct. USPSTF recommends that after 3 normal pap smears, women can have them every 3 years since every single study shows NO incremental benefit of doing it more often – most cases of cervical cancer are in women who hadn’t been tested for over 5 years. ACS is a bit more conservative and says that women under 30 still do it every year, but those over 30 do it less often. ACOG makes additional exception from ‘less-often’ rule for women who engage in high-risk behaviors, but according to USPSTF there is no evidence for it.
If you don’t believe me – feel free to look up recommendations from major organizations yourself.
Of course, doctors keep forgetting to mention these new recommendations…
Anonymous
A revision for diora, In the part of the country I live in OB/GYNs still recommend women have yearly pap tests!
Personally, I think it’s a great idea!
diora
Anon at 11:27, ObGyns are supposed to follow evidence-based guidelines not make them. In my post, I wasn’t talking about what individual doctors do or don’t do. I was talking about the evidence-based guidelines from USPSTF.
The same page points to clilnical considerations which explain the reason for the recommendation and also reference somewhat different recommendations American College of Obstetrics and Gynecology (ACOG) and American Cancer Society (ACS). These are evidence-based guidelines. This is what I was referring to.
You may ask doctors in your part of the country why they ignore USPSTF and what kind of evidence they have for doing so. I am sure ObGyns who read this blog will explain why they fail to mention latest guidelines to their patients – with appropriate studies and all.
Of course, you are entitled to your opinion. I am sure you can also show some evidence that screening every year as opposed to screening every 3 years saves lives and not just results in more false positives. It’ll be nice if you read the evidence behind USPSTF recommendations as well.
For the record – I was not expressing my opinion in the post, I simply mentioned recommendations.
Anonymous
This is a much more complicated issue than people realize (that is, the cost of the vaccine and whether or not it is worth it):
First, several things are not being as well emphasized in the current media campagn around HPV and the vaccine. One is that 85-90% of women exposed to oncogenic HPV subtypes will clear the virus on their own within 1 year of exposure. So while plenty of women will get infected, only 10-15% will go on have persistant HPV disease leading to cervical dysplasia. That process (ASCUS, leading to CIN1, leading to CIN2/3, leading to CIS, and then to invasive cervical cancer) takes many years (15-20).
Second off, one should note that we have a fairly good system in place for contending with the burden of oncogenic HPV (16,18) disease: pap smears. Routine pap smears during that time should pick up changes and lead to interventions to prevent the development of disease. They’re not entirely cheap (annual US cost of approximately $3 billion for doing them, following up on spurious results, following up and treating early cervical dysplasia). However, the incidence of invasive cervical cancer in the US is low (relative to lung cancer, breast cancer, colon cancer, heart disease): about 10,000 cases per year, about 3500 deaths per year. Of course, any case is tragic, as is any death, but we’re talking money and cost right now. Of the $3.7 billion (US) total spent on HPV-disease in the US (most recent numbers are from 2003, I think), the cost of treating cervical cancer (those 10,000 or so cases) was only about $150million.
Now, let’s look at the vaccine: it’s good for only 2 of the 30-40 oncogenic HPV subtypes. HPV16 and HPV18 cause, together, about 2/3 of cervical cancers. So no vaccinated or not, women will still need routine pap smears. You don’t save that $3 billion in pap costs. You may reduce, by 2/3, the $150m in costs associated with cervical cancer, and you’ll reduce by 2/3 the costs of treating cervical dysplasia caused by HPV16 and 18. And then you’re going to add a significant cost. How much? A birth cohort is 4 million kids per year. Half are girls. Set the capture rate at 70% and you end up spending about $500 million per year for vaccine. Not bad, you might think, but you’ll never get herd immunity because you’re not immunizing the males! So men can still spread oncogenic and non-oncogenic HPV willy-nilly.
Will it help some? Probably. Will it help more overseas in developing countries? Definitely. Are there cheaper ways to prevent cervical cancer? Probably.
It’s never as easy as it looks.
Anonymous
anon 10:39, thank you for this explanation. It was a couple years after being diagnosed with cervical cancer with invasion that I asked how long it had taken it to get to that point. My onc/GYN told me some where between 10-20 years.I had not had a pap for about 10 years but my ones prior to that had never showed a problem. But, I had been married almost exactly 20 years. I must havce gotten HPV on my very first encounter.
This disease is very very stressful not only in the fact that you have cancer but the knowledge that it came from a sexual encounter. So then you have cancer and are also made to feel ashamed of it. It ruined my marriage before I put it in perspective. I was having no part of STD, and if I had cancer because of one, then it had to be “his” fault. It’s really a shame I didn’t have all the info back then, to make educated decisions. My answers came to late. I hope doctors now do a better job of explaining this diagnosis right at the time it is made. Marriages could depend on it.
ipanema
Will it help more overseas in developing countries?Definitely.
Really appreciate your detailed explanation, Anon 10:39. It’s enlightening.
This is actually good news for people in developing countries but price will definitely be a major reason why people can’t avail of such vaccine. If there are cheaper alternatives then I think it must be put forward.
Sadly, this is no means a guarantee for the spread of HPV, as you mentioned, men are not vaccinated.
Anonymous
I will be starting treatment for cervical cancer in about 6 days. Radiation and chemotherapy are my treatments. My cervical tumor is too big for surgery. IT’s 7 x 7 cm. I am almost 40 and have never missed a pap smear. I had 2 in the past 24 months that were normal, as well as all previous ones. I am completely baffled about how this can be. How do I go from normal to invasive cancer stage 2b in less than 16 motnhs? I had one partner prior to marrying my spouse, who was a virgin, so I am guessing I was exposed 20 years ago at 19 with my first sexual encounter. Of course, this is based on the knowledge that it takes 10 plus years to reach my stage. Naturally I am scared to death, my lymph nodes are also involved. I do have a strange family cancer case. My mother had tongue cancer, but has never smoked in her life and consumes little alcohol. I know there are studies to link the two cancers. I would like more information on this and will be researching it. We both had/have squamous cell cancer. Seems like some similarities. If anyone has any info for me, please post. Thanks.
Anonymous
anon, 10:00…I don’t have any information about a link between the two cancers you speak about. I wanted to offer you my support as you face this treatment plan. I was just a little luckier with my diagnosis. My cancer was a 1-B when diagnosed. I also had radiation though and a radical hyst. It is brutal treatment, but I beat cancer and so can you. I think the survicor rates for 2-b are quite good. I also was concerned about my prior paps being so good and then finding out I had this HPV for something like 20 years. Its all very disturbing and confusing. If you would like to talk more privately just let me know and I will give you my email address.
Best of luck to you!
Anonymous
anon 2:24pm – Would love to talk to someone who has faced and beaten this! My email is susan_iyv2001@hotmail.com Thank you for the offer.
Anonymous
At least in the U.S. you have that vaccine, here in Israel I can’t get it no matter how much I’m willing to pay. It’s ironic that finally there is a vaccine to some kind of cancer, but it’s not available. My clock’s ticking, I’m already 25. I would pay the equivalent of $360, but that won’t get me the vaccine…
Anonymous
Sometimes it pays to be the shy ones on campus – my husband and I were virgins when we met and have been together ever since…
None of the textbooks covered our situation – they covered virgins or assumed multiple partners.
My risk of cervical cancer is tiny….
You’re never out of the woods though – breast cancer is a concern, several friends have it and I have a couple of risk factors.
I think the best way of protecting yourself is to be informed – don’t listen to half-truths and scare campaigns – get to the facts.

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