The thought of any family member dying of cancer is always emotive, and all the more so if you think you might have been able to do something to prevent the disease from wreaking havoc. In the Channel 4 current affairs series Dispatches, journalist Jane Moore considered the forthcoming campaign to treat all 12 year old girls in the UK with a vaccine that can prevent cervical cancer.
This sounds on the face of it like an excellent idea and Moore is not an immunisation skeptic, indeed she paid privately for her older daughter to have the jab, and fully expects her younger daughter to have the injection in the fullness of time. She does, however, raise a number of interesting arguments that show that the decisions about whether or not the UK should be entering into such a full-scale vaccination programme is rather more complicated. The main issues are: (1) is the vaccine safe?; (2) is the vaccine effective?; (3) will the vaccine offer false security?; (4) will it lead to greater promiscuity?; and (5) does this represent good use of NHS resources? Let’s take each of these in turn.
(1) Is the vaccine safe? Going back a few years, the safety of a vaccine would generally have been assumed. In the light of the controversy surrounding the MMR vaccine (see MMR: our children, our choice? ), however, many parents have the gnawing concern that they may be putting their children at risk by the very action they were taking to protect them. Worries about a lack of research and their daughters effectively being “guinea pigs” were raised in the documentary. Despite the fact that no independent study has confirmed the link between MMR and autism, Moore points out, 1 in 6 parents still elect not to give their child the MMR vaccine (see MMR uptake falls to record low and MMR uptake still short of target), even though a failure to maintain high enough levels for “herd immunity” to be achieved has led to an increase in cases of measles (Measles ‘surge’ prompts warning) and even one death (Decline in MMR uptake blamed for measles death). Vaccine suspicion is now part of the national psyche. The issue of trust is discussed, with Jessica Allen of the Institute of Public Policy Research pointing out that people are particularly suspicious of government-led interventions when experts and lobby groups seem to be advocating a different position. 26 million doses of Gardasil, one of the vaccines, have been used worldwide. 18 deaths have been reported within 2 months of the innoculation, but no connection has been identified. No deaths have been associated with the other vaccine, Cervarix (although side-effects of headaches, muscle pain and tiredness have been noted).
(2) Is the vaccine effective? Alongside concerns about safety, worries are raised about the effectiveness of the vaccines. Moore is surprised to discover that the jabs on offer only provide cover against the two most common strains cancer-causing strains of Human Papilloma Virus (HPV-16 and HPV-18), the infective agent responsible for cervical cancer. There are over 100 known strains of HPV, of which 15 can cause cancer. Thus only 7 out of 10 women who might get cancer are protected by the vaccine. The vaccine is also not effective if a woman has already been exposed to the virus (hence the young age at which innoculation will be taking place).
(3) Will the vaccine offer false security? Concerns are raised that overconfidence in the effectiveness of the vaccine might lead some women in the future to spurn invitations to attend routine cervical smear examinations on the assumption that they are no longer at risk. The programme raises the importance of smear testing in picking up pre-cancerous conditions. One GP friends with reservations about the HPV vaccination programme has pointed out that other sexually-transmitted diseases are also often picked up when women come for their smear, and a rise in STD infections may follow a decline in attendance.
(4) Will it lead to greater promiscuity? Roman Catholic parents and a Muslim doctor interviewed in the documentary express worries that having the jab might lead girls to be sexual active at a younger age. Whilst one was willing to discuss sex with her 12 year old, she would not want to be discussing STDs. Dr Loretta Brabin, lead investigator in a parental attitudes study following the Manchester pilot of the vaccination programme acknowledges some parents feel uncomfortable raising the issues of STDs. She points out, however, that giving the vaccine does not imply license to participate in sexual activity – but, as noted above, it has to be given prior to sexual activity and, the fact of the matter is that 1 in 5 14 year olds report that they have had sex, with an average of 3 partners.
(5) Does this represent good use of NHS resources? Finally, the mass vaccination of girls raises the thorny issue of resource allocation; as Moore comments “if you spend a pound saving the life of one patient in the National Health Service, you can’t spend it saving the life of another”. The debate here is not whether the NHS has chosen the right vaccine from the two on offer (which has been a debate in its own right), but rather whether HPV vaccine is a good investment at all. Dr Angela Raffle, from the UK public health commisioning network, has her doubts. Spending half a billion pounds over the next three years on an expensive vaccine for an already uncommon disease is, she suggests “probably not best use of NHS resources”. Elderly patients with strokes and others suffering with diseases that do not demand front-page news will be the net losers, she argues. Professor David Salisbury believes this is “good use of resources” and points to the extensive computer modelling that has been undertaken to show this is the case. Dr Raffle, however, dismisses this evidence, reasoning that it simply highlights the degree of guestimation involved in justifying the vaccination programme; there would have been no need for such effort if the net benefit of the vaccine was as great as was being implied.
In an interesting insight into the marketing of pharmaceutical drugs, Moore looks at the campaigns used to generate demand for Gardasil, the original anti-HPV vaccine manufactured by USA drug company Merck, and for Cervarix, produced by GlaxoSmithKline (the drug which the NHS has adopted). This section of the documentary introduced me to a new term astroturfing, which is the artificial manufacture of apparent grassroots support for an issue. Merck has run a very successful direct marketing campaign in the USA focusing on the notion of being “one less” (victim of cervical cancer, such as this advert). In Europe, Sanofi Pasteur MSD (the same company) have sponsored a range of TellHer websites in different languages. They also paid for a number of freelance journalists to attend a conference they were holding about cervical cancer, a move they now admit was in contravention of the rules set out by the Prescription Medicines Code of Practice Authority. Dr Pim Kon, UK medical director for GSK, argues that healthcare professionals and primary care trusts need to be kept informed about innovative breakthroughs and their extensive communication with doctors has not been about generating demand for the product.
Teaching using The jab that can stop cancer: Would I use this programme for a classroom discussion? Overall I felt the documentary was more balanced and less sensationalist than I had feared that it would be. Nevertheless, anyone intending to show it with secondary school pupils would have to approach the situation with considerable caution. Not only is the subject matter generally sensitive (cancer and sex – the latter issue possibly necessitating formal permission from parents), but also female members of a class may well have had or be due to have the vaccine themselves.
Having said that, vaccination (and specifically mass vaccination programmes) is a feature of several of the new GCSE and A level courses, and I think that this documentary does helpfully outline some of the important ethical issues that have to be grappled with when launching a major medicine. Teachers are strongly recommended to watch the episode in full before using it with a class.
The jab that can stop cancer was first transmitted on Channel 4 at 8 pm on Monday 21st July 2008 (TRILT code 00A59DF2).