Stalking a silent killer

Medicine | The viruses leading to cervical cancer have gone underdiagnosed for too long; now, with a new vaccine, women-and girls-face ethical challenges over making use of it

Issue: "Autumn books," Oct. 7, 2006

Eva Perón never knew what killed her. In the early 1950s, before patients' bills of rights and managed care, doctors and families commonly kept cancer diagnoses a secret from those afflicted. But Argentinian president Juan Perón went to great lengths to hide his wife's diagnosis of cervical cancer from her. He never told his wife before her death in 1952 that an American specialist performed her hysterectomy in place of her local doctor. Historians have speculated that the deception was part political maneuvering and part denial; President Perón did not want the country to learn of his misfortune in an election year, and his wife did not want to know.

But there was something neither Perón nor the public knew about Evita, even after a Broadway musical memorialized the story of her populism and humanitarianism. Her cancer was caused by a sexually transmitted virus that she most likely caught from her husband, whose first wife also died of cervical cancer.

The CDC estimates that 80 percent of women under 50 have had human papillomavirus (HPV), the virus that causes cervical cancer. Doctors have known about the disease for at least 20 years, but until recently it remained as much a mystery to the public as it did to Juan and Eva Perón.

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The release of an HPV vaccine in June finally gave women a reason to talk to their doctors and each other about the disease. The facts of HPV challenge what they thought they knew about sex and sexually transmitted diseases (STDs).

HPV can occur in monogamous relationships if one of the people in the relationship has had previous genital contact with someone else. As with all STDs, abstinence until marriage will prevent HPV, but it has to be abstinence from all genital contact, and on the part of both spouses. HPV is similar to HIV, the virus that causes AIDS, only in that both can be transmitted sexually. But statistically speaking, the population that exposes itself to HPV is much larger than the one that exposes itself to HIV. About 40,000 new U.S. cases of HIV occur every year, while there are over 6.2 million new cases of HPV.

There are more than 100 kinds of Human papillomaviruses, all of which cause changes to skin cells. The majority of types cause the common skin wart; about 40 kinds of HPV are transmitted through genital contact. Most HPV infections clear up on their own with no symptoms. Some types of HPV cause genital warts in men and women, while a handful of strains change the cells of the cervix into pre-cancerous cells. The cells will develop into cancer if not detected and removed. Men can carry the kinds of HPV that cause cervical cancer, but they rarely experience any symptoms from it. Doctors now believe HPV is the sole cause of all cervical cancer.

With 6.2 million new cases of HPV every year-more than gonorrhea, chlamydia, and syphilis combined-the Centers for Disease Control predict that if every American ages 14 to 49 took an HPV test on the same day, 15 percent-20 million people-would be infected. More than half of sexually active men and women get HPV at some point in their lives; and, the CDC says, by age 50, 80 percent of women have had HPV. A recent study showed people who use condoms were 70 percent less likely to get HPV than those who do not, but condoms are not 100 percent effective at preventing the virus.

Gynecologists now use HPV testing as a follow-up to an abnormal Pap test, which analyzes cervical cells for early signs of cancer. But HPV has a long, unpredictable latency, so a woman can contract the virus early in her adult life and have it for years before it affects the cells in her cervix. A man can also carry the virus for a long time and never experience symptoms. Without abstinence, both may give the disease to others in the meantime.

Connie Mao, a gynecologist at the Harborview Women's Clinic in Seattle, said most of her patients with HPV had never heard of the virus before she diagnosed them with it. "They want to treat it, they want to know it's gone, and they want to know who gave it to them," said Mao, who is also on the faculty at the University of Washington, the country's leading HPV research center. "All of those questions with HPV are very hard. You could have had it for 10 years, and I can't treat it."


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