Health

The cervical cancer puzzle

Data on cervical cancer suggests we do not need HPV vaccine, especially when there is doubt about its efficacy

 
By Vibha Varshney
Last Updated: Saturday 09 June 2018

The vaccine offers protection only from two strains of HPV. Credit: Health. milThere is a big push in India to vaccinate adolescent girls against human papillomavirus (HPV) which causes cervical cancer. HPV Information Centre, which puts down cervical cancer as the second leading cause of deaths among women in India. The vaccine, which comes at Rs 3,000 per jab, is a big business. Each child needs at least two doses. Market research shows that global HPV vaccine market is likely to grown to USD 3.5 billion by the end of 2025, up from USD 2.0 billion in 2016. The market finds additional prospects in young boys who, too, need to be vaccinated as they are reservoirs of the virus and could infect the girls.

Countries, however, are divided on this front.

But HPV vaccine is contentious

In India, the central government continues to debate whether the vaccine should be included in the universal immunisation programme despite recommendations of the National Technical Advisory Group on Immunisation, an advisory body constituted by the government itself. Trials carried out in India have been mired with controversy as they resulted in deaths of eight girls in 2008. A PIL was filed in the Supreme Court and it is quite likely that the government would be able to take a decision on the inclusion of this vaccine in the immunisation programme only after the verdict.

Recently, a person used a false name and affiliation to Karolinska Institutet in Sweden to publish a paper in Indian Journal of Medical Ethics, saying that HPV vaccine was the reason for recent increase in the number of cases of cervical cancer in parts of Sweden. According to media reports, the paper has been retracted and Karolinska Institutet has clarified that this person does not work for them.

Dip in cervical cancer cases 

There is another conundrum. If we go by data, there is evidence that between 2006 and 2016, there has been a decrease in cancers caused by infectious agents such as cervical cancer despite an overall increase in cancer cases across the globe. These findings have been published in the journal JAMA Oncology on June 2. This trend has also been seen in India where cervical cancer was, historically, the most predominant of cancers.

A study published in 2009 in Indian Journal of Medical Research shows that in urban population-based cancer registries such as those in Bengaluru, Bhopal, Chennai, Delhi and Mumbai, there has been a significant decrease in cervical cancer. For example, the data shows that in urban areas like Chennai, the reduction in age adjusted rate was from 42.3 per 100,000 population in 1982-83 to 22.3 in 2004-05.

This happened without using HPV vaccine.

But if this is the case, should we even go in for vaccination? At the recently organised 1st Conference on Environmental and Occupational Determinants of Cancer: Intervention for Primary Prevention, this question was asked to the panelists who justified vaccination saying that reduction is seen only in urban areas and vaccination is important to protect people in the rural areas. This is supported by the fact, which the paper in Indian Journal of Medical Research also showed, that in rural areas such as Barshi, the decline was merely from 23.5 (in 1988-89) to 22.8 (in 2004-05).

But the problem is that the vaccine offers protection only from two strains of HPV. Other than the virus, other risk factors include early marriage, multiple pregnancies, poor genital hygiene of both men and women, poor healthcare facilities, lack of testing facilities, poor diet and smoking.

These risk factors are modifiable and instead of depending on vaccine, improving the environment might be a better strategy. If these worked in, what are now, the urban areas in India, they would surely work across the country. As of now, most of the uptake of the vaccine is in urban areas, where it is not needed.

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  • Why be so selective? Don't those 2 viruses account for more than 70% cervical cancers?

    Posted by: Vinay Kulkarni | 6 months ago | Reply
    • HPV strains 16 and 18 can lead to cervical cancer only if the viral load is high. Environmental and lifestyle factors such as availability of sanitation, improved diet and protection from tobacco smoke can keep the viral load down. There is no reason to disregard these basic things and insist on vaccines. The very fact that the incidence has gone down without vaccine suggests that other factors are crucial.

      Posted by: Vibha Varshney | 6 months ago | Reply
  • You are having your data incorrect. Only where there were structured screening programs it has gone down. It is not viral burden but persistence is critical. That vaccine is not cost effective at current price is given. But really one needs to stop this anti vaccine tirade.

    Posted by: Vinay Kulkarni | 6 months ago | Reply
    • Using published data to show that cervical cancer incidence can be brought down by environment/ lifestyle modification cannot be called as being anti vaccine. When we find that screening is effective, we should be willing to say so and not demand a vaccine.

      Posted by: Vibha Varshney | 6 months ago | Reply
  • I would respond point by point.

    There is a big push in India to vaccinate adolescent girls against human papillomavirus (HPV) which causes cervical cancer.

    True.

    HPV Information Centre, which puts down cervical cancer as the second leading cause of deaths among women in India.
    Absolutely correct.
    The vaccine, which comes at Rs 3,000 per jab, is a big business. Each child needs at least two doses. Market research shows that global HPV vaccine market is likely to grown to USD 3.5 billion by the end of 2025, up from USD 2.0 billion in 2016. The market finds additional prospects in young boys who, too, need to be vaccinated as they are reservoirs of the virus and could infect the girls.

    As I already said at current cost it is not at all good for public program but if the costs come down it would be a boon. To oppose something just because it is a big business or even to call it not useful is scientifically wrong. (Anti HIV medicines were also a big business, but that led to fights and production of generics, saving millions of lives). In fact many believe that only universal vaccination of boys would be good enough as majority infections among women come from men.

    Countries, however, are divided on this front.

    That is but natural. But a few facts- There is almost no cervical cancer without persistent HPV infection. Vaccine is highly effective as far as immunogenicity is concerned. Studies after studies have shown that it reduces pre-cancer lesions. Recent studies from northern europe also have shown they reduce cancers.

    But HPV vaccine is contentious

    The only contentious issue is therefore the cost.

    In India, the central government continues to debate whether the vaccine should be included in the universal immunisation programme despite recommendations of the National Technical Advisory Group on Immunisation, an advisory body constituted by the government itself. Trials carried out in India have been mired with controversy as they resulted in deaths of eight girls in 2008. A PIL was filed in the Supreme Court and it is quite likely that the government would be able to take a decision on the inclusion of this vaccine in the immunisation programme only after the verdict.

    Yes there were controversies about the trials mainly on the ethical issues. There were deaths but they were all unrelated. There is safety data available of millions of doses. There was little to do with the science. As a boon in disguise there have been published reports showing efficacy of two doses and now recently even of a single dose that came out of the analysis of the suspended trials.

    Recently, a person used a false name and affiliation to Karolinska Institutet in Sweden to publish a paper in Indian Journal of Medical Ethics, saying that HPV vaccine was the reason for recent increase in the number of cases of cervical cancer in parts of Sweden. According to media reports, the paper has been retracted and Karolinska Institutet has clarified that this person does not work for them.

    That is the issue. There seems to be a lobby unfortunately working against vaccines; and of what kind I do not know but having vested interests of different kinds.

    Dip in cervical cancer cases

    There is another conundrum. If we go by data, there is evidence that between 2006 and 2016, there has been a decrease in cancers caused by infectious agents such as cervical cancer despite an overall increase in cancer cases across the globe. These findings have been published in the journal JAMA Oncology on June 2. This trend has also been seen in India where cervical cancer was, historically, the most predominant of cancers.

    A study published in 2009 in Indian Journal of Medical Research shows that in urban population-based cancer registries such as those in Bengaluru, Bhopal, Chennai, Delhi and Mumbai, there has been a significant decrease in cervical cancer. For example, the data shows that in urban areas like Chennai, the reduction in age adjusted rate was from 42.3 per 100,000 population in 1982-83 to 22.3 in 2004-05.

    This happened without using HPV vaccine.

    Yes true but what contributed we do not know. That is exactly the period in which all STIs showed decrease, there was safe sex promotion at its peak. But recently there is reversal of trends or at least early signs of the same. Changing sexual behaviours of youth are likely to reverse the trends.

    But if this is the case, should we even go in for vaccination? At the recently organised 1st Conference on Environmental and Occupational Determinants of Cancer: Intervention for Primary Prevention, this question was asked to the panelists who justified vaccination saying that reduction is seen only in urban areas and vaccination is important to protect people in the rural areas. This is supported by the fact, which the paper in Indian Journal of Medical Research also showed, that in rural areas such as Barshi, the decline was merely from 23.5 (in 1988-89) to 22.8 (in 2004-05).


    But the problem is that the vaccine offers protection only from two strains of HPV. Other than the virus, other risk factors include early marriage, multiple pregnancies, poor genital hygiene of both men and women, poor healthcare facilities, lack of testing facilities, poor diet and smoking.

    These risk factors are modifiable and instead of depending on vaccine, improving the environment might be a better strategy. If these worked in, what are now, the urban areas in India, they would surely work across the country.

    Benevolent idea but no one knows how.

    As of now, most of the uptake of the vaccine is in urban areas, where it is not needed.

    Yes that is why there needs to be a wider vaccination program.

    Vinay Kulkarni

    Posted by: Vinay Kulkarni | 6 months ago | Reply
    • I fail to understand your point. I am merely suggesting out that vaccine may not be the only solution to the problem of cervical cancer. Economy of scale cannot be used as an excuse to vaccinate everyone. I say that HPV vaccine is contentious not because of cost but because we have seen a fall in cervical cancer incidence without its use. You are saying that surveillance and education for safe sex helped. So, let’s go for these. What we need is to try to understand the real problem and find the real solution. Data, both pro and against, should be considered for this.

      Posted by: Vibha Varshney | 5 months ago | Reply