A doctor's dilemma

The news last October that cervical cancer could be prevented through a vaccine against a sexually transmitted disease aroused the expected media hype.

On the one hand there were claims of ‘thousands of lives saved’ and on the other accusations of ‘promoting promiscuity’.

Our immediate Christian response should be to follow the biblical admonition to first ‘enquire, probe and investigate it thoroughly’ (Deuteronomy 13.14) before jumping too hastily on either bandwagon. So what are the facts?

Easily preventable

Worldwide, about 500,000 new cases of cervical cancer are diagnosed each year, resulting in 250,000 deaths. The disease affects the cervix, the neck of the uterus (womb), and is the second most common cancer among women. In the UK over 1,000 women die from the disease each year, and it is estimated that a further 4,500 lives are saved each year through cervical cancer screening. Once established, cervical cancer is difficult to manage with surgery, radiotherapy or drugs, so more and more effort has been focussed on preventive measures and diagnosing the disease at the pre-cancer stage.

The major factor predisposing to cervical cancer is infection with the human papilloma virus (HPV), a sexually transmitted disease. There is no treatment for HPV, but most HPV infections, like many other viral infections, get better by themselves. However, some have more serious consequences. Of the more than 100 types of HPV that have been described, about 40 can infect the delicate inner lining of the anus and genital tract. Infection with so-called ‘low risk’ HPV types (e.g. 6 and 11) can result in anogenital warts or persistent subclinical infection (i.e. infection without symptoms). More seriously, at least 95% of cervical cancer results from infection with the 15 or more HPV types classified as ‘high risk’, with HPV types 16 and 18 together accounting for around 70% of all cervical cancer. High risk HPVs have also been implicated with other serious cancers, including cancer of the penis and anal area in men, and head and neck tumours, including some forms of oral, respiratory, and esophageal cancers.

HPV is incredibly easy to catch and condoms offer only minimal protection, a fact that has been very poorly publicised. More than a third of teens and young adults in various Western countries have acquired HPV at some point, many having contracted the infection from their first sexual partner. This has led some researchers to conclude that HPV in the teenage population ‘should now be considered an inevitable consequence of sexual activity’.

Trials

Large scale, multi-country, multi-site trials of several HPV vaccines are currently under way and the World Health Organisation is expecting at least one of these vaccines to be licensed for use in 2006. The leading contenders among the vaccines are Gardasil (active against HPV types 6,11,16 and 18) and Cevarix (HPV 16 and 18) produced by the drug companies Merck and GlaxoSmithKline respectively. The Merck study, FUTURE II, which published results in October 2005, showed the vaccine was 100% effective in preventing both HPV infection and also pre-cancer changes in the lining of the cervix in the more than 5,000 women tested. Furthermore there were no adverse side effects apart from occasional discomfort at the injection site. Datamonitor estimates that the total market potential for HPV vaccines in the seven major markets (UK, US, France, Germany, Italy, Japan and Spain) is around $3.7 billion.

Uncertainties and certainties

There are still many unknowns. We do not know what fraction of cervical cancer overall will be prevented by a vaccine against HPV 16 and 18, but it may only be 70%. We don’t know how long the vaccine will last, and therefore whether booster vaccinations will be necessary, and if so, when. We also don’t know whether the vaccine will be effective against other HPV types or whether it will have long term side effects; or whether it will be ‘cost-effective’ to offer it to those other than sexually active young people. And we don’t know how the public will react to any imposition of a vaccine that prevents a disease only caught by sexually active people. These questions will only be answered with more research and the passage of time. As cervical cancer can occur ten to 20 years after exposure to the virus there would be no justification, even if a 100% effective vaccine were introduced today, to stop cervical cancer screening for another 20 years. So in the short to medium term at least, cervical cancer screening (regular smears, etc.) will need to continue and the vaccine will simply add to the cost of disease prevention.

The new vaccine will not, of course, protect people against any one of the 20 other sexually transmitted infections (STIs) currently resurgent in Britain, including chlamydia, HIV (the AIDS virus), gonorrhea, syphilis, herpes and hepatitis B. It will also not protect people against pregnancy, emotional damage or spiritual harm.

But one thing is certain even from a purely secular perspective. The only really effective way of preventing sexually transmitted diseases, like HPV and cervical cancer, is for each person to have only one sexual partner for life. In a recent major review by Genius and Genius, published in the American Journal of Obstetrics and Gynecology in March 2004, the authors concluded:

‘Although risk reduction and treatment of existing infection is critical, the promotion of optimal lifelong health can be achieved most effectively through delayed sexual debut, partner reduction, and the avoidance of risky sexual behaviours.’

A biblical response

The Bible teaches that marriage is the only proper context for sex (Genesis 2.24; Matthew 19.4-6). It should, therefore, come as no surprise to see science confirming that premarital abstinence and marital faithfulness are the healthiest sexual choices.

By contrast, the government’s £150 million campaign to reduce pregnancies and STIs in young girls, through promoting condoms, more sex education in schools and the morning after pill has been an embarrassing failure. Official statistics released on February 23 showed a rising number of girls under 14 becoming pregnant and led to criticisms of government policy as a waste of taxpayers’ money.

These findings follow on the heels of the June 2003 House of Commons Health Committee Report on Sexual Health showing that sexual health in the UK is ‘in crisis’, with steep rises in STIs (gonorrhoea rates had doubled and syphilis risen by 500% in the past six years) and a breakdown in NHS services to cope with the rise.

Studies from both Uganda and the US have clearly demonstrated that informing young people about the physical and emotional consequences of premarital sex and promoting sexual abstinence really do effect behaviour change. The ABC programme in Uganda, which promotes abstinence and faithfulness in marriage, has more than halved the level of HIV infection in that country over a ten-year period while virtually all other African countries that have ignored the dictum have seen rates of HIV increase. In the UK, Christian charities promoting abstinence and faithfulness include Lovewise, Love for Life, Challenge Teams UK, Romance Academy, Oasis Esteem and Evaluate.

The mainstay of any Christian response must therefore be the promotion of abstinence before marriage and faithfulness within marriage coupled with serious warnings about the physical, emotional and spiritual consequences of sexual immorality. But how should we respond to a vaccine against a disease that is primarily the consequence of sexual sin?

It might be that the availability of the HPV vaccine could encourage some teenagers to become even more promiscuous. There is little doubt that the free availability of contraceptives has helped pave the way for the so-called ‘sexual revolution’; and the more recent increase in sexual activity amongst young people has more than cancelled out any protective effect that condoms might have, leading to spiralling rates of STIs. But, as most teenagers do not consider their health when having sex, a preventive measure against the distant possibility of cervical cancer is unlikely to affect sexual behaviour much one way or the other. I suspect that, for most, the major factors contributing to promiscuity are the breakdown of the family, exposure to ‘sex-without-consequence’ and pornography through magazines, TV, film and internet, and a lack of warnings about the real results of sexual immorality. The government is just waking up to the obesity epidemic and considering stringent messages to bring about behaviour change, such as banning junk food advertising and restricting its availability in schools. Why has it not embarked on similar strategies to forestall the STI epidemic?

Saving a life?

On the other hand, cervical cancer is a terrible disease that claims thousands of lives worldwide, and a vaccine that prevents it is to be welcomed. To deny a potentially life-saving prevention to young people because they may, now or later, contract a disease as a result of sexual sin, in my view undermines both God’s mercy and grace. If a vaccine against the AIDS virus became available, to deny it to at-risk populations would be selfish, ungracious and foolish, not least because a significant number of innocent victims, as with HPV, contract HIV through rape, sexual abuse, non-consensual sex or an unfaithful marriage partner. We would not dream of denying ‘harm-reduction measures’, including drugs and surgery to people who smoke, drink too much, misuse drugs or are obese, despite the fact that they may spurn our efforts to help them by indulging even more.

All of us live on at all only because God in his mercy withholds the judgment we do deserve, and grants us the grace we don’t deserve. Sexual sin, like drunkenness, drug misuse and gluttony, grieves God’s spirit; but, in my view, failing to act when it is within our power to protect young people from a deadly disease, is not mediating God’s mercy and grace. What mother, after urging her son to ride safely, does not also encourage him or her to wear a safety helmet, to safeguard against his own, or some third party’s, recklessness or stupidity?

When this vaccine becomes available, as it most certainly will, there will undoubtedly be much media hype about ‘cures for cancer’ and probably, given current form, no change in the government’s policy to promote condoms and the morning after pill, while neglecting to promote behaviour change. As Christians we have a responsibility to promote premarital abstinence and marital faithfulness and to tell the truth about the temporal and eternal consequences of sexual immorality. I believe we should resist any attempt to impose this vaccine on all, while at the same time supporting its use for those at high risk. Whether or not we encourage our own children to be vaccinated, to protect them from theirs or others’ sexual immorality, will be a matter for each parent, after a careful weighing of the issues. But however we decide, we must ensure that we don’t neglect to promote to them God’s pattern of sex as a gift for marriage alone and to warn them about the physical and spiritual consequences of sexual sin.

Peter Saunders,
General Secretary, Christian Medical Fellowship
(http://www.cmf.org.uk)

Cervical cancer jabs - promoting promiscuity or providing protection?

Easily preventable

Trials

Uncertainties and certainties

A biblical response

Saving a life?

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