The pursuit of happiness vs. the reality of HPV

November 2007

Every day I learn something new in my office.

The 15-year-old girl whom I have seen frequently over the last five years called the office for a consultation. She had a remarkably troubled background: depression, living with her grandparents, removed from her home because of wayward drug-using parents, and she had been recently placed in a temporary shelter for out-of-control behavior. She had just returned from living at a girls’ shelter for two months.

During the past two years, petulant and rebellious, she had demanded and obtained the freedom to act like an adult — to run around with any boy she chose, to drink whenever, etc. As Patrick Henry cautioned more than two centuries ago, “Suffer not yourselves to be betrayed with a kiss.” She wanted all this by age 13. Such is the exaggerated risk of having no stable parent.

Life

She requested to see me specifically for a discussion — the magnitude of which was astounding.

While in temporary custody, she was recently discovered during a routine PAP exam to be afflicted with grade 3 cervical precancer. This in turn meant she would need a major portion of her cervix removed, which in turn meant she would possibly never finish a pregnancy of her own due to the resultant cervical incompetence from the surgery. Less extensive surgery would increase her grave risk for full blown cervical cancer.

She was asking me as her pediatrician, and her long-time child advocate, for a second opinion. This was not my expertise in any way, but I did tell her that this treatment was very standard for the gynecologists, and I would gladly send her to one of my friends in that field for a second opinion. A quite painful and life-altering surgery must be decided quickly. At least three surgical options await her; and each must then be interpreted from her teenage perspective.

She was flabbergasted and terribly saddened to say the least. I could not provide her any other way out of the trap her lifestyle had laid.

Ironically we had just started her HPV vaccination two months earlier — too late for this young lady who had a few too many sex partners and too many risky behaviors!

As her surrogate father figure in the office, I had befriended her and rationalized with her over the years about the importance of taking care of herself first. I had persuaded her to take her oral contraceptives last year and I had cajoled her to respect the rules of her home.

I explained to her she would have to sacrifice for her immediate personal well being first and extirpate the precancer. Or else she would face a potentially deadly silent nemesis. She was finally realizing that this possibly meant no childbearing in her future if she selected the safest surgical option.

This life and death decision at age 15? This kind of devastating decision is not supposed to strike until the adult years.

The truly incredulous part was the rapidity of her HPV’s deadly onset — sexual activity at age 13 and ominous cancerous changes within two years — which should serve as a call to arms for the medical field. According to current guidelines, physicians are not even supposed to obtain PAP smears until more than three years have lapsed after sexual debut in teenagers.

So why are the younger patients at risk for such severe and rapid disease? Four probable reasons:

• Inadequate production of cervical mucus,
• Immature columnar epithelial cells in the transformation zone of the cervix,
• Incomplete local immunity,
• Increased cervical susceptibility to minor trauma during sexual intercourse.

This specific case will likely affect our office procedure with our multitudinous teenaged girls, many of whom also happen to be sexually active.

First we must continue to vigorously recruit the young female preadolescents and adolescents for the quadrivalent HPV vaccine types 6, 11, 16, 18 (Gardasil, Merck) vaccination.

Second, we should probably consider initiating the first PAP screening earlier, within two years, after sexual debut particularly for higher risk teens.

And yet the current HPV vaccines will still only protect against 70 to 75% of the cervical cancers and precancers. We have got a way to go.

But medical research is moving forward and could attain a nearly 90% coverage by adding five more HPV types to a new vaccine, which is in development. We hope to be a part of that study.

“The pursuit of happiness”

How monumental are the choices most teenaged girls must balance:

• abstinence and/or pregnancy prevention vs. “love” lost?
• sexually transmitted disease and its prevention vs. parental discovery/discipline? (And HPV often circumvents latex sheaths and parental commands.)
• human desire vs. tempered restraint?

Each of these dilemmas creates diametrically opposed issues and their own respective dire consequences in the teenage mindset.

She left the office teary-eyed, and gave me a hug. She thanked me for taking the time to listen. Some nights I do not sleep so well.

For more information:

• Kahn JA. Curr Opin Pediatr. 2001;13:303–309.
• Rager KM, Kahn JA. Curr Women Health Rep. 2002;2:468–475.