Gardasil: The Argument Against
For anyone who happens to have been hiding under a psychedelic mushroom for the last year or so, there is a new vaccine recently approved for the "prevention of cervical cancer" called Gardasil. This vaccine is administered as a three-dose series, costs about $120 per dose, and is being marketed for girls and women ages 9-26. So what, if anything, is wrong with this picture?
Just this: The American Cancer Society estimates that in 2006 there will only be 9,710 new cases of cervical cancer, and only 3,700 deaths. I am not disputing that these are horrible deaths, as are many other cancer deaths. But with a total female population of just over 147,000,000, that translates to only about one in 2,500,000 women dying of cervical cancer. At a cost of $360 dollars for the full 3-shot course of vaccine, that comes to about $900,000,000 to prevent one death. One. I'm sorry; no matter how horrible a death, it's not worth 9/10ths of a billion dollars to prevent just one.
Merck (the vaccine's manufacturer) of course uses different numbers, coming up with a much greater benefit by calcualting how many CIN2/3 (abnormal/precancerous paps) were prevented, according to the following statement in their package insert:
CIN 2/3 and AIS are the immediate and necessary precursors of squamous cell carcinoma and adenocarcinoma of the cervix, respectively. Their detection and removal has been shown to prevent cancer; thus, they serve as surrogate markers for prevention of cervical cancer.Here's the fallacy: yes, every cervical cancer began with a CIN2 or 3, but not every CIN2/3 will go on to an invasive cervical cancer. And of those, only about a third of those patients (in aggregate) will go on to die. But the real catch-22 of the situation is that the women overwhelmingly more likely to die are those who never get a pap test.
Thus we have a huge paradox: those who come for cervical cancer screening, even relatively sporadically, are not going to die of it. The vast majority of cervical cancer deaths are in women who have never had a pap. Not ever. Even one lifetime pap reduces the already very small chance of dying of cervical cancer from tiny to ridiculously miniscule. Those who die are those who do not get screened (for whatever reason, be it financial, cultural, socioeconomic, or other access issues.)
So no; I am not going to recommend Gardasil to my young female patients. (We're completely ignoring the role of males as reservoirs of HPV infection, but then females have historically been on their own dealing with the consequences of sex; but I digress.) We are also not discussing the overall global burden of HPV disease, which is considerable. None of the above analyses apply to women in Africa, where horrible cervical cancer deaths are sickenly common.
What could change my mind?
If Merck were to donate 2 free doses of Gardasil to women in Africa for each dose sold here (which would still net them a ton o'cash) then I would push it like a street-corner crack dealer. But I'm not holding my breath.