A shot at protection

HPV causes cancer. There’s a vaccine that will prevent HPV. Should we mandate its use?

The Texas House and Senate rescinded an order by Gov. Rick Perry this spring mandating that girls entering the sixth grade be given the vaccine Gardasil to protect against a virus that can cause cervical cancer. The debate continues. Nursing professor Suzy Lockwood, past-president of the Society of Gynecologic Nurse Oncologists, is an advocate for the vaccine and has written extensively on the topic. She answers some of the subject's burning questions.

Q: What is HPV and what does it do? How is it detected?

A: HPV is human papillomavirus virus. It is the second most common cause of cancer death in women worldwide. There are about 200 types, but there are four main varieties that we know cause 70 percent of all cervical cancers, which most often affects women during their reproductive years—and can rob those affected of their ability to have children and can threaten their life. HPV is also responsible for oral cancers, head and neck cancers, rectal cancers and penile cancers. It's also responsible for warts. Women can be tested for it easily with a pap smear performed by their doctor.

Q: What of this vaccine?

A: The vaccine Gardasil, which is approved by the FDA, is specific for those four main varieties: 6, 11, 16 and 18. It will protect women from 70 percent of cervical cancers. It not only can save lives and reduce fear related to potentially acquiring the disease. There are no other vaccines against cancer. The role of the vaccine is cancer prevention.

Q: Until recently, the public didn't know a lot about HPV. Why is that?

A: I don't think science knew a lot about HPV itself. We knew it was a virus. But there is a catch phrase in medicine: "Anything we don't understand, or for any condition for which we don't know the cause, we say that it must be a virus."  In this case, it really is a virus and we identified it. We just didn't know much about it. We also didn't know until they did studies over 10 to 20 years to make the connection between it and cervical cancer. It is similar to the AIDS virus in that we didn't know about it. But after it was discovered, we thought, "How did we not know about this?" HPV is a virus you can get and not have any symptoms, unless you also have genital warts. You can have the virus and have no symptoms at all. It can also be in remission. It can take 15 months to 3 years to show. That's why the recommendation is for girls to be vaccinated between ages 9 and 11 because it can take 15 months or more to develop.

Q: You were in favor of Gov. Perry's plan to mandate Gardasil for all girls entering the fifth grade. What went wrong?

A: The value of the vaccine got lost in the politics and the controversy. The other thing that made it fail is you never tell parents how to care for their children. If I wasn't a firm supporter of it, I might have reacted the way some people did. I think a lot of people still need the education about the vaccine and the cancers. The cancers it protects against are sexually transmitted cancers but we also know that girls are having sex at 9, 10, 11 years of age. The other issue with the vaccine and executive order is how it will be paid for and will everyone be covered. Unless it is on the list of required child care immunizations for school, most insurers won't cover it. So there is an inequity already. The implementation of the plan had some holes in it.

Q: Why age 9 through 11?

A: Because it takes a while for the virus to take hold and develop and we want to make sure the vaccine is in place before children start sexual activity. We can't continue to be naive that kids will wait to get to high school before they have sex. We have too many young teens having babies. Fifteen years ago when researchers were first presenting their data, they talked about adding the vaccine to the immunization schedule given to newborns. But then we learned that we wouldn't know how long it would last. But it was clear that at some point, it would have to be routine. It would have to be one of the things we do to protect our children. 

Q: Are children getting adequate sexual education?

A: Not at all. That is obvious when you talk to high school age and middle school age students, especially when it comes to oral sex. The prevailing belief is that it's okay, that oral sex is not really sex. They don't understand that it is sex and they can get HIV or HPV or other viruses from oral sex. When I was growing up, the biggest consequence of having sex was getting pregnant. For the generation between me and my daughter, the biggest consequence was getting HIV or AIDS. Now there is HPV, and it's like herpes and the others, it stays with you for life.

Q: There is a moral dimension to this debate, and Gov. Perry's plan even had an "opt out" clause for those whose religious beliefs were in conflict. Many say that the state should not be in the business of making this kind of decision for parents. Do you agree or is there a greater good?

A: Yes, I think there is a greater good. When you have a chance to prevent a cancer that is preventable by either administering the vaccine or not having sex, then why would you not want to guard against the cancer?  I ask this when I talk to my nursing students: When you got your MMR (Measles/Mumps/Rubella) vaccine or booster, did you run out and be around people with measles? No. There is this idea that getting this vaccine suddenly gives a person license to have sex or act in ways out of character for them. That's not why we give a vaccine. We give it to prevent a virus.

Q: You have a brand-new granddaughter. Would you want her vaccinated?

A: When she turns 9, yes, I would want her to get vaccinated.

Q: Some would argue that it is still too early to mandate a vaccine that has only been available recently, that there is uncertainty about whether it is completely safe. How would you respond?

A: Those are valid concerns. But it has been approved by the FDA. They do their homework. We do have some information that is 10 years out that shows that it is safe. However, we don't yet have information that looks 20 to 30 years out. But that is being researched. What we also don't have is whether we will need a booster. That's the bigger issue to me. If we give this vaccine at age 9 or 10, will girls need a booster at 19 or 20? We don't know that yet. Researchers are working to find out.

Q: Where do boys figure in all this?

A: Currently, the vaccine is approved by the FDA for girls. But there is research being done - that hopefully will be completed by the end of this year - on boys. Hopefully, they'll have a recommendation for them. Girls can go in and be tested fairly easily. They can test for it with a pap smear. For guys, there is no easy test. (They could be tested but no one is going to volunteer for that test.) The only way we know for sure if a boy has it is if they have external warts. My feeling is that if we vaccinate guys, we probably won't have to vaccinate the girls. Men are the primary carriers of it. If we only focus on the girls, we're not completely solving the issue. The research is looking at using the same vaccine in boys.

Q: There is a stigma surrounding the HPV vaccine because the virus is contracted through sexual contact. But Hepatitis B is a required vaccine in the state of Texas and it can be transmitted through sexual contact. Why is HPV different?

A: Hep B can be transmitted sexually, but that's not the only way. It's blood borne. It can be passed a variety of ways.

Q: Because HPV is spread exclusively through sexual contact, there are some who argue that giving the vaccine gives children permission to have sex or to experiment with sex. How do you respond?

A: You have to educate you kids about why they're getting it. A lot depends on who you present it to them. If you say, "This is helping prevent you from getting a cancer," that is a lot different from saying, "I'm giving you this vaccine so you'll be safe to have sex." It's the wordsmithing. As parents, we're responsible for protecting our children. But we're also responsible for being aware of what our kids are doing, even if we don't like to think about what they're doing. Another thing that is coming out of this that is not getting a lot of publicity is that there are some girls who are being exposed to HPV who did not have sex voluntarily. What about the girls who are raped or in an abusive relationship at home? This vaccine protects them from further harm down the road.

Q: Where do things go from here, with Gov. Perry's order overturned? How will the health care industry respond?

Doctor nurse

New doctorate prepares nurses for advanced practice.

TCU’s Harris College of Nursing and Health Sciences is adding a doctor of nursing practice (DNP) degree, a move that puts TCU ahead of the curve: American Association of Colleges of Nursing stipulates that APN master’s degrees must advance to the doctoral level by 2015.

The DNP is progressing through the state approval process, with plans to start this fall. It will accept qualified applicants from any of the four advanced practice nursing roles: certified registered nurse anesthetist (CRNA), clinical nurse specialist (CNS), nurse practitioner (NP) and certified nurse midwife (CNM).

“There is only one DNP program in Texas, and it currently only serves NPs,” said Linda Harrington, director of the new DNP program. “We could be the second and the only one serving CNRAs, CNSs and CNMs.”

TCU’s DNP is not a PhD program, which traditionally focuses on research and theory. Instead, it will emphasize practical application. Course work will be online, with some immersion experiences that bring students together for speakers and group projects. Full-time students can complete the DNP in 21 months, meaning that the first class could graduate by May 2009. — RSM

Contact Linda Harrington at l.harrington@tcu.edu.
Comment at tcumagazine@tcu.edu.