In two years, cervical cancer has gone from obscure killer
confined mostly to poor nations to the West's disease of the moment.
Tens of millions of girls and young women in the United States
and Europe have been vaccinated against a virus that can cause many
types of the disease in the two years since two vaccines were given
government approval in many countries and, often, recommended for
universal use among females ages 11 to 26.
One of the vaccines, Gardasil, from Merck, is made available to
the poorest girls in the United States, up to age 18, at a potential
cost to the U.S. government of more than $1 billion; proposals to
mandate the vaccine for girls in middle schools have been offered in
24 of the 50 U.S. states, and one will take effect in Virginia this
autumn. The British National Health Service will start giving the
other vaccine - Cervarix, from GlaxoSmithKline - to all 12-year-old
girls at school this September.
The lightning-fast transition from newly minted vaccine to must-
have injection in the United States and Europe represents a triumph
of what the manufacturers call education and their critics call
marketing. The vaccines are far more expensive than earlier vaccines
against other diseases - Gardasil's list price is $360 for the three-
dose series, and the total cost is typically $400 to nearly $1,000
when including markup and office visits.
Award-winning advertising has promoted the vaccines. Before the
film "Sex and the City," some U.S. moviegoers saw ads for Gardasil.
On YouTube and on television, a multiethnic cast of young
professionals urges girls to get vaccinated.
The vaccine makers have also brought attention to cervical cancer
by providing money for activities by patients' and women's groups,
doctors and medical experts, lobbyists and political organizations
interested in the disease, sometimes in ways that skirt disclosure
requirements or obscure the companies' involvement.
In the United States, hundreds of doctors have been recruited and
trained to give talks about Gardasil - $4,500 for a lecture - and
some have made hundreds of thousands of dollars. Politicians in
Britain have been invited to receptions catered with drug company
money.
Legislators in dozens of countries rallied behind a vaccine that
combined two popular, hot-button issues: cancer prevention and
women's health.
"There was incredible pressure from industry and politics," said
Dr. Jon Abramson, a professor of pediatrics at Wake Forest
University who was chairman of the committee of the U.S. Centers for
Disease Control and Prevention that recommended the vaccine for all
girls once they reached age 11 or 12.
Cervical cancer kills close to 250,000 women a year globally, but
Pap tests, which can detect precancerous cells early, help limit
deaths in countries with good medical care. The annual death toll is
about 3,870 in the United States, 1,000 in France and 950 in
Britain.
Even critics of the marketing efforts recognize the benefits of
the vaccines. Girls who get the shots are less likely to have Pap
tests with worrisome results that would lead to further treatment,
saving themselves anxiety and discomfort and, in those cases, saving
money. When it occurs, cervical cancer is a dreadful disease;
genital warts, partially prevented by the Merck vaccine, can be a
painful nuisance.
But some experts worry about the consequences of the rapid
rollout of the new vaccines without more medical evidence about how
best to deploy them. They say that because of the aggressive
marketing and lobbying campaigns, even parents of girls who are far
from being sexually active may feel pressured into giving them a
vaccine that is not yet needed and whose long-term impact is still
unclear.
"This big push is making people crazy - thinking they're bad moms
if they don't get their kids vaccinated," said Dr. Abby Lippman, a
professor at McGill University in Montreal and policy director of
the Canadian Women's Health Network.
Merck's vaccine was studied in clinical trials for five years,
and Glaxo's for nearly six and a half, so it is not clear how long
the protection will last. Some data from the clinical trials
indicate immune molecules may wane after three to five years. Some
experts are concerned about possible side effects that become
apparent only after a vaccine has been more widely tested over
longer periods.
And some experts wonder: Why the sudden alarm in developed
countries about cervical cancer? A major killer in the developing
world, particularly Africa, where the vaccines are too expensive for
use, cervical cancer is almost always preventable through regular
Pap smears. Indeed, because the vaccines prevent only 70 percent of
cervical cancers, Pap smear screening must continue, anyway.
"Merck lobbied every opinion leader, women's group, medical
society, politicians, and went directly to the people - it created a
sense of panic that says 'You have to have this vaccine now,'" said
Dr. Diane Harper, a professor of medicine at Dartmouth Medical
School. Harper was a principal investigator on the clinical trials
of both Gardasil and Cervarix, and she spent 2006-07 at the World
Health Organization developing plans for vaccine programs.
"Because Merck was so aggressive, it went too fast," Harper said.
In receiving expedited consideration from the Food and Drug
Administration in the United States, Gardasil took six months from
application to approval. Most vaccines take three years, Harper
said, and then 5 to 10 more for universal acceptance.
"In that time, you learn a lot about safety and side effects and
how to use it," Harper said. "Those getting it early should be the
ones who really want it and willing to accept the risk."
Dr. Richard Haupt, medical director at Merck, said it was crucial
to get a groundbreaking vaccine into use as quickly as possible.
"You can only study a vaccine for so long before you license and use
it in a population where it has enormous value," Haupt said. "Our
hope and belief is that this is a remarkable vaccine that will have
huge impact on women."
Haupt said that five years in clinical trials was a normal period
before applying for licensing. He said Merck educated physicians,
politicians and the public about the new vaccine to "accelerate and
facilitate access."
Spokesmen for Merck and Glaxo say that their vaccines are safe
and effective and that there is no evidence a booster shot will be
needed.
But with their high price, the vaccines are straining national
and state health budgets as well as family pocketbooks. These were
the first vaccines approved for universal use in any age group that
clearly cost the health system money rather than saved it.
Health economists estimate that, depending on how they are used,
the two cervical cancer vaccines will cost society $30,000 to
$70,000, or more, for each year of life they save in developed
countries. That number would be far higher still if a booster is
needed.
"This kind of money could be better used to solve so many other
problems in women's health," Lippman said. "I'm not against
vaccines, but in Canada and the U.S., women are not dying in the
streets of cervical cancer."
By contrast, if the vaccine were to become cheap enough to be
used in the developing world, it would revolutionize women's health.
Charities like the Global Alliance for Vaccine and Immunizations,
backed by the Bill & Melinda Gates Foundation, are trying to devise
a solution.
The vaccines offer partial protection against infection from
human papillomavirus, or HPV, a common and generally benign sexually
transmitted virus that can, in rare cases, cause cancer after years
of silent infection. The Merck vaccine also prevents some genital
warts that are caused by other strains of the virus.
Dr. David Salisbury, head of the British Department of Health's
Vaccine and Immunization Committee, said the government decided to
vaccinate schoolgirls because "this initiative was seen as a good
use of resources that fits with the government's health priorities
and political priorities."
But critics urge restraint. Angela Raffle, a specialist in
cervical cancer screening with the National Health Service in
Britain, said, "If we do this quickly and badly, we could cause more
deaths," for example, from side effects or from giving girls false
security that they no longer need to be screened.
Marketing has helped make Gardasil one of Merck's best sellers,
with projected sales of $1.4 billion to $1.6 billion outside Europe
this year, and more from sales in Europe, where Merck sells the
vaccine through a venture with Sanofi Aventis.
Aggressive pharmaceutical advertising is nothing new, but the
campaign was a revolution for a vaccine, which are generally cheap
and not particularly profitable.
In 2006, hundreds of doctors and nurses in the United States were
signed up as unofficial spokesmen for Gardasil, trained by Merck,
provided with a multimedia presentation and paid $4,500 for each 50-
minute talk, presented over Merck-sponsored meals. Many were paid
for attending Merck "advisory board" meetings to discuss the shots.
Merck said it provided assistance to speakers "to make sure they
are providing accurate information in accordance with FDA approval
and to make sure dissemination of information is always
appropriate," said Amy Rose, a company spokeswoman.
Promotion and marketing for Cervarix, the Glaxo version of the
vaccine, has been far less visible, in part because it is not yet
approved for use in the United States and because consumer
advertising of medicines is prohibited in much of Europe.
But on both continents, there has been a proliferation of
cervical cancer awareness campaigns, sponsored by new or newly
energized scientific and patient groups financed with the assistance
of Merck and Glaxo. In some cases, the financial support has often
been indirect, so that patients are unaware that expert advice has
been at last partly financed by the vaccine makers.
In country after country, Merck and Glaxo also appealed to
politicians. "We support policy leaders and try to educate
legislators," Haupt said.
In Italy, parents of 10-year-olds have received letters from the
Ministry of Health encouraging them to get their daughters
vaccinated.
In the United States, 41 states have passed or begun considering
legislation on cervical cancer, according to the National Conference
of State Legislatures, and 24 have considered proposals to mandate
the vaccine for schoolgirls.
One bill to require the vaccine for school entry has been passed,
in Virginia; it will first apply for the 2009-10 school year. In
December 2006, Merck announced it would invest $57 million to expand
its Elkton, Virginia, plant to make Gardasil, helped by a $700,000
grant from a state economic development agency. Two months later,
Governor Tim Kaine signed legislation requiring Gardasil for
schoolgirls. Four months after that, Merck pledged to invest $193
million more in the plant.
Delacey Skinner, a spokeswoman for the governor, said the
Virginia vaccination program includes an unusually broad freedom to
decline the shot.
"Without hesitation or question," the decisions about the plant
and about the mandate legislation "were completely separate," she
added.
However, as in many U.S. states where cervical cancer legislation
has been considered, there were ties between drug makers and members
of government.
In Britain, drug makers visited the nurses and family
practitioners who are the backbone of the National Health Service,
urging them to offer the vaccine privately if the NHS turned it
down, Raffle said. "The people who understood the issues, with black
belt cancer screening experience, were left out," she said.
In Belgium, the health minister approved the vaccine before the
country's health technology evaluation committee had finished
deliberating.
Many questions about the vaccines remain unanswered, including
how long immunity will last. Even commercials for Gardasil say - in
small print - that "the duration of protection has not been
established."
Harper said that in the data from Merck's clinical trials, which
she helped conduct, the vaccine was no longer protective after just
three years in some girls. "The immunity of Gardasil will not last -
that is dangerous to assume," she said.
She believes that at least one booster shot, and probably more,
would be needed over a lifetime.
Other independent experts have worried that eliminating the two
cancer-causing HPV strains covered by Gardasil and Cervarix might
actually allow the other cancer-causing strains of HPV to increase
in frequency, reducing the vaccine's effect. But Haupt said these
were "theoretical possibilities" that should not deter rapid
distribution of an important vaccine. "We'll worry about whether
boosters are needed down the road," he said.
The Centers for Disease Control asks health care centers to
report side effects through its Vaccine Adverse Events Reporting
System; reporting is voluntary. There have been 9,749 reports,
almost all from doctors and nurses, of post-vaccine adverse effects,
the agency announced in a joint report with the FDA at the end of
June. Ninety-four percent of them were not serious, including arm
pain and fainting; 6 percent were classified as serious, including
blood clots, paralysis and at least 20 deaths.
But Merck has distributed 16 million doses of the drug in the
United States, and, in a population so large, "by chance alone some
serious adverse effects and deaths" will occur, the FDA and CDC
said.
The agencies said there was no indication that the deaths or
serious side effects were caused by the shot, concluding that
"Gardasil continues to be safe and effective and its benefits
continue to outweigh its risks."
Both the agencies and Merck acknowledge that there does appear to
be a high rate of fainting, so doctors are now advised to observe
patients for 15 minutes after the shot.
Cervical cancer is the second most common cancer in women
worldwide, with about 500,000 new cases each year. Almost 80
percent of those cases are in developing countries, according to the
World Health Organization; 274,000 women died of this cancer in
2006, nearly 95 percent of them in developing countries. Where there
are Pap smear programs, few women die of cervical cancer.
Meanwhile, the vaccine's proponents are moving to the next
frontier: older women and boys.
One rationale for inoculating boys is that entire populations
should be vaccinated to achieve what is called herd immunity.
Said Raffle, the British cervical cancer specialist: "Oh, dear.
If we give it to boys, then all pretense of scientific worth and
cost analysis goes out the window."
(C) 2008 International Herald Tribune. via ProQuest Information and Learning Company; All Rights Reserved