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SOGC Statement on CMAJ Commentary, “Human papillomavirus, vaccines and women’s health: questions and cautions”

August 14, 2007 - The Society of Obstetricians and Gynaecologists of Canada (SOGC) is disappointed with the recent publication of a Canadian Medical Association Journal (CMAJ) commentary by Dr. Abby Lippman entitled “Human papillomavirus, vaccines and women’s health: questions and cautions”. It is the opinion of the SOGC that the arguments expressed in this commentary lack grounding in scientific evidence.

The SOCG stands by its contention that Canadian governments have made exactly the right decision in moving quickly to provide immunization against the human papillomavirus (HPV) for young girls and women. This country’s 1,600 obstetricians and gynaecologists, the professionals who provide daily medical care and guidance to Canadian women, strongly believe that the institution of this nation-wide immunization program is one of the most important health care initiatives of this century. It will protect the health of the next generation of Canadian women and prevent unnecessary disease, health complications and death. In support of this approach, the SOGC issued clinical guidelines on the diagnosis, treatment and prevention of HPV, published this month in the Journal of Obstetrics and Gynaecology Canada (JOGC).

Canada has taken this bold, and appropriate, step forward based on science. The research behind the development of this vaccine and the careful work of the National Advisory Committee on Immunization reinforces the science that tells us that immunization of women between the ages of 9 and 26 will protect them from strains of the HPV virus responsible for approximately 70 per cent of cervical cancers. And let us be clear, cervical cancer poses a serious threat to the lives of women in this country. The SOGC is dismayed that the authors of this article chose to dispute this reality, without the use of science, or even quality epidemiological evidence, to support their contentions.

The Gardasil vaccine being used for this immunization program is one of the most extensively tested vaccine to ever come to the Canadian market. Over 25, 000 women participated in carefully monitored top quality clinical trials, and over a decade of research and development has now gone into this vaccine. Following extensive consultation with healthcare experts, the Canadian Federal Government concluded that publicly funded immunization programs are the best way forward, allocating $300-million in its 2007 Budget to support provincial immunization programs.

The facts clearly line up in favour of a national, publicly funded HPV immunization approach. It is a fact that:

• Cervical cancer is the second most common cancer in Canadian women between the ages of 20-44 and world-wide is the second leading cause of years of life lost. In Canada, about 1,350 women will be diagnosed with cervical cancer this year, and another 400 will die from the disease. Thousands more women will be diagnosed with pre-cancerous conditions, and approximately 400,000 women will receive abnormal Pap smear results. Still others will acquire genital warts, another outcome of HPV.
• The new vaccine can prevent HPV types 16 and 18 which are responsible for 70 per cent of cervical cancers, as well as types 6 and 11 which cause 90 per cent of genital warts.
• We cannot rely on Pap screening alone to catch cervical cancer early. First, not all Pap tests are 100 per cent accurate (in fact, there is a 15 per cent false negative rate) and despite efforts to increase the number of Canadian women who do get a Pap test, the rate has plateaued at about 80 per cent. Women don’t always get their Pap smears, or get them on time. While cervical cancer is known to progress slowly, a missed early diagnosis put women at considerable risk of allowing a cancer to progress. In women with impaired immune systems (e.g. transplant patients, HIV positive women) that cancer can move very rapidly.
• More vulnerable populations such as immigrant women, women in remote parts of Canada and Aboriginal women are less often screened, if at all.
• Unlike breast cancer where survival is increasing, the outcome for women with cervical cancer has not improved.
• HPV is also linked to other cancers in both men and women, such as cancer of the penis, anus, vagina or vulva.
• As women age the transformation zone of the cervix matures, making them less susceptible to cervical dysplasia. The government funded vaccine programs will cover the most vulnerable age when girls have not yet experienced intercourse.
• Canada’s National Advisory Committee on Immunization has recommended the use of HPV vaccination for women and girls between the ages of 9 and 26.

If these facts are not compelling enough, the SOGC and its members are of the view that an HPV immunization program must be pursued for a variety of other reasons. These include:

• The cost of the vaccine would be prohibitive for many if the HPV vaccine was not available through a publicly funded program. This is especially true for vulnerable women who for reasons of culture, language, poverty or remote location are already marginalized or disadvantaged in terms of their health care.
• While most HPV infections clear on their own, many women must endure the emotional and physical consequences. They often bear the stigma of having a sexually transmitted infection (STI) and there is pain and discomfort associated with genital warts. HPV is also related to loss of fertility and premature ovarian failure.
• The authors of this article make a disturbing suggestion that somehow this vaccination will encourage early and unprotected sexual activity among young women. SOGC members hold an opposing view. The risk of HPV is not what determines women’s sexual choices, and it is insulting to them to suggest that the presence of a vaccine would change their decisions and inspire high risk behaviour. Are teenage girls more likely to practice unsafe sex after a hepatitis immunization? Experience with the hepatitis vaccination program shows that there was no rise in contaminated needle use after vaccinations commenced.
• When our members prescribe birth control pills to young women we counsel them that they must still protect themselves against STIs. Getting ready for their first HPV vaccination is also a golden opportunity for parents to talk to their young daughters about the risks associated with unprotected sex, unwanted pregnancies, STIs, etc.
• Protection and education can and must go hand in hand. As a society, we need to continue educating everyone that HPV is not all that women need to worry about in terms of sexually transmitted diseases and infections.
• And finally, there is the issue of follow-up. It is true that we don’t currently know if more booster vaccinations will be required in the future. But why deny protection today and for the next seven to eight years? Research and study will continue; for the time being we know that this vaccine gives women much-needed protection.

Canada’s obstetricians and gynaecologists interact daily with women, young and old. Their reproductive health is our top priority. As a professional society, the SOGC makes its medical recommendations based on quality science, member input and broad-based consultations with other professional groups, researchers and scientists. As a profession, we are unequivocal in our support for a national, publicly funded HPV Vaccination Program. We have responsibly put forward evidence-based clinical guidelines, and we continue to advocate for strong cervical screening programs and registries that gather data and ensure that women are getting the care they need. We applaud the Canadian governments that have already committed to this approach.

The SOGC is disappointed that the CMAJ has chosen to publish this article which encourages fear and skepticism about such an important national health issue. It is particularly disturbing that these arguments have been allowed to go forward without a grounding in scientific evidence. We think the science speaks for itself. This vaccine program and the costs associated with it are warranted in the face of this terrible disease and its capacity to take the lives of so many Canadian women.

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Last Updated February 19, 2008