By: Stacey Starkman
beingwell magazine Fall 2007

When Liz Ellwood saw her doctor about some unusual bleeding she experienced, she assumed it was related to her use of birth control pills and was not overly concerned.  Neither was her doctor.

Although the results from a  pap screening she’d had seven months earlier were normal, the test she took during this visit showed abnormal cells in her cervix, which led to a series of progressively more invasive tests to determine the cause. On Christmas Eve last year, Ms Ellwood received the diagnosis she had dreaded: cervical cancer.

Surgery, chemotherapy and radiation treatments followed and a hysterectomy, commonly performed in cases of cervical cancer, was recommended. Ms Ellwood, only 24 years old and looking toward the prospect of marriage and children in her future, declined the procedure and, instead, travelled to Quebec City where a very specialized procedure was available; a trachelectomy, which surgically removes the cervix, part of the vagina and surrounding tissue but preserves the ovaries and uterus.

Even with this, she has no guarantee she will be able to conceive in the future. One of her ovaries was lost during radiation treatments and it is too soon since her surgery to determine if the second ovary or uterus remain viable.

Though considerably less well known, cervical cancer is second only to breast cancer as the most common cancer in Canadian women aged 20 to 44. About 1,400 cases of cervical cancer are diagnosed in Canada every year and more than 400 women die from it.

The good news is, this statistic is poised to make a dramatic drop as Health Canada approved the use of a breakthrough vaccine designed to protect against cervical cancers.

This is possible because, unlike most cancers, almost all cases of cervical cancer are caused by a virus, the human papillomavirus (HPV), which is one of the most common families of viruses in the world — and the most prevalent sexually  transmitted infection. In addition to causing cervical cancer, HPV is also linked to vaginal, vulvar and anal cancers, as well as pre-cancerous lesions, benign tumors and genital warts. Researchers are also investigating its association with throat, tonsil, mouth and tongue cancers and are just beginning to study the virus in males.

About 75 per cent of all sexually active women will have at least one HPV infection in their lifetime; for most, the infection goes away on its own without inflicting lasting damage.

A small percentage, like Ms Ellwood, will develop cancer as a result of HPV infection.

Of all the many different types of HPV (more than 100 have been identified to date), two strains cause 70 per cent of all cervical cancers. Identified as types 16 and 18, it is the first type which caused Ms Ellwood’s disease. Two other strains of HPV, types 6 and 11, can cause genital warts and are also prevented by the new vaccine.

Developed by Merck Frosst and marketed under the name Gardasil, the vaccine is available in Canada at a cost of about $400 a prescription.  A second, similar cervical cancer vaccine called Cervarix has been developed by Glaxo Smith Kline but it has not yet been approved for use in Canada.

“It is a very big step towards the elimination of cervical cancer,” said Dr. Barry Rosen, president of the Society of Gynecologic Oncologists of Canada (GOC).

“The GOC supports its use," he added and, as the father of a teenage daughter himself, is excited by the implications of this vaccine.  

The wider medical community agrees. The National Advisory Committee on Immunization (NACI) issued a statement in January recommending use of the vaccine. Comprised of experts in various medical disciplines, NACI provides medical, scientific and public health advice and counsels the chief public health officer of Canada concerning the use of vaccines.

The Canadian government is also impressed: The 2007 budget earmarked $300 million in per capita funding for the provinces and territories to fight HPV. In making this announcement, Jim Flaherty, minister of finance said, “Let the day come when people look back on this cancer as a disease we have conquered, in the same way we do polio today.”

While that possibility certainly exists, in practical terms, the vaccine is in a transitional stage and it will be a while yet before the expected long-term benefits are measured.

This past August Ontario decided to follow the lead of Nova Scotia and take advantage of this funding to implement a school-based immunization program for girls in Grade 8; other provinces have opted to wait for the recommendations of the Canadian Immuni-zation Committee (CIC) on how best to carry out a vaccination program before developing a strategy.

The CIC is a national body composed of provincial, territorial and federal representatives responsible for making recommendations on immunization programs, once a vaccine has been approved by Health Canada and recommended for use by NACI . The CIC recommendations for a national protocol are expected by the end of 2007.

“With these recommendations in hand, we are hopeful that the Canadian Immunization Committee will move quickly to take the next vital step, to operationalize a publicly-funded vaccine program,” said Dr. Donald Davis, president of the Society of Obstetricians and Gynaecologists of Canada.

Whatever vaccination program the CIC may suggest, it will almost certainly follow the NACI recommendations for the vaccine to be given to females between the ages of nine to 26. Because HPV is a sexually transmitted infection, the vaccine is best administered before the onset of sexual activity and, since a number of Canadian studies show about 20 per cent of girls have sexual intercourse at least once by the age of 15, public vaccination programs will likely target girls younger than that. However, not everyone waited for public funding before having the vaccine administered.

Mississauga resident Linda Smith, a 37 -year-old mother of two daughters, was diagnosed with cervical cancer three and-a-half years ago following an abnormal pap smear. She underwent a radical hysterectomy and has been cancer-free ever since.

“I thank God every day that I had my children before this happened and, like any mother, I would be devastated to have this happen to my daughters, especially with the knowledge that there is a  vaccine out there that could prevent it,” she said.

More than 100,000 doses have already been distributed in Canada since the vaccine was initially approved in July 2006.

As with any new medical treatment, there are caveats.

“We all need to be careful during this transition time and be aware that women still need to undergo screening,” said Dr. Rosen.

Dr. Erica Weir, associate medical officer of health for York Region, is emphatic on this point. “I don’t think it will reduce the number of pap tests required — or it shouldn’t, because the vaccine doesn’t protect against all strains of cancer-causing HPV. It would be unfortunate if the vaccine reduced a young woman’s willingness to undergo screening because she thinks she is (fully) protected. They still need to be tested for these other strains.

“It should, however, reduce the number of abnormal pap tests we get as a result of that screening and, consequently, the number of women that need to be treated for pre-cancerous lesions of the cervix. It’s not a panacea but, rather, a component of the whole preventive strategy in dealing with HPV; It’s only part of the picture,” Dr. Weir stresses.

Although the vaccine is primarily recommended for females before the onset of sexual intercourse, NACI also advocates its use for women up to age 26 who are already sexually active, as they may not yet have the HPV infection and, even if they have already been infected with one of the strains, are very unlikely to have all four HPV types contained in the vaccine. Research into its use in other populations, including women over the age of 26, is ongoing.

Sheila Murphy, manager of public affairs for Merck Frosst Canada, says this vaccine is a good start in winning the battle against cancer.

“As a woman I feel privileged to be part of the team that is responsible for this vaccine,” she said. “Cervical cancer kills women so the ultimate aim of this vaccine is to save people’s lives. It is going to save women’s lives.”

Ms Ellwood agrees. “It’s difficult because of how close my cancer was to being prevented. If the vaccine had been available earlier I would have gotten it and that’s why I feel it’s really impotant to tell my story, to motivate women to get the vaccine and to tell parents to give it to their daughters. There are many ways in life that you can protect your children and this is one of those ways. Because I didn’t have the opportunity to get it, I got cancer,” she said.

“Getting the needle is nothing compared to what a women would have to go through with a diagnosis of cervical cancer.”

© Copyright 2008