Cervical cancer: What you don’t know may kill you

Kuala Lumpur, Malaysia – Do you know that cervical cancer is caused by a virus?

That’s the big, riveting question you may come across as you leaf through the pages of a local newspaper in Kuala Lumpur, Malaysia, where an ad, that’s part of an education campaign supported by Merck Sharp & Dohme and the Obstetrical and Gynecological Society of Malaysia, appears.

And did you know that there’s now a vaccine that could prevent cervical cancer? But that’s getting ahead of our story.

"Are you sexually active? That’s the first question I ask women who come to me," Dr. Saunthari Somasundaram tells a roomful of women who flew in from different parts of Asia Pacific, including this writer, to attend the journalist workshop on cervical cancer and other HPV-related diseases at FIGO in KL, that’s home to the Petronas Twin Towers, the world’s tallest freestanding twin towers.

From the twin towers to the double C: cervical cancer. Progress has indeed come to Kuala Lumpur, now a vibrant cosmopolitan city that plays host to prestigious international events. But some things just refuse to change. Even as Malaysia forges forward, the women are still not on equal footing with the men.

Dr. Somasundaram, currently honorary general secretary and executive director of the National Cancer Society of Malaysia, gives us the whys and wherefores: "I asked this woman who came to my workshop if she was sexually active, and she looked back at me and said, ‘How dare you ask me that question. I’m single. You should know I’m not sexually active.’ That’s the issue women face in Malaysia because of the cultural/religious constraints that they put on themselves or the community puts on them: that if I’m not married, I can’t be seen going to a gynecologist or getting a Pap scan. That because I’m not married, I don’t want people to know I’m sexually active. There’s just a lot of miseducation, there are a lot of misconceptions."

Take the story of this married woman, a teacher, who joined one of Dr. Somasundaram’s workshops. "She said she didn’t need to do a Pap scan because she was a virgin when she got married and had never had sexual intercourse with anybody else. I went on to tell her about HPV and how men can transmit it to women. She got up and said, ‘How dare you say that my husband is cheating on me.’ I never said that. What I was trying to say was maybe in those days, not now ... Majority of Malaysian women are virgins when they come to the marital bed. But the men are not – they must have had one or two sexual experiences before getting married. So the risk of getting HPV is there even before marriage. So no woman is safe, no matter if you’re in the most wonderful of marriages and monogamous. And I’m sorry, but we cannot expect the men to look after women’s health. It’s still very much a male-dominated society, where men make the decisions for women, including the latter’s health. Women need to be pro-active about their own health."

The "totally mortified" doctor shares yet another morbid story: "I had a woman in front of me dying of cancer of the womb, but she refused to have her uterus taken out. Why? Because her husband said that if her uterus was taken out, she could have sexual intercourse with anyone and he wouldn’t know about it."

The scenario gets grimmer as you go farther into rural Malaysia. Says the good doctor, "Women are continuously afraid that these are parts which make us who we are as women: our breasts, our cervix, our uterus. If anything happens to any of them, we’ll be less of a woman. These fears, irrational though they may be, stop us from prevention and early detection of cancer."

The focus is on demystifying the Big C, the mere mention of which is enough to make us cower in fear. "We’re here to teach people that, yes, we can prevent cancer, we can find it early," stresses Dr. Somasundaram.

She goes on to tell us that there are so many clinics in Malaysia but not many women go for a Pap smear. "Outside of child birth, no woman wants to be touched down there or a man to look at her private parts, although there are women doctors now."

The focus is on sex education.

"You need to be educated about sex while still a teenager so when you do become sexually active, you’re aware of the risks you’re taking, ways to try to prevent it, to keep yourself safe," asserts Dr. Somasundaram.

Sad to say, in Malaysia, the government does not agree that sex education should be taught in school. "A lot of the schools I go to would not allow the mere mention of the word sex," Dr. Somasundaram tells her astonished audience. "The book How to Talk to Your Child About Sex is banned in Malaysia. It’s a very good, very moralistic book that talks to you about not having free sex, about being careful, etc. If a parent cannot talk to his/her child about sex education, who’s supposed to teach the child? I call this miseducation."

The statistics are bleak. "At least half of sexually active men and women will acquire HPV at some point in their lives," says Margaret Stanley, professor of epithelial biology, Department of Pathology, University of Cambridge. "Eighty percent will be infected by age 50. It is most common among young adults, 18 to 28 years old. (In the US, one in four people, ages 15 to 24, is infected with HPV.) Women will acquire it from their husbands/male partners. But penile cancer is rare so I always tell my students that God is, indeed, a man."

The focus is on prevention.

"We’re targeting nine-, 10-, 11-year-olds because that’s when you get the best immune response," Prof. Stanley tells us in her warm schoolmarmish voice. "It’s not necessarily before sexual activity. When you hit puberty, it’s downhill all the way."

The focus is on the world’s first vaccine for cervical cancer developed by Merck Sharp & Dohme (MSD).

Dr. Carlos Sattler, director, Biologics Clinical Research, Merck & Co., Inc., brings glad tidings: "The quadrivalent (four-type) vaccine was specifically designed to prevent HPV-related clinical disease by targeting HPV types 6, 11, 16, and 18, the four most common types of HPV. In clinical trials, the vaccine has shown high efficacy in preventing diseases caused by these four HPV types."

Developed after years and years of painstaking work, the vaccine has been approved for use in more than 40 countries and is currently under review with regulatory agencies in approximately 50 countries around the world. Make that 49. Because only a few weeks ago, Merck Sharp & Dohme Philippines announced that the vaccine has been approved in the Philippines by the Bureau of Food and Drugs. Gardasil, the quadrivalent human papillomavirus recombinant vaccine, is the first and only vaccine to prevent cervical cancer, vulvar, and vaginal cancer, and vulvar and vaginal pre-cancers caused by HPV types 16 and 18, and to prevent low-grade and precancerous lesions (CIN 1) and genital warts caused by HPV types 6, 11, 16, and 18.

Says MSD medical director Cesar Recto II, "Bringing forward this life-saving scientific advance is yet another testament to MSD’s long-standing mission to research and develop novel vaccines and medicines that can greatly improve public health."

In the Philippines, according to the Philippine Cancer Facts and Estimates published by the Philippine Cancer Society, Inc., cervical cancer was the second leading cause of cancer death in women in 2004. Last year, there were an estimated 7,277 new cases and 3,807 deaths due to cervical cancer.

Dr. Susan Nagtalon, president of the Philippine Obstetrics and Gynecological Society, notes, "The use of the vaccine can help significantly reduce the human and economic burden of cervical cancer, precancerous or low-grade lesions, and genital warts caused by HPV 6, 11, 16, and 18 throughout the world, in this generation and future generations."

Here’s how the vaccine works: The vaccine contains virus-like particles (VLPs) of HPV types 6, 11, 16, and 18. VLPs are empty shells consisting of viral protein – but no viral DNA – that closely simulate HPV and are capable of generating an immune response in the body without causing disease. Its efficacy is associated with the development of antibodies, which are proteins used by the immune system to identify and neutralize viruses. These antibodies prevent the virus from establishing infection.

How effective is this vaccine?

The MSD vaccine prevented 100 percent of HPV 16- and 18-related cervical cancers in women not previously exposed to the relevant HPV types. The efficacy of the vaccine, including results from an HPV-16 prototype of the vaccine, was evaluated in four placebo-controlled, double-blind, randomized Phase II and Phase III clinical studies. Together, the Phase II and Phase III studies evaluated 20,541 women aged 16 to 26 years old. Study participants were followed for up to five years after enrollment.

The vaccine prevented 100 percent of HPV 16- and 18-related cervical pre-cancers and non-invasive cervical cancers. There were no cases in the 8,487 women who received the vaccine compared to 53 cases in the 8,460 women who received placebo.

The vaccine also prevented 100 percent of HPV 16- and 18-related vulvar and vaginal pre-cancers. And 99 percent of cases of genital warts caused by HPV 6 or 11.

In all the studies, the MSD vaccine was generally well tolerated and only a few subjects (0.1 percent) discontinued due to adverse events.

Of course, the ideal time to administer any vaccine is before exposure to infection. MSD has zeroed in on adolescents as an important group to vaccinate against HPV. Studies show that one in four people, 15 to 24 years old, is infected with HPV.

What do mothers say about this?

In a survey of 525 mothers with children as young as 11 years old, up to 80 percent said they would allow their daughters to receive a vaccine that helps protect against cervical cancer. In the US, where young people are said to be more sexually active and adventurous than their counterparts elsewhere in the world, this vaccine is available in the schools.

Can the vaccine be given to boys, too?

"Yes, it can," comes Dr. Somasundaram’s quick reply to a question at the open forum at the end of the journalist workshop. "In a sane world, we’d be giving it to boys and men so we could impact on transmission."

Our distinguished panel of speakers at this forum can’t stress this enough: Cervical cancer is potentially deadly. But it can be prevented. Talk to your doctor about cervical cancer and go for regular Pap smear tests. It could save your life some day.

And now that you know, go tell someone.