The last two weeks have seen a flurry of comments about the merits of screening mammography for women under the age of 50. There is nothing new here. This debate has been going on for more than 20 years now. Evidence has existed for years, that in population terms, screening younger women does not save lives from breast cancer and probably harms more woman than it helps. The US has chosen for years to ignore this, while the rest of the western world generally does not promote screening to women under 50.

Before we get into the details let me make two things perfectly clear:

• Screening versus diagnostic mammograms: the general public often doesn't understand the difference between screening and diagnostic mammograms. Screening takes a healthy population of women with absolutely no symptoms and tests them with regular mammograms. A diagnostic mammogram, on the other hand, is done when there is a detectable lump, a discharge,  a change or puckering in the skin or when a woman is found or suspected by family history to carry BRCA-1 or BRCA-2 genes. The debate about mammograms is around screening healthy women with no symptoms or genetic risk and its value in saving lives. If you or a loved one at any time has any symptoms  or carry the gene for breast cancer, get a diagnostic mammogram as fast as you can. In the same way, screening breast self exams -- which means teaching healthy symptomless women how to check their breasts in a routine way at the same time ever month -- has not been found to help. That is completely different from the need for all women to simply know her breasts and notice any change -- a lump, a puckering, a discharge or thickening of the skin. As soon as you have a symptom, get into the doctor right away.
• The need for clear informed consent and personal decision-making:  A woman  must be the master of her own body. If, with her family doctor, a woman at any age is fully aware of the pros and cons of mammograms and decides she needs one or wants one, and the doctor agrees, she should be able to get one. But as I will detail below, there has been a lack of clear informed consent around mammograms. Only the benefits, and none of the downsides, are widely promoted in the invitations to screening programs. But, if a woman knows the pros and cons and decides to get one, I absolutely support that right. I personally know many women who chose screening and had early cancers, mostly DCIS,  found. They firmly believe this saved their lives and I support their right to believe that and make that choice. More informed consent is needed.

Now that those two things are clear, let me tell you a story. Back in 1987, when I was medical reporter at the Vancouver Sun, I got a call from the BC Cancer Agency that the Canadian National Breast Cancer Screening Study was comparing the outcomes of women screened to women not screened in huge numbers -- more than 90,000 Canadian women. But there was a problem - not enough women knew about the study and so not enough were signing up to take part. I wrote a story about a woman whose breast cancer was found on a screening mammogram, and how grateful she was. And I urged women to take part in this important study. The Cancer Agency had so many calls in the week after my story ran -- more than 3,000 -- that they had to put in extra phone lines. The BC arm made its target number for the study in part based on my promotion of it. I firmly believed early detection was the way to go.

But then, around 1988/89, I began to hear concerning rumors among my sources that results of the study were astonishing and confounding. In the 40 to 49 age group, more women were dying in the screened group than were dying in the control group. This did not make sense. We all believed so firmly that early detection would save lives, and that the earlier that screening was started, and a cancer detected, the better. No one wanted to believe that finding it earlier might in fact be harmful.  Canadian lead researcher Dr. Cornelia Baines says the data about worse outcomes in screening in younger women started showing as early as 1983, but by the early 1990s, with more than 90,000 women studied,  it was clear - the young mammography group had more deaths, more false positives and more overdiagnosis ( treatment of harmless cancers) than the control group. When Baines et al published the results in 1992 they were roundly criticized, their study methods were faulted (there was nothing wrong with the study) and the Canadian team's credibility was assaulted. It was shocking to see how ideology trumped the research. The message was ignored and the messengers shot instead.

But two otherr large European controlled studies found exactly the same result -- women under 50 had more deaths.  UK surgeon and breast cancer expert Dr. Michael Baum, who in in the 1980s was the strongest proponent in that country for mammography and set up its national screening program, has become one of its strongest and most vocal critics. Baum is particularly concerned by the huge increase in ductal carcinoma in situ ( DCIS) found in women under 50 who have mammograms.

Here is what Dr. Baum has said widely in various interviews, including to me in an article I did on DCIS in spring 2008 Best Health, about his theory about what is occurring:

" Ductal carcinoma in situ is probably not a good word, and we should call it latent cancer. These latent cancers, particularly in premenopausal women, are grossly over-represented in women given mammograms--something like five times more, compared to what you would expect. This suggests that if left to their own devices, these latent cancers might never trouble a woman. But if you identify these latent cancers and biopsy them, you have traumatized the area. You immediately trigger the natural healing mechanisms, and natural healing mechanisms involve angiogenesis ( formation of new blood vessels.) So, effectively, the biopsy could be considered an angiogenic switch. You take a latent cancer that would never hurt a woman, biopsy it, turn on the angiogenic switch, and it ceases to be latent. A latent disease becomes an aggressive disease."

This theory of angiogenesis is highly controversial and you won't hear it discussed much, but it is strongly supported Michael Retsky, PhD, a researcher at Harvard Medial School and the late, famed researcher Judah Folkman, also of Harvard, who is credited as the father of angiogenesis research in many disease processes including cancer. Another interesting finding that might support the theory that mammography may somehow help turn on a switch making some breast cancers more aggressive. For years researchers have known about "interval cancers"  -- breast cancer that shows up, suddenly between the screening as a felt lump in women who have been having mammograms every year or two.  There is no evidence of a cancer at all on the screen, but then one suddenly grows rapidly before the next scheduled mammogram. Interval cancers are usally more aggressive than those found at the time of screening or those found in women who have never undergone screening. They don't know why interval cancers are particularly nasty, but Baum theorizes that perhaps radiation or the intense squeezing of the breast during the screen may switch on the healing response of angiogenisis that also spurs a cancer growth.

Baum resigned from the UK screening program in the 1990s when it refused to share the pros and cons with all women taking part in screening as a necessary discussion about informed consent. He believes that fully informed women over the age of 50 should choose for themselves as there is evidence past age 50 it saves lives, but he is on the record saying: "To promote screening mammography to women under the age of 50 is absolutely unethical."

But let's take a closer look at that age of 50 -- that age is chosen because the median age of menopause in western women is around 49.  Onset of menopause ranges from the early 40s to the late 50s. Some women do not experience menopause ( a full year without a menstrual period) until age 58 or 59. The evidence is that it is likely menopause not age, that is the defining factor of whether screening mammograms are helpful.  ( It could again be angiogenesis and the menstrual cycle, some theorize.) The evidence is convincing enough for me that I have decided I will not undergo a screening mammogram until I have had one full year of cessation of menstruation. The best results for screening is among women aged 60 to 69, likely because all women by that age are menopausal.

Here is another fact that more women should know. The huge drop in the use of hormone replacement therapy corresponds exactly, with a lag time, with a significant drop in breast cancer incidence. In fact, more lives may be saved by not doing HRT than from screening.  There was a 13 per cent drop in hormone receptor positive breast cancer between 2001 and 2004 and an 8 per cent drop in a single year ( 2002/2003) that tracks exactly to the sudden stop of HRT by millions of women following the 2001 results of the Women's Health Initiative, that found HRT was harming women.

Look at these two graphs from the New England Journal of Medicine and note the  drop  corresponds to the sudden decline in prescriptions for HRT. Although the issue is still being debated, a similar decline was seen in Canada, Spain and the UK, and a special study by regions in California also showed the same result. Click to enlarge the thumbnail to better read the graph, from New England Journal, Berry et al, April 19, 2007 

For those of you wanting more references, here are a few ones to start. The literature is huge. Just google pubmed and go to the National Library of Medicine data base. You could be reading for hours. I am citing the British Medical Journal and European journals primarily because there seems to be a more open discussion of the pros and cons over the last decade in Europe than in North America,  which may be interesting to Canadian women. Here in North America we still shoot the messenger, as has been seen by the coverage of the past week. Thus, I am wearing my flak jacket.

H Gilbert Welch. Overdiagnosis and mammography screening.

BMJ 2009 339: b1425. [Extract] [Full Text]

Zackrisson S, Andersson I, Janzon L, Manjer J, Garne JP. Rate of over-diagnosis of breast cancer 15 years after end of Malmö mammographic screening trial: follow-up study. BMJ 2006;332: 689-91.[Abstract/Free Full Text]

Duffy SW. Some current issues in breast cancer screening. J Med Screen 2005;12: 128-33.[Medline]

Moller B, Weedon-Fekjaer H, Hakulinen T, Tryggvadottir L, Storm HH, Talback M, et al. The influence of mammographic screening on national trends in breast cancer incidence. Eur J Cancer Prev 2005;14: 117-28.[CrossRef][ISI][Medline]

H Gilbert Welch, Lisa M Schwartz, and Steven Woloshin. Ramifications of screening for breast cancer: 1 in 4 cancers detected by mammography are pseudocancers
BMJ 2006 332: 727. [Extract] [Full Text]

 Michael Baum. Ramifications of screening for breast cancer: Consent for screening BMJ 2006 332: 728. [Extract] [Full Text]

• I've had differing reactions to my blog on peanut bans, one of which was that young allergic children cannot be charged with keeping themselves safe. I totally agree and I did not want to give that impression. Risk management must have responsible adults oversee it. Adults ensure safe processes are followed. It means that teachers or cafeteria staff must enforce the rules that everyone sits in place and eats their food, with no food sharing. It means that the adult asks who has an allergenic food that day, and that kids are separated in a way that no one feels bad, or singled out or isolated. It means the adult oversees the safe and effective clean up - "Johnny, you missed that spot there, wipe it up again." or " Dylan, don't throw that wash cloth, walk over to the sink and rinse it out." Without a process that all agree to, responsible adults to monitor the process and consequences if the process is not followed, the allergic child is left to fend for his or her self and risk management is equally unsafe as peanut bans or no plan at all.
• An interesting article on HPV vaccination appeared in the Nov 5 New England Journal of Medicine. Instead of using the vaccine to prevent infection with HPV -- as it is being used now -- Dutch doctors created a variant of the HPV-16 vaccine and gave it to 19 women with early precancerous lesions of the vulva. Typically these women would have had to undergone an invasive course of repeated ablations with a carbon dioxide laser ( burning) or wide excision via surgery ( cutting) of their vulva to remove these lesions to stop them progressing to cancer. Recurrence is almost universal. So instead the Dutch doctors gave the vaccine to prime the women's immune systems to fight the HPV strain themselves. Of the 19, 15 had a marked improvement of symptoms  and 9 women completely cleared the lesion and remained lesion free 2 years later. The use of immune modulating to fight early cancer is a fascinating and hugely important area of medicine. The HPV vaccine and the Hepatitis B vaccine are both proving that some future cancers can be prevented by immunization. Now new evidence is emerging that early cancer may one day be widely treated by the same means. I believe the viral role in cancer will be an area of explosive research in the decade ahead. Some are suggesting that viral causes of prostate cancer and some forms of  breast cancer may also be revealed.

Recently peanut bans have come under fire, particularly by writer Patricia Pearson who in the October issue of Chatelaine wrote a provocative piece claiming peanut bans are nuts. She is the mother of a picky child, whose favourite food is peanut butter. She writes that schools are over-reacting to peanut allergies.  Naturally, some 270+ comments have now been posted on the Chatelaine website, the majority from parents of allergic children saying "Shame on You Chatelaine," calling Pearson irresponsible and stressing that life-threatening allergies must be taken seriously. Other parents have praised her for finally speaking out, saying parents of allergic children are hysterical and irrational.

As the mother of a peanut allergic child I have a unique perspective. Both sides are right: allergies must be taken seriously, but parents of allergic children often do blindly promote peanut bans without reflection. I support a sensible third way: risk management.

 Early in Kate’s school years we learned peanut bans were actually dangerous to her.  Their effectiveness relied completely on all the school's parents, staff and children honouring the ban. Twice peanut bans were broken around Kate by parents whose children would only eat peanut butter sandwiches. One parent at our tiny preschool told the child to quietly eat his lunch out in the play area. He did so on the swing set and he put his hands all over the swing's chain. Kate touched the chain later that day and there was enough residue that her face swelled up to twice its size and her eyes closed shut. She was taken to hospital where we tried to figure out how in the world she had come in contact with peanuts. Fortunately she did not put her hands into her mouth or she might have died. In search for the reasons for her reaction, we were told other children had seen the child eating his sandwich on the swing. The parent confessed that she had encouraged him because he would eat nothing else. She didn't want him to starve. The ban forced her to act surreptitiously and that put Kate in danger. A second incident occurred when a grandparent made a peanut butter sandwich and it came into Kate's Grade 1 classroom without anyone knowing. The fumes caused a serious asthma attack for Kate.

Those two incidents convinced me that peanut bans are quietly breached all the time leaving no protection in place. In fact Kate's safety was in the hands of some 600 people we did not know.  I wanted the control in our hands, and ultimately in Kate's hands. She is the one who must move through the world with her allergy. She must learn how to manage risk to keep herself safe.

 Here is how risk management deals with food allergies at schools and is applied to all children with or without allergies:

• All food is eaten at children’s desks or the cafeteria ( no food in school yards, halls or playgrounds – this reduces risk of choking too.)
• All desks or eating surfaces are wiped clean and hands washed before and after all food consumption. In particular, kids are charged with keeping their desktop and their hands clean and free of food residue ( This reduces transmission of viruses, too.)
• The serious allergies in each classroom are noted and posted – nuts, peanuts, fish, egg, etc. If another child has a food that contains an allergen, it is announced. In Kate’s classroom, the kids would say: “I have peanut butter today, Kate” and arrangements would be made to put the two of them far apart and be extra careful with the clean up. Most of Kate’s friends decided they would not eat peanuts around her. But she always knew who had what.  It promoted communication and understanding. And the child with the shrimp allergy was safe, too.
• We stressed to Kate, “If you don’t eat it, it won’t kill you.” She might get hives or wheezy, but she would be okay. She was calm around other people's food. She didn't freak out if she saw peanuts, she just kept herself away or washed her hands really well. She always carried her epi pen, asthma meds and antihistamines.
• We also stressed: “Don’t eat what you don’t know” which meant no experimentation or food sharing. She learned to assess the risks of each situation and judge the places where peanuts traces might be hiding ( chocolate, ice cream, a jam or honey jar at a friend’s house, cross contamination at a Thai or Vietnamese restaurant.) She would avoid those situations.

These simple clear techniques not only kept her safe and in control of her own health – she had no further peanut reactions despite peanuts being all around her  – but kept other kids safe, too, no matter what their allergies. While I agree peanuts must not be eaten in closed air environments like airplanes – the risks are too high – I strongly encourage all parents of allergic children to lobby for the adoption of risk management rather than peanut bans. Then we can stop the ridiculous name calling and truly reduce the chance that an allergic child will come to harm.

A girlfriend sent me a note today, after my previous blog, saying her GP told her the HPV vaccine has "not been studied enough" and advised her against having her daugther get  it.

I will present a summary of some of the research facts and you can judge.

But first, if you don't trust my interpretation, you can go yourself to read abstracts from all the medical literature at the US National Library of Medicine. The US National Institutes of Health provides an incredible free research tool which is a searchable database of every medical journal in the world. Just put "Pub Med" into google and it will come up. Then in its search bar put "HPV vaccine" ( for everything about it) or "HPV" adverse events" if you are particularly interested in the risks.

The medical language can be hard for neophytes, but I go to Pub Med almost everyday to look up something in my job as a medical writer and summarzing medical literature is a big part of what I do.

Since 2000, there are more than 3100 research studies, commentaries and reviews about the HPV vaccine in the world's medical journals. One or both of the two available vaccines are now licensed in 98  countries and being used in high school innoculation campaigns in hundreds of jurisdictions, including all of the provinces of Canada. Australia has been doing school innoculations since 2006, UK since 2007, so Canada is slow to adopt it as this is the first year it is being offered to highschool girls in mass immunizations. Millions of girls and women have now been vaccinated

• Prior to licensure in 2006, more than 60,000 young women had been given the vaccine in trials. In that number, the incidence of adverse events following immunization (AEFI) was very low but 60,000 was too small to find the true incidence of serious rare events.
• In August of this year, the US Centre for Disease Control published in the Journal of the American Medical Association the "Postlicensure Safety Survelliance" of the vaccine now that millions of women and girls have received it. All jurisdicitons report AEFI rate. ( It is a passive system, in that the people doing the shot must report. So some events may go unreported, but not likely the serious ones.)  Here is the most recent AEFI per 100,000 innoculated :
  • 8.2 girls per 100,000 fainted ( syncope)
  • 7.5 had local site reactions
  • 6.8 got dizzy
  • 5.0 were nauseated
  • 4.1 got headaches
  • 2.6 got hives (uticaria)
  • 0.02  ( 2 in a million) got a venous-thromboembolic event (a blood clot) or developed Guillan-Barre syndrome ( they are not clear these events were vaccine related)
  • 0.01 had anaphylaxis and/or died  ( 1 in a million )
  • There have been 32 deaths reported world wide now that upwards of 32 million women have been innoculated. Some of the deaths such as a 14 year old girl in Coventry England two hours after the shot is now being ruled not related.
• The first women innoculated were back in 1998-1999 in Seattle. IN that research study 100 % of the women with the vaccine were negative for HPV and there were no AEFI except site soreness, dizziness and headache. Koutsky has followed up with 200 of these women and found, 9 years later, more than 90 per cent were still negative.
• Australia also now has data on about 8 years post vaccine followup. They report an 87 per cent still negative rate  8 years later.
• There is a lot of debate in the medical literature about the psychological impacts and a number of studies have done surveys of parents and young girls for attitudes. Here are some of the findings
  
  •   Parents not signing the form, more than 50 percent feel it encourages sex without risk and condones premarital sexual activity. (Hmm, "I would rather have my daughter at risk of cancer, genital warts than have her think sex is normal and healthy.")
  •   Most 11-12 year old girls, when surveyed, say they want the vaccine when told about the pros and cons. Among girls whose parents did not sign the form, 50 per cent said they wanted it but their parents wouldn't allow it.

A lot of debate exists about HPV's impact on the PAP screen and fear that it will undermine the Pap Screen process and the 40 years of its success.  Here is some of that debate:

• All agree, women must still have regular paps
• With much fewer cases, will the PAP screen have a higher false negative rate? ( Screeners seeing less cancer, and therefore becoming less good at catching it?)  - This to me is a quality control issue and saying we need more women getting cancer so that our screeners can properly read the slides is a ridiculous argument. We already know in some jurisdicitons, quality control is poor. I say put the resources in primary protection ( stopping it in the first place) and not secondary ( catchng after it has occured and women need invasive treatment to cure it.)
• 50 per cent of women who get cervical cancer haven't had a PAP in 7 years. Many of these are aboriginal, immigrant or poor women.  Pro side says mass innoculation of young girls removes this socio-economic determinant and levels the playing field. Cons say " we have to reach out to them more and get them regular medical care and not accept the status quo." I say do both -protect all the girls equally now, and work upstream to ensure disadvantaged women are not lost to medical care through life circumstances. Where's the conflict?
• Cons say only 1,700 women in Canada each year get cervical cancer but the cost of the vaccine is so high that it is disproportionately spending resources on a cancer that is no longer a big problem.  But, as the pro side points out, it is not just cervical cancer in the total cost. HPV causes ( and costs) for all the following:
  •  genital warts ( 50 per cent of all sexually active people get it) - it can take multiple trips for docs to burn off the warts.
  • recalls of PAP tests
  • Colposcopies ( viewing the cervix)
  • Cone biopsies of precancerou cells
  • treatments of displasia ( - freezing, buring, cutting away the cervix) all in the pre cancer stage.
  • other cancers likely caused by HPV ( penile, anal, oral and esophageal, vaginal and vulvar -- although low in numbers, collectively significant.)

Despite the PAP test and the huge drop in cervical cancer, world wide cervical cancer remains the second most common malignant disease in women. In third world countries it is still the leading cause of death for women. In developing countries like Africa and South East Asia, where PAP screening is deplorable, the HPV vaccine may make a huge impact in protecting women and saving lives.

In the Western world, HPV vaccine provides very high rates of prevention for at least 8 years post vaccine, preventing women from getting cancer in the first place. Why in this day and age, when a vaccine has been proven safe enough and effective for the years when girls are most at risk, would we be arguing that waiting for cancer to strike and then spending all sorts of resources to find it is the more logical option?

( Perhaps look at the vested interests in the systems at work in finding the cancer.)

And note, some of the objections to the HPV vaccine is actually moralistic religious view points, hiding behind "scientific" argument. That moralistic view ( as seen in the parents interviews) has at its basis that sex with less risk is inherently wrong and that teenage sexuality must be discouraged and must have its negative outcomes. That, to me explains, why the Catholic diocese in Vancouver has advised parents not to let their girls have the shot. It is not science folks, its morality.

Me, I know my teenage girls will be exploring with sexuality. It is human. I want them to do so safely.

 But don't just listen to me -- after 7 years of reading about this, I am very firmly in the pro camp. Read the literature yourself at www.ncbi.nlm.nih.gov/pubmed/

I just got off the phone with an old friend, a dad of two teenager daugthers. One of his daugthers this year is set to receive the mass immunization taking place in Grade 9 girls in BC. The mom, a close friend, signed the permission form, but the dad was hesitant.

"Call Anne", the mom said, "She will convince you."

He called me up tonight, all worry and concern about unnecessary vaccinations and immune modulations, risks and benefits. And this is what I told him in a 30 minute conversation:

Back in 2002 I was ghost writing a massive provincial health document - The Health and Wellbeing of People in British Columbia -- for Provincial Health Officer Dr. Perry Kendall, a doctor and epidemiologist whom I know very well.  Perry is the best of public health officials, firmly committed to the principles of pubic health, constantly weighing the pros and cons of intervention versus the cost of doing nothing, assessing the evidence and formulating a reasoned, safe, proactive response to keep BC on the cutting edge of health protection.

 We were finishing this 245 page tome about how to improve the health of British Columbians when a study in the New England Journal of Medicine reported amazing findings of a new vaccine. It was one of those situations were researchers prematurely broke the anonymous code in a double blind study because one arm had such unamimous results that it was unethical to continue. The results were this: 0f 768 women who received the HPV vaccine, none developed any cervical changes nor even had any HPV-16 residing in their genital tract where it could infect new sexual partners. Not one! ( Koutsky et al, 2002; Crum, 2002) The placebo group had 16 infections, three of which had already developed cervical lesions. The trial had run 17 months.

We knew the results were highly preliminary. We knew there were almost 70 different strains of HPV and this vaccine only protected for the two most virulent strains, HPV-16 and HPV-18. But those two strains alone were responsible for more than 50 per cent of all cervical cancer. This was an amazing result - 100 per cent effectiveness in the vaccine group.  It is estimated that 50 per cent of all seuxally active men and women will have an HPV infection at some point in their sexual lives and while 90 per cent clear, it is now known that HPV is not only behind all cervical cancer, it is also a cause of anal, rectal, oral, penile, vulvular and vaginal cancer.

BC had an important history in the cervical cancer story. In the 1950s this province was the first in the world to institute the PAP screen and make it a part of necessary pro-active health care for all sexually active women. Over the last 4 decades, because of PAP screening, cervical cancer has fallen by 85 per cent. Cervical cancer used to be much more common than breast cancer and was a horrible cancer to get. Its dramatic reduction was a true success story.

But here is what frustrates public health and cancer officials: while 50 per cent of women who get cervical cancer have not had a PAP test in the previous 7 years, the other 50 per cent have had regular tests like clock work. They have been coming, year after year, for their PAP test, and they still get it. That 50 per cent has stuck in the craw of cancer prevention officials for years. ( They always focus on the 50 per cent who don't have the tests. "If only we could increase the participation of Aboriginal and immigrant women in the provincial screening program," they say, not mentioning the diligent compliant gals who put their feet in the stirrups year after year to no avail.)

Some HPV viruses are so virulent the can take hold and destroy in less than a year. Researchers do know that the younger the age at first intercourse the faster the advance to cervical cancer. In Canada about 1400 cases of cervical cancer are diagnosed each year and 400 women die from it.  What is not stated is how many thousands of women get the call that unusual cells were found on the PAP test and they need to come back, or they need a cone biopsy, or an cryro-ablation for pre-cancerous cells. The impact of HPV is much, much greater than that 1,400 number of cervical cancer cases. I bet that the majority of sexually active woman in Canada will have in her life time at least one of her PAPs come back with unusual cells, prompting worry and follow up tests, even invasive therapy.

Was this new vaccine a potential cure? Perry and I carefully selected our words for the report and I inserted a special text box in the 11th hour: "Although results are very preliminary and the length of protection is not known, research on expanding the vaccine to protect against more strains of HPV continues. While experts predict PAP smears will still be needed to screen women in conjunction with the vaccine, over the next decade we may see widespread adoption of the HPV vaccine to help further reduce the toll of cervical cancer."

Those words stand up remarkably well 7 years later. I have followed the debate about HPV ever since. I've seen all the various research studies, read all the articles of pros and cons.

Of course, there are some who are against all vaccinations in general.  That is their choice to make - but only because the vast majority chooses vaccination. By doing so, by us absorbing the risk, the  nay-sayer's children are kept safe - lucky for them. We give them herd immunity. They don't have their children die in their arms, like my grandmother did. My paternal grandmother at the beginning of the 20th century lost five of her 11 children to vaccine-preventable illnesses - whooping cough, diptheria, meningitis. In my family, vaccines are seen as one of the greatest advances of medical science. To reject vaccination for the serious childhood illnesses, in the eyes of my father, who became a doctor, is an abroggation of your societal duty. 

All vaccines, of course, must be weighed for their pros and cons, their risks and benefits. For me the pros of the HPV vaccine vastly outweigh the cons. I had a girlfriend die of cervical cancer in her 30s. I had a Pap test come back with concerning cells.  My girls are too old for the first mass innoculation. I had them vaccinated at my own expense ( $400!! each.) I felt it was a must and they both wanted it.

Some parents recoil that the vaccine is to be given in Grade 9. "They are still such little girls. Couldn't they give it when they are more obviously sexually mature?"

But here is the problem: we know that in grade 9 more than 90 per cent of the girls are still virgins; by Grade 12, some 50 per cent, or more, are not. How can we determine the right age for each girl? A vaccine program must get them well before they need it.

Here are the things we do know:

• Women will still need regular pap tests.  It is just one more arrow in the quiver. They will have to have their partners still wear condoms. It does not allow complacency.
• The protection may wear off in the girl's 20s. To me that is understandable -- it gives them protection in the early years when they are most likley to be exposed for the first time. By the 20s it is likely most girls are in more stable relationships. Koutsky et al has now followed more than 200 of the original women who got the shot in 1998 and 1999 in Seattle -- the vast majority still remain negative for HPV. The protection is lasting for most women at least 8 to 9 years or more.
• Research has shown the teenage cervix is more susceptible to infection and HPV infections in those years can be particularly virulent and advance more rapidly to cancer. The need for innoculation is in the teen years.
• With mass innoculations, bad side effects will arise. It is sheer statistics. The media will focus on this: " High school girl has fatal reaction!" if and when it occurs. Rare reactions don't happen among just 768 women. But as thousands and then hundreds of thousands and then millions get innoculated it is inevitable that some rare reaction will occur. So far the efficacy and safety of the vaccine has been remarkably good, with very few side effects. But it is certain that a 1 in 100,000 or a 1 in a million occurence of anaphylaxis will happen. That risk ratio exists in all medical care.  I accept and live with that risk. Alas many people don't understand it. 1 in 100,000 is a reasonable risk. But if you are that unlucky 1, I am truly sorry.
• The viral connection to cancer, that has been revealed by HPV will lead to huge gains in cancer understanding in the coming decade. This HPV vaccine is the cusp of very exciting medicine. We may finally  understand the origin of some of the common cancers in our life because of what HPV teaches us.

I believe that all young boys should also get the HPV vaccine -- that way the transmission of this nasty virus would truly stop. But the expense of the vaccine program is such they will only target the girls. That's because it is girls and women who bear the brunt of its impact.

And that's the way it has always been, whether fair or not. Contraception has significant risks - women bear the brunt of it. Pregnancy has even more risks -- all on women's shoulders.

HPV vaccine has risks. But the risks are far greater without it.  I accept those risks for my charges. And we have to ask, what would our daughters want as sexually active adult women? My daughters would want this vaccine. And I want it for them.