‘Everyone is at risk’
“Every woman is at risk,” doctors say about cervical cancer. But as it turns out, every man is at risk, too, because other cancers are likewise caused by or linked to the human papillomavirus or HPV.
HPV is a family of about a hundred types of viruses, of which seven are found to be “oncogenic” or cancer-causing, with two types—16 and 18—linked to 70-80 percent of cervical cancer cases. But HPV has also been linked to cancers in other sites—the vulva, the anus, the head and neck, the throat, the vagina and the penis.
Most people will get infected with HPV at one time or another because it is spread most commonly by “skin-to-skin” contact, or contact with infected towels, bed sheets, or even makeup brushes. HPV infection can sometimes cause skin warts (which have to be removed by “cauterization” or burning them away) or genital warts, which may be “icky” but do not cause cancer.
But genital warts are also considered “markers” for possible infection by other HPV types, since they are indicators of sexual activity and of HPV infection. During the “HPV Summit” held last Wednesday, I joked with Dr. Cecile Llave of the National Cancer Institute that these days, before jumping into bed with a man, a woman should ask him to strip off his pants so she can check for the presence of genital warts. And if a widower lost his wife due to cervical cancer, it would be a good idea for his future wife to have him undergo an HPV-DNA test to see if he is a carrier of the deadlier HPV types.
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If I have put a damper on your sex drive with all this talk of HPV, don’t worry. Most adults will get infected with HPV in their lifetime, but the majority of infections will disappear in a short while.
In the early part of the last century, a test was also developed for the presence of “precancerous” lesions in or around the cervix. Known as the “Pap Smear,” the test is considered the “gold standard” for cervical cancer screening. But since the “pap” needs lab work done to get the results, in “low resource” settings, like most areas of the Philippines, it can be impractical and costly. This is why the most common test employed today here is the VIA, or “visual inspection through acetic acid wash,” which needs only ordinary table vinegar applied to the cervical area, observed by a trained nurse or midwife for signs of lesions.
The VIA has also been paired with what is called the “single visit approach,” in which visible or suspicious lesions are “cauterized” (“making your cervix a frozen delight” is how Dr. Llave puts it), eliminating the need for a follow-up visit for treatment.
As long as they are detected early, there is a pretty good chance that precancerous lesions can be treated and eliminated, because it takes about 10 years before lesions develop into cancer. Which makes it all the more puzzling and tragic why so many Filipino women die from cervical cancer, the number roughly equivalent to the toll of maternal deaths. And the reason is that too many women have their first screenings done too late.
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The most hopeful news about HPV is that there are now two types of vaccines available in the market that protect young women and men from getting infected with the HPV.
The bivalent vaccine protects from infection from HPV types 16 and 18, which cause most cases of cervical cancer, and the quadrivalent vaccine protects against types 16 and 18, as well as the two most common types causing genital warts.
Previously recommended only for girls and women, the quadrivalent vaccine is now recommended for use on boys and men as well, in the Philippines as well as in the United States and in Australia. Dr. Efren Domingo of the University of the Philippines College of Medicine, who spoke on the vaccines during the “Bulong-Pulungan sa Sofitel,” said early vaccination is recommended “before exposure”—that is, before an individual engages in sexual activity. Which is why guidelines put the “optimal” age for vaccination at between 9 and 12 years old, with “catch-up” immunization for boys and girls between 13 and 26 years old.
But the real bad news for the Philippines is that only about one percent of the target population of preadolescents, teens and young adults have been vaccinated since the introduction of the vaccines a few years ago.
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The most common reason given for this low uptake on the vaccines is cost. The HPV vaccine is given in a series of three injections over six months, with the cost having gone down from P6,500 per dose at the beginning, to P3,500 per dose today, or nearly half the cost.
Representatives of MSD, which developed and markets Gardasil, the quadrivalent vaccine, say that at its current price, “the Philippines enjoys the lowest price for the HPV vaccine in the world.”
Despite the proven efficacy and safety of the vaccine, many factors still keep more people from accessing the vaccine. At present, the vaccine is available only in the clinical setting, among private pediatricians or ob-gyns. And not all doctors are all that convinced about the need for a vaccine among nonsexually active youth.
The Philippine government, except for a few local government units which have made the HPV vaccines a priority, has yet to include these in its expanded program of immunization. In Australia, by contrast, the HPV is given for free, through the public school system, while in the United States, the HPV vaccine is given in the clinical setting, covered by health insurance.
At the “HPV Summit,” a representative of PhilHealth revealed that while state health insurance covers screening for cervical cancer, it has yet to consider insurance coverage for vaccines, despite the proven savings in potential health costs.
