A Precancerous Condition (or Premalignant Condition) is a disease, syndrome, or finding that, if left untreated, may lead to cancer.

Examples of pre-malignant conditions include:
* Actinic Keratosis - a premalignant condition of thick, scaly, or crusty patches of skin. It is more common in
fair-skinned people. It is associated with those who are frequently exposed to the sun, as it is usually accompanied by solar damage.

* Barrett’s Esophagus - Sometimes called Barrett’s Syndrome, CELLO [Columnar Epithelium Lined Lower Esophagus] and colloquially referred to as Barrett’s refers to an abnormal change (Metaplasia) in the cells of the lower end of the Esophagus [a muscular tube through which food passes from the pharynx to the stomach] thought to be caused by damage from chronic acid exposure, or Reflux Esophagitis [inflammation of the esophagus]. The normal lining of the esophagus (Squamous Epithelium) is replaced by an intestinal-type lining (Columnar Epithelium).

* Atrophic Gastritis – Also known as Type A or Type B Gastritis more specifically, is a process of chronic inflammation of the stomach mucosa, leading to loss of gastric glandular cells and their eventual replacement by intestinal and fibrous tissues. As a result, the stomach’s secretion of essential substances such as hydrochloric
acid, pepsin, and intrinsic factor is impaired, leading to digestive problems, vitamin B12 deficiency, and
Megaloblastic Anemia [Anemia that results from inhibition of DNA synthesis in red blood cell production. This is
often due to deficiency of vitamin B12 and/or folic acid.].

* Cervical Dysplasia – Cervical Intraepithelial Neoplasia (CIN), also known as Cervical Dysplasia, is the potentially premalignant transformation and abnormal growth (Dysplasia) of squamous cells [tissue composed of cells that line the cavities and surfaces of structures throughout the body] on the surface of the cervix. Most cases of CIN remain stable, or are eliminated by the host’s immune system without intervention. However a small percentage of cases progress to become cervical cancer, usually cervical Squamous Cell Carcinoma (SCC), if left untreated.The major cause of CIN is chronic infection of the cervix with the sexually transmitted Human PapillomaVirus (HPV), especially the high-risk HPV types 16 or 18. Over 100 types of HPV have been identified. About a dozen of these types appear to cause cervical dysplasia & may lead to the development of Cervical Cancer. Other types cause Warts [ also known as Verruca, is generally a small, rough tumor, typically on hands and feet but often other locations, that can resemble a cauliflower or a solid blister. Warts are common, and are caused by a viral infection, specifically by the Human PapillomaVirus (HPV) and are contagious when in contact with the skin of an infected person. It is also possible to get warts from using towels or other objects used by an infected person. They typically disappear after a few months but can last for years and can recur.].

[References: http://en.wikipedia.org/wiki/Pre-malignant
http://en.wikipedia.org/wiki/Actinic_keratosis
http://en.wikipedia.org/wiki/Barrett%27s_esophagus
http://en.wikipedia.org/wiki/Atrophic_gastritis
http://en.wikipedia.org/wiki/Megaloblastic_anemia
http://en.wikipedia.org/wiki/Cervical_dysplasia
http://en.wikipedia.org/wiki/Wart]

(Istockphoto)

WEDNESDAY, Nov. 25, 2009 (Health.com) — Teens girls can skip Pap tests, according to new guidelines that say women should start cervical cancer screening at age 21. But some experts are concerned that rates of sexually transmitted diseases or unplanned pregnancies could increase without the Pap test to prompt a doctor’s visit.

As it stands, as many as 1 in 4 U.S. teenage girls has had an STD at some point in her life, often soon after she becomes sexually active, according to research published this week in Pediatrics.

“I am concerned that without the recommendation for young women to get Pap smears early on, they will lose important opportunities to seek advice and to learn about their health—particularly their sexual health—at a time in their lives when they need it most,” says Kimberly Spector, an adolescent health educator in Los Angeles. “Regardless of the tests performed during a gynecologist visit, the conversation regarding sexual health risks and preventative measures can be very informative and empowering for young patients.”

In the past, women were told to start Pap tests, which can detect abnormal cells in the cervix, three years after becoming sexually active or at age 21—whichever came first. However, these abnormal cells often go away on their own, particularly in young women. If they don’t, such cells grow so slowly that catching them at age 21 is still early enough to remove them before they become cancerous. And catching them sooner could lead to unnecessary tests and treatments that sometimes damage the cervix, increasing the risk for a premature birth later in life.

The new guidelines still recommend that girls who are under 21 see a gynecologist; they just don’t need Pap tests, according to the American College of Obstetricians and Gynecologists.

Next page: Will some teens misinterpret the guidelines?

The fear, however, is that some teens may misinterpret the new rules and miss out on important discussions about contraception and protection against STDs such as gonorrhea, bacterial vaginosis, chlamydia, and human papillomavirus (HPV).

“If women hear that they no longer need Pap tests annually or until they are 21, perhaps they wouldn’t seek any preventive health care, and whether this results in decreased screening and identification of chlamydia and other STDs remains to be determined, but it is concerning,” says Harold Wiesenfeld, MD, the director of the division of reproductive infectious diseases at the University of Pittsburgh School of Medicine.

Many STDs, including chlamydia and gonorrhea, have no symptoms. “Unless screened, young women will remain undiagnosed, untreated, and at risk for complications, including pelvic inflammatory disease, which results in infertility,” says Dr. Wiesenfeld, who is also an associate investigator at Magee-Womens Research Institute, in Pittsburgh. “[Still] the Pap test is not the 100% trigger to do chlamydia screening,” he says. “We need to do a better job about STD screening overall.”

Teens who are sexually active should use contraception and take steps (such as using condoms) to prevent STDs, even if they don’t need Pap tests, says Alina Salganicoff, PhD, the vice president and director of women’s health policy for the Henry J. Kaiser Family Foundation, an advocacy group based in Menlo Park, Calif.

“We are going to have to pay special attention to how we educate our adolescent patients about contraception and STD prevention,” she says.

However, most experts agree that Pap tests are indeed unnecessary for younger women and that the new guidelines will not put them at risk. Most also agree that the new guidelines are not an effort to limit care.

“I do not fear the consequences because these guidelines are well thought out and give us a great opportunity to focus on who is at risk for cervical cancer,” says Bobbie Gostout, MD, the chair of the department of obstetrics and gynecology at the Mayo Clinic, in Rochester, Minn.

“Cervical cancer screening is very important, but we are getting smarter at screening,” she says. “We are backing off from screening those that have less to gain from it.” The cervical guidelines, which recommend that sexually active teens still be counseled and tested for STDs (although a pelvic exam might not be necessary), “hit it right,” she says.

Teens who have received HPV vaccines, such as Gardasil, are protected against several HPV strains that are linked to many, but not all, cervical cancers and to genital warts. These types of vaccines may eventually reduce cervical cancer rates even further (rates have been dropping since the 1970s), although experts say the impact won’t be seen for 10 to 15 years. Therefore, girls and women given the HPV shot need to have Pap tests starting at age 21 and every two years after that, just like those who haven’t had the shot.

Next page: Experts recommend doctor’s visit before sexual activity

The Centers for Disease Control and Prevention, in Atlanta, added Gardasil to its routine childhood vaccine schedule. It recommends that Gardasil, which is administered in three doses, be given to all girls ages 11 and 12, and even for girls as young as 9, with catch-up doses for girls and women ages 13–26 who haven’t been vaccinated.

“We know that the HPV types targeted by the new vaccine are linked to cervical cancers that tend to occur five years earlier than cervical cancers caused by other HPV types,” Dr. Gostout says. “So once adolescents are well vaccinated against HPV, we should have even more confidence in eliminating Pap tests in younger women.”

“We are now rolling out the vaccine, and clearly the first group that will experience broader protection is young women,” agrees the Kaiser Family Foundation’s Salganicoff. “The HPV vaccine is a really important step that young women can take in terms of protecting themselves against HPV and subsequent cervical cancer.”

Ideally, teens should have an HPV shot and see a gynecologist for counseling about STDs before they become sexually active, experts say. HPV vaccines don’t protect women who have already been infected with the virus.

“Ideally, women need to establish a relationship with a reproductive health provider before they become sexually active,” Dr. Wiesenfeld says.

Reflecting back on the H1N1 outbreak during the Michigan 2009 “MacRib Test”:

http://www.publicbroadcasting.net/michigan/news.newsmain/article/1/0/1568739/Michigan.News/114.Michigan.Schools.Closed.by.%27Swine.Flu%27

114 Michigan schools have closed so far this school year [within less than a week], amid concerns that Swine Flu is spreading.

School officials across the state are seeing rising student absentee rates.

Martin Ackley is the spokesman for the State Department of Education. He says schools are reacting quickly to reports of H1N1.

Southwest Michigan by itself had more than half of all schools closed nationwide that week due to H1N1 aka swine flu. Despite that, there was barely a mention of Michigan being the “epicenter” (the word used by the CDC in local coverage) in the mainstream media. However, while Michigan schools were closed down and restaurants went empty that week, the MSM only reported school closings in distant countries like Iraq. But, let’s look back a week before the outbreak happened:

http://www.wwmt.com/articles/kalamazoo-1368197-margin-0in.html

The number of flu-like cases in a nine county region of southwest Michigan is nearly double what it was the year before. Experts say the high number of cases is due to H1N1. There have been 1,100 cases since the beginning of 2009.
 
Now, the first H1N1 vaccination clinic is operating in Kalamazoo.
 
The clinic is by invitation only, and first up was health care workers from around Kalamazoo County.

….

Most of those at the clinic Thursday [10-15-09] were given the flu mist, the shots are being saved for those who can’t get the mist because of other health concerns.
 
Among those at the clinic on Thursday were paramedics and public safety officers who are also first responders.

A few days later that area of Michigan became the CDC’s “epicenter” during the week of 10-19-09. Let’s move over to Detroit on the southeastern side of Michigan:

http://www.freep.com/article/20091016/FEATURES08/91016048/1319/Swine-flu-vaccine-arrives–fire-fighters-roll-up-sleeves

Firefighters and other emergency personnel today rolled up their sleeves and submitted their upper arms for the injectable vaccine at the Wayne County Department of Public Health’s administration building in Wayne, as officials repeatedly urged the public to get inoculated.

….

Authorities said they’ve received both injectable vaccine and nasal mist. The mist is now set aside for emergency preparedness and health professionals; the vaccine is being distributed — at least in the district covered by the Wayne County Department of Public Health — to targeted populations.

….

The Wayne County Health Department has made free shots available at the following locations…

Detroit is a major population center and has easy highway access (via interstate 94) to Kalamazoo, but Detroit schools stayed open. BTW, why would a major outbreak happen in a little rural area instead of one of the major population (incubation) centers nearby like Detroit, Chicago, or Indianapolis? Why did the outbreak never cross the state line south of Kalamazoo and enter rural northern Indiana?

In any case the article itself is a bit confusing: the first responders were getting shots, but later it said they’re supposed to get the mist. I guess it’s just a coincidence that the kids of Detroit where their first responders got shots didn’t get sick while the kids around Kalamazoo where their first responders got mist did get sick a week later.

Let’s move over to some other articles that got my attention on vaccines, resistance, and immunity:

http://www.healthzone.ca/health/newsfeatures/article/700026

Unpublished Canadian data are raising concerns about whether it’s a good idea to get a seasonal flu shot this season.

Drawn from a series of studies from British Columbia, Quebec and Ontario, the data appear to suggest that people who got a seasonal flu shot last year are about twice as likely to catch swine flu as people who didn’t.

A scientific paper has been submitted to a journal and the lead authors – Dr. Danuta Skowronski of the British Columbia Centre for Disease Control and Dr. Gaston De Serres of Laval University – won’t speak to the media. Journals bar would-be authors from discussing their results publicly before they go through peer review.

That got my attention like a 2×4 to the face considering I received my first seasonal flu shot in 3 years in Fall 2008 and became sick with a very high fever for the first time in at least 5 years in June 2009. I would later find out this fever was during a time our state health officials stated that the only active virus roaming the region was H1N1. I guess it’s just another coincidence…

A number of influenza and infectious diseases experts know of but are unwilling to speak publicly about the paper. But several were quick to note that British and Australian researchers haven’t seen the phenomenon either. The lack of corroboration in other jurisdictions is “a red flag,” said one expert, who does not believe the findings are true.

Another flu expert who was willing to speak on the record said they do not make sense to him either.

“I cannot think of a good reason why this is biologically likely, especially since we have sufficient evidence now that … there is priming in the population by the way the vaccine is working,” said Dr. Arnold Monto, of the University of Michigan.

He was referring to the fact that studies of swine flu vaccine show a single dose induces a strong and likely protective response in teens and adults. That suggests humankind’s long exposure to seasonal H1N1 viruses has “primed” or awakened our immune systems to recognize the new virus and fight it off.

Dr. Donald Low, chief microbiologist at Toronto’s Mount Sinai Hospital, was reserving judgment on the findings. But he said this kind of effect of previous exposure raising the risk of future illness is seen in some diseases, like dengue fever.

“We don’t see that in flu,” Monto countered.

Unless there is a different sort of “priming” taking place. Or a mismatch. This next article is very important when considering vaccines and the concept of “cellular immunity”:

http://www.google.com/hostednews/canadianpress/article/ALeqM5gJLYIRDvHWdvSLZTUQ_yymuF5rBg

Just when you thought the issue of seasonal and pandemic flu shots couldn’t get any more confusing, European researchers are questioning whether it makes sense to vaccinate little kids against seasonal flu.

The scientists, from the Erasmus Medical Center in Rotterdam, the Netherlands, argue preventing small children from being infected by – and developing immune responses to – seasonal flu viruses might make them more vulnerable when a flu pandemic rolls around.

Note: this is a different set of researchers than the previous article.

But the Dutch scientists, who don’t refer to the Canadian research in their article, say giving kids aged six months to 59 months flu vaccine prevents them from acquiring a broad immune response to flu viruses that can only be induced by infection.

Vaccines trigger development of antibodies to the proteins on the surface of flu viruses, proteins that change often to evade the immune system. But when you catch the flu, something called cellular immunity also kicks in. It teaches the body to recognize other parts of a flu virus; those parts don’t change as much from one virus subtype to another.

The next few paragraphs are extremely important. Read closely:

Without that cellular immunity, the Dutch researchers say, children who experience a pandemic could have more difficulty fighting off the new flu strain. They suggest this may explain why the majority of fatal cases of H5N1 avian influenza have occurred in children and young adults.

They also report that they tested the theory in mice, some of which were vaccinated against the H3N2 strain of flu and others of which were experimentally infected with the same virus.

The mice were then exposed to the highly lethal H5N1 virus. The vaccinated mice died but the mice that had been previously infected with H3N2 suffered milder disease.

….

The Dutch researchers, led by Dr. Guus Rimmelzwaan, say more research is needed to see if their theory is true.

But they also suggest young children who live in areas where H5N1 viruses are endemic in poultry should not be vaccinated against seasonal flu, because blocking the development of cross-protective immune responses in these kids could raise the risk they face if they become infected with H5N1.

I know we started off discussing H1N1 and ended up with H5N1, but this doesn’t change the concept of cellular immunity. This next article explores how parents are approaching the concept of building natural immunity instead of using vaccines:

http://www.thrivinghealthywomen.com/info/infoprint.asp?documentid=397

And although many pediatricians are readying stern lectures in support of vaccinating children, several in Southern California contacted by The Times acknowledged they have doubts about recommending a vaccine that is still in testing for all of their young patients.

“A significant proportion of our population don’t want to get it,” says Sherman Oaks pediatrician Mikayel Abramyan. “I don’t even know whether I will advocate for it right now.”

To date, notes Abramyan, who saw a fair amount of novel H1N1 over the summer, the illness has been mild, and many parents of the children he cares for “want them to get their immunity that way instead of a flu shot,” he says. While Abramyan says he rarely lets such preferences go unchallenged, “it’s a reasonable position, and I understand it on an individual level. . . . I understand where they’re coming from.”

….

“I haven’t seen enough evidence to show that swine flu is as deadly and as scary as it’s made out to be,” says Stuart-Nystrom, who last week was fighting a respiratory infection. Stuart-Nystrom thinks that media outlets have whipped up the threat in a bid to gain viewers. And “anything brought out by big business, by corporations, that makes me wary for sure. . . . I’m not sure they have our interests in mind.”

Nor is the Venice mother confident that the Food and Drug Administration can reliably assure the overall safety of the vaccine. Pointing to a recent spate of contaminated-food recalls, she said that the FDA’s relationship with the industries it regulates may be too close for the agency to operate effectively as an honest broker.

She also voiced the widely held belief that immunity acquired the natural way — through a child’s having caught an illness — is stronger and longer-lasting than that acquired by vaccination. That claim is much debated among physicians and infectious-disease specialists, with evidence falling on both sides of the debate.

….

“There’s so much information out there,” Stuart-Nystrom says. “The scary thing is, you don’t know what’s right and what’s wrong.”

Since one paragraph in the above article mentioned a “debate” over the long-lasting effects of vaccination, I’d like to jump to another virus, the vaccines promoted, and their not-so-lasting protection. Here’s one link straight from the FDA:

http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm187048.htm

The FDA today approved Cervarix, a new vaccine to prevent cervical cancer and precancerous lesions caused by human papillomavirus (HPV) types 16 and 18. The vaccine is approved for use in girls and women ages 10 years through 25 years.

Genital HPV infections are the most common sexually-transmitted diseases in the United States, and HPV types 16 and 18 are the cause of about 70 percent of cervical cancers worldwide.

….

The primary clinical study for Cervarix included more than 18,000 women ages 15 years through 25 years in the United States and 11 other countries. Of these women, about 9,000 received Cervarix and 9,000 received Havrix, a licensed hepatitis A virus vaccine, as a control.

….

Studies also were performed to measure the immune response to Cervarix in girls ages 10 years through 14 years. Their immune response was similar to that of women ages 15 years through 25 years, indicating that the vaccine should have similar effectiveness in the 10 through 14 year age group.

The current data show that Cervarix provides protection for about 6.4 years, but additional information on the length of protection is forthcoming.

No vaccine is 100 percent effective, and Cervarix does not protect against HPV infections that an individual may already have at the time of vaccination, nor does Cervarix necessarily protect against those HPV types not in the vaccine.

Provides protection for 6.4 years against a virus which I’ve heard other people state that most healthy females will overcome on their own. But wait, what else is in this vaccine:

Cervarix contains the adjuvant ASO4. ASO4 is a combination of aluminum hydroxide and monophosphoryl lipid A (MPL) and is the first vaccine licensed by the FDA that includes MPL as an adjuvant. An adjuvant is a substance incorporated into a vaccine that enhances or directs the immune response of the vaccinated individual.

Little is known about how adjuvants really work and there is a lot of debate in the scientific community. However, every time I hear about a new adjuvant being injected into someone I can’t help but think this is just a modern version of snake oil. Let’s switch to a different HPV vaccine and some recent revelations from one of its former researchers:

http://www.cbsnews.com/stories/2009/08/19/cbsnews_investigates/main5253431.shtml

Amid questions about the safety of the HPV vaccine Gardasil one of the lead researchers for the Merck drug is speaking out about its risks, benefits and aggressive marketing.

Dr. Diane Harper says young girls and their parents should receive more complete warnings before receiving the vaccine to prevent cervical cancer. Dr. Harper helped design and carry out the Phase II and Phase III safety and effectiveness studies to get Gardasil approved, and authored many of the published, scholarly papers about it. She has been a paid speaker and consultant to Merck. It’s highly unusual for a researcher to publicly criticize a medicine or vaccine she helped get approved.

Dr. Harper joins a number of consumer watchdogs, vaccine safety advocates, and parents who question the vaccine’s risk-versus-benefit profile. She says data available for Gardasil shows that it lasts five years; there is no data showing that it remains effective beyond five years.

This raises questions about the CDC’s recommendation that the series of shots be given to girls as young as 11-years old. “If we vaccinate 11 year olds and the protection doesn’t last… we’ve put them at harm from side effects, small but real, for no benefit,” says Dr. Harper. “The benefit to public health is nothing, there is no reduction in cervical cancers, they are just postponed, unless the protection lasts for at least 15 years, and over 70% of all sexually active females of all ages are vaccinated.” She also says that enough serious side effects have been reported after Gardasil use that the vaccine could prove riskier than the cervical cancer it purports to prevent. Cervical cancer is usually entirely curable when detected early through normal Pap screenings.

I’m going wrap up this blog post and let you contemplate the “risk-versus-benefit” comment from Dr. Harper. It will be helpful for deeper thinking by putting that comment into context with the earlier articles on cellular immunity, the unintended consequences of vaccinating for weaker (or the wrong) viruses and how this will play into long term health. I will do some more posts on health care in the future. Thanks for reading today.

Defining a “MacRib Test” as used earlier in this post.

Atomic Model of Papillomavirus

The majority of a federal advisory panel agreed that the data on a recombinant bivalent human papillomavirus vaccine indicate that the vaccine is safe and effective in preventing cervical cancer and certain precancerous or dysplastic lesions caused by HPV types 16 and 18 in girls and women aged 10-25 years.

The FDA’s Vaccines and Related Biological Products Advisory Committee, voted 12-1 that the data on the GlaxoSmithKline Biologicals human papillomavirus bivalent (types 16 and 18) vaccine, recombinant, supported the efficacy of the vaccine for preventing HPV 16/18–related cervical cancer, cervical intraepithelial neoplasia (CIN) 2+, adenocarcinoma in situ (AIS), and CIN1+ in girls and women aged 15-25 years.

In a separate vote, the panel again voted 12-1 that the results of an immunogenicity bridging study from the United Kingdom, which compared immune responses to the vaccine in recipients aged 10-14 years with those of older recipients, supported effectiveness of this same claim in girls aged 10-14 years. There were no efficacy data in the younger age group, but immune responses for HPV 16/18 in the younger girls were similar to those in the older group. If approved, GSK plans to market the vaccine as Cervarix. GSK has proposed that Cervarix be licensed for prevention of cervical cancer (squamous cell cancer and adenocarcinoma, and protection against precancerous or dysplastic lesions and persistent/incident infections), caused by HPV types 16 and 18, in girls and women aged 10-25 years. It is administered in a three-dose schedule at 0, 1, and 6 months.

The majority of the panel also voted that the data supported the safety of the vaccine in girls and women aged 10-25 years but recommended that safety issues, which included spontaneous abortions, be studied further after licensure. In the pivotal study, there was a higher number of spontaneous abortions around the time of vaccination than in the comparison group.

GSK already has a Cervarix pregnancy registry in the United Kingdom and has announced plans to combine that with a registry in the United States pending FDA approval. The company has also announced plans to conduct a postmarketing safety study.

There were more musculoskeletal and neuroinflammatory events with potential autoimmune causes—although rare—among almost 30,000 Cervarix recipients, compared with controls. The three most common adverse events associated with the vaccine were headache, injection site pain, and fever.

The FDA usually follows the recommendations of its advisory panels. HPV 16 and 18 cause most cervical cancers in the United States. The vaccine was approved in May 2007, in Australia and is now licensed in 98 countries.

In the pivotal phase III, randomized, double-blind international study, more than 18,000 girls and women aged 15-25 in the general population received Cervarix or the active control, Havrix, an inactivated hepatitis A vaccine.

Over a mean follow-up of 39 months after the first dose, the vaccine was 93% effective against HPV 16/18 CIN2+ in seronegative subjects. There also was evidence that vaccination was effective in preventing this end point in women who had been previously infected with HPV 16/18, according to GSK.

Merck’s quadrivalent HPV vaccine, Gardasil (human papillomavirus [types 6, 11, 16, 18] quadrivalent vaccine, recombinant), is approved for girls and women aged 9-26 years, for preventing cervical, vulvar, and vaginal cancer caused by HPV types 16 and 18 as well as associated precursor lesions and genital warts caused by HPV types 6 and 11.

Okay, I give. I had promised that I wasn’t going to be just one more voice in the breast cancer screening debate. But when the US Preventive Screening Task Force (USPSTF) of the Department of Health and Human Services came out with revised Breast Cancer Screening and Pap Smear recommendations in one week, I could no longer sit idly by and say nothing.

Last week the USPSTF blew us all out of the water when they recommended that women no longer perform breast self examinations (BSE’s) and that annual screening mammography not begin until age 50. This is a huge departure from the previous guidelines promoted by the task force, The American Cancer Society and the American College of Obstetricians and Gynecologists which state that “women should perform breast self examinations monthly and that they should have clinical breast examinations by their physicians annually. Screening mammography should begin at age 40, be performed every 1-2 years and then be performed annually after age 50.”

Courtesy of BreastCancer.org

The Task Force concluded that BSE is not effective in reducing the incidences of breast cancer and that rather than doing BSE, women should just be “aware” of their breasts.” WTF??? How are you going to be aware of your breasts if you don’t know how they feel? Are women to rely solely on visible discoloration, dimpling or nipple retraction? What about non visible tumors, such as those that are close to the axilla (arm pits) that are typically only found on palpation? Many breast cancers in young women under 40 are found via BSE. Just before my 33rd birthday I found a cyst during a BSE. It actually bursted when I had a mammogram, but I found it initially myself. What if I hadn’t been doing BSE and it hadn’t been a benign cyst?

As far as the mammography recommendations go, the USPSTF states that for every 1900 women screened between the ages of 40 and 49, only one breast cancer is diagnosed. According to them, this small yield does not make the test worthwhile. However, the one breast cancer that will be detected out of 1339 women screened between the ages of 50 and 59, makes the test worthwhile. So what makes the life in the 50’s more valuable than the life in the 40?  Their argument is that you have to screen more women in the 40’s to find a cancer and the rates of false positives, “unnecessary” biopsies and  surgeries make the screening in this age population “not cost effective.” And with that statement, I think we have found the rationale.

Thankfully the American Cancer Society and The American College of Obstetricians and Gynecologists have flat out rejected these recommendations. Research studies have repeatedly demonstrated that breast self examination and annual screening mammograpy after age 40 saves lives. While the USPSTF may not be impressed at” just one life saved”, the families of those mothers, sisters, daughters, aunts, cousins, etc…are most grateful that their loved ones with breast cancer were diagnosed early and that many of them are alive and well today.

Later in the week news broke that Pap smear guidelines were also revised. The USPSTF now recommends that Pap Smears, the test used to detect cervical cancer, no longer be performed annually, but every 2 years and that the screening not be initiated until age 21. Previously the recommendation was that Pap Smears be initiated at age 18 or at age of first intercourse and then be performed annually but at least once every 3 years. Since cervical cancer is rare in women under age 25, the Task Force feels comfortable recommending that onset of screening not take place before age 21. Again their rationale stems from the fact that many women will have abnormal pap smears and be subject to potentially invasive screening and treatment and yet have no actual abnormality. In simple terms, It’s just not cost effective.

This makes me wonder, if  Pap smears are of little benefit for women under age 25 because they are at little risk for developing cervical cancer, why the big push to vaccinate 11 year old girls with Gardasil, The “Cervical Cancer” vaccine ? If the task force is not concerned about screening for Cervical Cancer before age 21 (since it is rare in women under age 25), why not wait until a girl is actually at risk for “developing” cervical cancer and give her the vaccine at say, 18? Gardasil is designed to prevent young women from contracting 4 strains of the Human Papilloma Virus, two of which are known to lead to cervical cancer and two which cause more than 90% of all cases of genital warts. If we are so concerned about each of our young women becoming “One less” woman stricken with cervical cancer, doesn’t it stand to reason that we should do all that we can to be sure that they are healthy, including routine Pap Smears? The USPSTF does not differentiate between those young women who are sexually active and those that are not, they  just issue the blanket statement that all women begin screening at age 21. Likewise, the recommendation for Gardasil is for all girls at age 11. But again, if cervical cancer is slow growing and highly treatable, is the vaccine really necessary? Why not just treat once disease is more likely detectable-that is what they are advocating for breast cancer, isn’t it? Seems to me that a “scare” tactic was utilized. Cancer scares people and fear sells.

More effective marketing would have been to market Gardasil as a prevention against genital warts. Each year women under the age of 25 account for the majority of new genital warts cases. Approximately 6.2 million new HPV infections occur every year in the United States and approximately 20 million individuals are currently infected. Some women are diagnosed via Pap smear and subsequent colposcopy or cone biopsy while other young women will actually present with lesions that can be excised and biopsied. Treatments for warts include cryotherapy, Tricloracetic Acid therapy, laser therapy and more invasive procedures such as Loop Electrosurgical Excision Procedures (L EEP). But with such readily available and effective treatments for genital warts available is there the same urgency to prevent genital warts as there is to prevent cervical cancer? Would consumers be willing to take the vaccine if marketed to prevent genital warts as opposed to cervical cancer? (Surveys show that less than 1/3 of young women in the appropriate age range for vaccination have actually received Gardasil to date.)  To push consumers towards vaccination, something stronger was needed and cervical cancer became the “buzz” used to promote (push) Gardasil.

But I digress. Has anyone else noted that these two new recommendations, both calling for reduction in screening for gynecologic cancers, came just before the US senate was about to debate the Democratic Health Care Reform Bill which includes a public (government sponsored) option? Look, if the public option is accepted and the Democratic Health Care Reform bill becomes law, women who are currently uninsured and very likely not receiving any sort of cancer screening, as well as women who choose the government sponsored health insurance plan instead of a private (more expensive) insurance plan (such as Cigna, Blue Cross & Blue Shield, Aetna, etc…) will cause an increase in utilization of health care screening services. A government subsidized plan with see an increase in claims and subsequent payout while private insurance companies may very well see a decrease in revenues. More utilization of services with less profit. Hmmm…

I won’t profess to know the collective mind of the USPSTF and since I was not present during the review of the recommendations nor privy to the discussions, I won’t state that these recommendations are a means of cost containment in the event that Congress does pass a health care reform bill that includes a public option. But the timing is suspect. It behooves all of us to watch vigilantly as the health care reform bills are debated. The recommendations by the USPSTF may be the very means by which the government and private insurances deny women access to preventive screening tests. I am worried that women won’t receive screening mammograms and Pap Smears more frequently than the USPSTF recommends-even if their health situations dictate more frequent screening. I worry that young girls will be forced to receive a vaccine for which we have no long term data (side effect profile) and no proven long term efficacy. I am worried that young girls may later be denied treatment for HPV related diseases if they didn’t take the vaccine, increasing their morbidity and mortality. I worry that we’ll see an increase in the incidence of more deadly cases of breast cancer. No one can predict the future, but I am concerned that if these guidelines are enforced “One Less” may very soon become “a whole lot more”.

As if the recent release of changes in recommendations regarding breast cancer early detection were not enough, we now have hot on it’s heels a major change in recommendations for cervical cancer screening.  The irony of these two recommendations, though from differing groups and based on review of extensive data (which certainly in the case of breast cancer is open to debate) is that they suggest changes in long standing policy regarding early detection, which have clearly had an effect on reducing the incidence and mortality from these two cancers.  The cervical cancer recommendations have some thoughtful commentary regarding using these tests too early in a young woman’s life.  These concerns are valid.  However, it is also true, that among many populations and peer groups early sexual activity is a fact of life.  Having said that, the rate of HPV is rampant  and it seems, from a public health perspective a bit perplexing, that when we have initiatives to use a new vaccine to prevent HPV, we would at that same time be suggesting taking measures that makes diagnosing HPV less likely.   Not sure ACOG has thought that angle through enough. Proper testing is important and excessive testing is not helpful.  However, the individualization of recommendations we applaud from a medical perspective, but we know that this will lead to coverage issues for patients and doctors as health insurers will adjust their payment policies to reflect these new recommendations.  Below is potpourri of comments from ACOG and various news leads on this most public story . . . ben kazie md

Women should have their first cervical cancer screening at age 21 and can be rescreened less frequently than previously recommended, according to newly revised evidence-based guidelines issued today by The American College of Obstetricians and Gynecologists (ACOG) and published in the December issue of Obstetrics & Gynecology. Most women younger than 30 should undergo cervical screening once every two years instead of annually, and those age 30 and older can be rescreened once every three years.  Cervical cancer rates have fallen more than 50% in the past 30 years in the US due to the widespread use of the Pap test. The incidence of cervical cancer fell from 14.8 per 100,000 women in 1975 to 6.5 per 100,000 women in 2006. The American Cancer Society estimates that there will be 11,270 new cases of cervical cancer and 4,070 deaths from it in the US in 2009. The majority of deaths from cervical cancer in the US are among women who are screened infrequently or not at all. Cervical cancer is a slow growing cancer caused by certain strains of the human papillomavirus (HPV), an extremely common sexually transmitted disease among women and men. HPV also causes genital and anal warts, as well as oral and anal cancer…..

First Cervical Cancer Screening Delayed Until Age 21 Less Frequent Pap Tests Recommended – http://www.acog.org/from_home/publications/press_releases/nr11-20-09.cfm

New guidelines for cervical cancer screening say women should delay their first Pap test until age 21, and be screened less often than recommended in the past. The advice, from the American College of Obstetricians and Gynecologists, is meant to decrease unnecessary testing and potentially harmful treatment, particularly in teenagers and young women. The group’s previous guidelines had recommended yearly testing for young women, starting within three years of their first sexual intercourse, but no later than age 21. Arriving on the heels of hotly disputed guidelines calling for less use of mammography, the new recommendations might seem like part of a larger plan to slash cancer screening for women. But the timing was coincidental, said Dr. Cheryl B. Iglesia, the chairwoman of a panel in the obstetricians’ group that developed the Pap smear guidelines. The group updates its advice regularly based on new medical information, and Dr. Iglesia said the latest recommendations had been in the works for several years, “long before the Obama health plan came into existence.”  She called the timing crazy, uncanny and “an unfortunate perfect storm,” adding, “There’s no political agenda with regard to these recommendations.”…..

Guidelines Push Back Age for Cervical Cancer Tests – http://www.nytimes.com/2009/11/20/health/20pap.html?_r=4

The cervical cancer screening advice follows another panel’s controversial mammogram report, but experts say it’s a much different situation. Still, Paps are the only reason some women see a doctor. Only days after a federal panel scaled back on breast cancer screening recommendations for many women, another organization — the American College of Obstetricians and Gynecologists — has done the same for a screening credited with drastically reducing the rates of cervical cancer in the U.S. Women of all ages should undergo Pap smears less frequently than they do now, those new guidelines say. And young women are advised not to bother until age 21. The pullback follows the U.S. Preventive Services Task Force’s dismissal of routine breast cancer screenings for women younger than 50. That move triggered a storm of protest from medical groups and individual women, with some breast cancer specialists and Republicans accusing health officials of moving toward a rationing of care and services. On Wednesday, U.S. Health and Human Services Secretary Kathleen Sebelius emphasized that the task force guidelines amounted to advice, not policy, and that women should continue to consult with their physicians about mammograms based on their own histories and needs…..

Group recommends less-frequent Pap tests – http://www.latimes.com/news/nationworld/nation/la-sci-pap-smears20-2009nov20,0,5747799.story

Women can delay having their first Pap test for cervical cancer until they turn 21 and many can wait longer to go back for follow-up screenings, according to new guidelines released Friday by a major medical group. The American College of Obstetrics and Gynecologists (ACOG) recommended the change after concluding that more frequent testing did not catch significantly more cancers and often resulted in girls and young women experiencing unnecessary stress, anxiety and sometimes harmful treatments because of suspicious growths that would not cause problems. “We really felt that the downsides of more frequent screening outweighed any benefits,” said Alan G. Waxman, a professor of obstetrics and gynecology at the University of New Mexico who led the revision of the guidelines. “More testing is not always more intelligent testing.” The change comes amid sharp controversy over new recommendations from a federal task force that women wait until age 50 before they begin having routine mammograms and that women age 50 to 74 scale back to getting the exams routinely every two years…..

Cervical cancer screening can wait till 21, group says – http://www.washingtonpost.com/wp-dyn/content/article/2009/11/19/AR2009111904743.html

Women in the United States should start cervical cancer screening at age 21 and most do not need an annual Pap smear, according to new guidelines issued on Friday that aim to reduce the risk of unnecessary treatment. The guidelines from the American College of Obstetricians and Gynecologists or ACOG now say women younger than 30 should undergo cervical cancer screening once every two years instead of an annual exam. And those aged 30 and older can be screened once every three years. The recommendations are based on scientific evidence that suggests more frequent testing leads to overtreatment, which can harm a young woman’s chances of carrying a child full term. “Overtreatment of minor abnormal pap tests in young women and adolescents can lead to consequences such as preterm labor in some cases. It increases the risk,” said Dr. Thomas Herzog of Columbia University in New York, who is chairman of an ACOG subcommittee on gynecologic cancers. “Preterm delivery has become a huge problem in the United States that has potential serious consequences for the unborn fetus,” said Dr. Jennifer Milosavijevic, a specialist in obstetrics and gynecology at Henry Ford Health System in Detroit, who supports the guideline changes…..

New guidelines: Pap smears should start at age 21 – http://in.reuters.com/article/worldNews/idINIndia-44108820091120

The revised guidelines released today by the American College of Obstetricians and Gynecologists also recommend that women 30 and older get screened with a so-called Pap test once every three years, instead of every two to three years. The American Cancer Society’s gynecologic cancer director said the society agreed with the advice of the doctors’ organization that additional screenings may lead to unnecessary treatment. The ob-gyn organization is the second medical group this week to recommend less-frequent cancer screenings, citing scientific data. A U.S.-backed panel said Nov. 16 that most women in their 40s shouldn’t get annual mammograms to prevent breast cancer, setting off protests from women, physicians and health advocacy groups such as the cancer society. “The data is very good that a Pap test every two years is as good as a Pap test every year,” said Alan Waxman, the lead author of the new guidelines and a professor of obstetrics and gynecology at the University of New Mexico in Albuquerque, in a telephone interview. The additional tests are inconvenient and costly, and research shows “it doesn’t make a difference in terms of lives saved,” he said…..

Screening for Cervical Cancer Should Start at 21 – http://www.bloomberg.com/apps/news?pid=newsarchive&sid=aLDLltBDBErU

For the second time this week, a major U.S. medical panel has revised recommendations for a key test that millions of American women use to detect cancer. On Monday, it was mammograms. Today, it’s Pap tests. The American College of Obstetricians and Gynecologists says that women no longer need annual cervical cancer screenings. It also says women can now wait until they’re 21 to get their first Pap test, instead of getting one after they’ve become sexually active. “The tradition of doing a Pap test every year has not been supported by recent scientific evidence,” said Dr. Alan G. Waxman of the University of New Mexico, who headed the American College’s guideline revision…..

Annual Pap tests no longer needed, panel says – http://www.tampabay.com/news/health/annual-pap-tests-no-longer-needed-panel-says/1052944

Most women in their 20s can have a Pap smear every two years instead of annually, say new guidelines that conclude that’s enough to catch slow-growing cervical cancer. The change by the American College of Obstetricians and Gynecologists comes amid a completely separate debate over when regular mammograms to detect breast cancer should begin. The timing of the Pap guidelines is coincidence, said ACOG, which began reviewing its recommendations in late 2007 and published the update Friday in the journal Obstetrics & Gynecology.  The guidelines also say: -Routine Paps should start at age 21. Previously, ACOG had urged a first Pap either within three years of first sexual intercourse or at age 21. -Women 30 and older should wait three years between Paps once they’ve had three consecutive clear tests. Other national guidelines have long recommended the three-year interval; ACOG had previously backed a two- to three-year wait. -Women with HIV, other immune-weakening conditions or previous cervical abnormalities may need more frequent screening…..

Report: 20-somethings can go 2 years between Paps – http://www.washingtonpost.com/wp-dyn/content/article/2009/11/20/AR2009112000089.html

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]]> http://obscenethoughtsofjanine.wordpress.com/2009/11/22/our-cartoon-show-is-broken/ Mon, 23 Nov 2009 07:03:15 +0000 janinerioux http://obscenethoughtsofjanine.wordpress.com/2009/11/22/our-cartoon-show-is-broken/

Song of the day:
“The Couplet” by Kill Paradise

Pretty piano!

So, there’s no Jazzband tomorrow… Yay! that means I can go and get yelled at by Mrs C. in the morning instead of at break… fun. lalala. Whatever. She’ll be fine half an hour later. I wonder if she’ll like my no-shit no-excuses confession. hm.
So I’m wondering why Fabricland doesn’t have a website… oh wait.. they got one! success. It might be a bit crap, but hey, it’s better than before. Dressforms are on sale. 50% off. I think I’m going with my dad to get one for me for christmas. Yusss.
Hey, I get my shots on wednesday. What class am I missing then? hmm… DRAMA!?! oh mah gawd. seriously. I get to miss one class, and it’s the best one of the day? Noooooo. Fail. Maybe I’ll come back when I’m done? I have band after school, anyways.. How long does it take to get a shot? I still don’t know if I should get the HPV one or not. hm. I guess I will. sigh.
So today I experimented with some royal icing for the ribbon-strip on the cake. After attempting to color it, I took out my fondant and tried that… It works so much better. and tastes better, too. So fondant it is, then. woohoo. I also developed my hazelnut filling. kching. Original recipe FTW.

Assorted things of interest from the previous week.
It’s not nearly as controversial as the USPSTF’s breast cancer screening recommendations, but ACOG released a new practice bulletin on cervical cancer screening. The New York Times has coverage of the change, which is basically that women can wait until up to 21 years of age to start getting Pap tests, and then can get Paps every 2-3 years instead of every year once they’ve had a few normal tests. This is not entirely new – the USPSTF’s 2003 recommendations are very, very similar. (so, 6 years from now, we’ll be cool w/ the breast cancer recs?)

Some lots of Vick’s Sinex nasal spray are being recalled due to bacterial contamination.

The FDA has tips on holiday food safety.

Presented without comment: Highest Rates of Obesity, Diabetes in the South, Appalachia, and Some Tribal Lands [w/ the exception of a request to think about what that might mean in conjunction with the frequent framing of obesity as a moral failing of individuals]

SisterSong has posted a new issue of its Collective Voices newsletter [PDF]; this issue has a reproductive justice theme. You can follow SisterSong on Twitter.

The Kaiser Family Foundation issued a brief on how health reform might affect health disparities experienced by racial/ethnic minorities.

Nov 20 was the Transgender Day of Remembrance, set aside to memorialize those who were killed due to anti-transgender hatred or prejudice. Learn more here, and see the any of a number of blog posts observing the day.

The Voices Against Violence Zine is “A small zine-diy style, with work from people of color, indigenous folks, trans people & queer survivors of domestic violence, sexual violence and sexual assault. Included topics can be: healing from trauma, transformative words used as a healing mechanism, enabling healing, life after trauma, self-help guides/resources, self-healing, dancing as means to healing, healing through narration, forgiveness (do we need it?), & collective trauma.” It will be accepting submissions for the next issue through Nov 30. Learn more at Hermana, Resist.

The 60th Disability Blog Carnival has been posted at FWD/Forward.

The CDC updated their 2009 H1N1 Flu Information for People with Disabilities and Their Caregivers or Personal Assistants.

Renee at Womanist Musings talks about people making class assumptions about her based on her scooter use.

Good for them: the Ames Public Library in Iowa carries Sex, Etc. magazine, which is written by teens for teens to provide accurate sex education information. There was a petition to have it removed from the library. It’s going to stay. I have a librarian happy.

วิธีการผ่าตัดมดลูก มี 3 วิธี คือ
1. การผ่าตัดทางหน้าท้อง เป็นวิธีผ่าตัดที่ทำกันเป็นส่วนใหญ่เพราะทำได้ง่าย คือ การทำแผลที่หน้าท้องยาว
    6 – 8 นิ้ว เอามดลูกออกทางหน้าท้อง
2. การผ่าตัดทางช่องคลอด คือ การเอาก้อนมดลูกผ่านทางช่องคลอด วิธีนี้ไม่มีแผลทางหน้าท้อง แต่ทำ
    ยากกว่าวิธีแรก แพทย์มักเลือกทำกรณีที่มีมดลูกหย่อน มดลูกไม่ได้มากและไม่มีพังผืด
   ข้อดีของวิธีนี้ คือ เจ็บน้อย กว่าและภาวะแทรกซ้อนน้อยว่า และระยะฟื้นตัวสั้นกว่าวิธีแรก
3. การผ่าตัดโดยใช้กล้องส่องช่องท้อง คือการเจาะช่องท้องเป็นรูเล็ก ๆ 3 – 4 รู แล้วใช้เครื่องมือพิเศษเข้าไป
    ตัดมดลูก แล้วเอามดลูกออกทางช่องคลอด หรือย่อยเอาออกทางรูเล็ก ๆ วิธีนี้ทำได้แม้มดลูกไม่หย่อน
   ข้อดีคือ มีแผลเล็กกว่า, เจ็บน้อยกว่า และฟื้นตัวเร็วกว่าวิธีแรก และทำได้ในกรณีที่วิธีที่ 2 ทำไม่ได้
   ข้อเสีย คือ ต้องใช้ เครื่องมือพิเศษ ค่าใช้จ่ายยังแพงกว่า

Rahim ağzı kanseri, sağlıklı kadınlarda yapılan düzenli tarama ile önlenebilen tek kanser türü.

Kadını ölümcül rahim ağzı kanserinden koruyan rahim ağzı kanseri aşısı HPV tip 6, 11, 16 ve 18’in neden olduğu kanser öncesi düşük dereceli lezyonları ve genital siğilleri önlüyor. Anadolu Sağlık Merkezi Kadın Hastalıkları ve Doğum Uzmanı Doç. Dr. Fatih Güçer, rahim ağzı kanseri aşısı ile ilgili soruları yanıtladı.

Rahim Ağzı kanseri nasıl oluşur?/ Neden oluşur/ oluşma sebepleri nedir?

Rahim ağzı kanseri, rahim ağzında anormal hücre çoğalmasıdır. En önemli nedeni Human Papilloma Virüs yani HPV’dir. Rahim ağzı kanseri, HPV enfeksiyonuna yanıt olarak rahim ağzı duvarında anormal hücrelerin kontrolsüz bir şekilde çoğalmasıyla gelişir. Bu anormal hücreler bir araya gelerek tümör adı verilen kitleleri oluştururlar. HPV, temas ve cinsel ilişki yoluyla bulaşır. HPV virüsünün kuluçka süresi yaklaşık dokuz aydır. Enfeksiyon etkilerinin ortaya çıkması için virüsü aldıktan sonra yaklaşık bir yılın geçmesi gerekir. Bir çok vakada enfeksiyon sessiz kalıp, birkaç yıl HPV virüsünün etkileri ortaya çıkabilmektedir.

Rahim ağzı kanserini önlemek için çocuk yaşta uygulanan aşılar kimlere uygulanabilir?

HPV aşısı, özellikle 9-13 yaş aralığındaki kız çocuklarına uygulanmalıdır. Bu yaş aralığı isteğe bağlı olarak 26 yaşına kadar uzatılabilir. HPV aşısının canlı bir aşı olmadığı ve hepatit aşıları gibi genetik teknoloji ile hazırlandığı için birçok kişiye rahatlıkla uygulanabilmektedir. Aşı üç doz olarak, altı aylık süre içinde, koldan uygulanmaktadır. Aşı, oral seks yoluyla geçen HPV’nin neden olduğu ağız içi ve gırtlak kanserlerine karşı da koruyucu. Çünkü aynı mekanizma o bölgede de işliyor.

Bu aşıyı her kadın yaptırmalı mı?

Bu aşının risk altında olduğunu düşünen herkese yaptırmalı. Aslında tüm toplumu aşılayacak olursak bundan 20-30 yıl sonra Türkiye’de hiçbir rahim ağzı kanseri kalmaz. Ancak şunu da muhakkak belirtmek lazım. Şu anda piyasada bulunan HPV aşısı kansere sebep olan tiplerden tip 16 ve 18’e karşı koruyucu, diğer tiplere karşı koruyucu değil. Kansere sebep olan HPV virüsleri içinde 16 ve 18 tüm kanserlerin yüzde 70′ini oluşturuyor. Demek ki, kanserlerin yüzde 30′u aşının korumadığı türden HPV tipleri ile oluşuyor. Yani aşı olmak demek kansere yakalanmama garantisi değil. Aşı olunduğu zaman da smear taramasının aynı şekilde devam etmesi gerekiyor

Bu aşıyı cinsel ilişkiye giren kadınların yaptıramayacağı söyleniyor. Bunun doğruluk payı nedir?

Aşı henüz hiç cinsel deneyim yaşamamışlarda daha etkili olmaktadır. Ancak cinsel ilişki burada tek kriter değil. Kadın, cinsel ilişki yaşamış olsa dahi, yüze yakın çeşiti olan HPV virüslerinden, kansere yol açan tipleriyle karşılaşmadıysa; bu aşı koruyacaktır.

Gebelere yapılabilir mi?

Gebelik sırasında önerilmiyor ama emziren kadınlara uygulanabilir. Gebelikten önce başlanmışsa, devam edilmez, gebelik sona erdikten sonra yeniden aşılama yapılabilir.

Erkekler de yaptırabilir mi?

Erkeklerin aşılanması hâlâ tartışılıyor. Çünkü onlarda da kansere yol açmayan genital siğiller oluşuyor. Tercih ederlerse erkeklerin de taşıyıcı olmama adına 9-15 yaş arasında aşılanabileceği bildiriliyor.

Cinsel ilişkide prezervatif kullanımı HPV bulaşmasını engelleyebilir mi?

Prezervatifle HPV’den maalesef değişik oranlarda olan koruma belki sağlayabiliyor ama tam olarak korunma için prezervatif bile yetersiz. Çünkü bulaşma için illa ki bir sıvı alışverişi gerekmiyor, ten teması ile bile bulaşabiliyor. HPV enfeksiyonu cinsel ilişki sonrası her kadına bulaşmamakta. Virüs ile karşılaşan insanların %80’i bu virüsü hiç farkında olmadan yenmekteler. Ancak %20 insanda bu virüs uzun dönem süren gizli enfeksiyona sebep olmaktadır. Hatta gizli enfeksiyonun da %70’i bağışıklık sistemi tarafından yenilmektedir. Ancak geriye kalan insanlarda rahim ağzında yıllar içerisinde kanser öncüsü lezyonlar ortaya çıkmakta ve bazı kişilerde öncü lezyonlar kansere ilerlemekteler.

Women’s health has been pulled in 500 different directions this week, and it doesn’t seem to be ending. One second the healthcare industry is telling women to get yearly mammograms after 40 years old, the next it’s after 50 years old. One second women are hearing to get pap smears yearly after the age of 18, the next they’re being told to wait until they’re 21 and to get the pap smear every two or three years. What’s next? Drinking heavily during pregnancy is good for the baby and calcium for bone strength is just a myth?

So, what do women do? Who do they believe? I tell you what, if you have had the same family physician and gynecologist for many years, ask them. In many cases, especially if you have a doctor who practices concierge medicine and has the time to take to discuss options with you, your doctor will know the best path for you to take.  

The American College of Obstetricians and Gynecologists made the release this week that stated women should wait until they’re 21 before their first pap smear, and then only have on three years after that until they reach their 30’s, when they should have one every two years. This is a huge step away from the yearly pap smears that start at age 18.

Many physicians are actually praising the new guidelines, saying that pap smears even before the age of 25 are unnecessary and cost patients more money than they need to spend. While a pap smear tests for many different conditions, it’s HPV that gets the most attention. Most physicians believe, and have the research to back them up, that women under the age of 25 still have a strong enough immune system to take care of any small HPV conditions on its own before it becomes cancerous. Only 0.1 percent of women are affected with cervical cancer before the age of 21.

According to ABCNews, the new guidelines were recommended based on the facts, and based on the concern for women’s mental health. Young women who are told, and scolded, for being affected by HPV in their early 20’s deal with fear, the embarrassment of the condition, and the depression that comes along with knowing cervical cancer is just around the corner. When, in reality, 90 percent of women who are affected by this condition in their early 20’s have a strong enough immune system to fight it before it turns into cancer, and all the worry and depression will have been for nothing.

Of course, there’s always two sides to every decision, and on the other side there are many physicians who are afraid that those women who only come into the office once a year for their ‘annual’ will only come in once every two years. This could create problems for any symptoms missed during those two years of not seeing a doctor for a routine check-up.

However, as the patient of a Signaure MD concierge physician, you have more time than any other common practice patients to give your doctor a call on their personal cell phone to discuss what options are best for you. With your concierge physician, you are completely assured that your doctor will know what’s best for you and your family, and will have an amplitude of available time to discuss your options with you. With Signature MD, your concierge physician has plenty of time to devote to each woman who is concerned with the ever changing field of women’s health.

If you are interested in learning more about concierge medicine and what Signarue MD can do for you, check us out at http://www.signaturemd.com.

I was out a few nights ago and a friend asked me my thoughts on vaccinating her daughters for HPV – Human Papillomavirus. We’ve all seen the ads but what is it? Why is it taking center stage now? And in the grand scheme of sexually transmitted infections (STI) how dangerous is it?  

I didn’t have an opinion – although my gut was telling something so I thought I’d take a look. I’m writing this as I’m doing my research… so I’m taking you on my “thought” journey to look at the data and see what I think. This is how I’m thinking about the numbers – but if you find a different way let me know.

HPV is actually better known as the virus that causes warts – yep those icky things on your hand and feet. There are around 100 HPV strains that have been categorized.

There are about 40 known strains of HPV that infect the genital region. Of these 9 of these are considered high-risk – causing anything from low-grade cervical changes to cancers in women. Low-risk strains (the American Cancer Society lists 2) may cause genital warts, respiratory pappillomas (very rare – and involves the transmission from a mother to a new born) or low-grade changes in the cervix.

So… what about the other 29 strains?

The Centers for Disease Control state that 50% of sexually active adults (men and women) will get HPV at some point in their life.

According to the American Cancer Society “70% of HPV infections appear to go away within a year and 90% within 2 years.” The CDC adds that “in 90% of the cases, the body’s immune system clears the HPV infection naturally.” Most people don’t even know that they’ve had it.

So for a huge number of the infected there is no cause for alarm – our body takes care of itself and off we go.

Forgive me while I do a little math… let’s start with 200 people, 100 men and 100 women. Okay out of each group 50 will get some strain of HPV – whether it is a high-risk or a low-risk strain 90% of them will clear it up in two years. That leaves 1 woman and 1 man left to worry about right (I know – it could be 2 women or 2 men – but this is a thought experiment)?

So what about that 10% – which is a huge number if you’re looking at the total population of the US – what happens to them? Remember they can have either high-risk or low-risk HPV infections.

Now I’m going to limit this to cancer – the other types of problems HPV creates can be dealt with fairly easily – but cancer kills.

To figure out the risk to our 10% I plugged in the American Cancer Society’s estimates of the number of HPV related cancers in 2008 and the US population curtsey of the US Census Bureau and got the table below.

So… this gets a little funky – I made the US Population numbers to equal 10% of the population. So the risk to the 10% is the percent below. Not the risk to the general population.

  *estimation of US births in 2008

Our two people – have less than a .08% chance of getting a HPV related cancer to their problematic HPV strain – less if you are male and a little more if you are female. And there isn’t a vaccine for men – so if you are looking at the 30 million remember that the vaccine could only help 15 million of them.

Which means that the Jill on the street has a .008% chance of getting a HPV related cancer and yes genital warts can be an embarrassment but they aren’t cancer. I think most lottery odds are better. On the site Dr. Math it is reported that a person has a 1:80,089,128 chance in matching all 5 numbers plus the power ball if playing Powerball Lotto. I didn’t look at his formula but thought we’d roll with it – it makes my point.

Now let’s play another game because even 15 million problematic HPV infections in women seems a like a lot. But remember there are 40 strains of HPV that infect the genital region – of which 9 are high-risk.  

Gardasil, one of the two vaccinations for HPV on the market, was designed to prevent the following:

• 2 types of high-risk HPV known to cause cervical cancer that are responsible for 70% of all HPV related cervical cancers.
• 2 types of low-risk HPV known to cause genital warts that are responsible for 90% of all genital warts.

Cevarix will protect against the same high-risk HPV but not the low-risk.

So, if our young woman gets cancer from HPV – she has a 41% chance of having a cancer that isn’t cervical. She also has a 30% chance, if she has cervical cancer, that it isn’t one of the two strains included in the vaccinations.

These odds become more astronomical by the minute….     

The American Cancer Society in their guidelines state:  

• girls ages 11 to 12
  The vaccine should be given to girls ages 11 to 12 and as early as age 9.

• girls ages 13 to 18
  Girls ages 13 to 18 who have not yet started the vaccine series or who have started but have not completed the series should be vaccinated.

• young women ages 19 to 26
  Some authorities recommend vaccination of women ages 19 to 26, but the American Cancer Society experts believed that there was not enough evidence of benefit to recommend vaccinating all women in this age group. We do recommend that women ages 19 to 26 talk to their doctors or nurses about whether to get the vaccine based on their risk of previous HPV exposure and potential benefit from the vaccine.

I’m not against vaccinations – I think they are great! In fact just got a booster shot at the doctor the other day for tetanus. No Small Pox almost no Polio – these were great things that saved lives and dealt with viruses that were killing us. But we are being asked to “protect our girls” from an almost nonexistent cancer. A cancer that appears in a sliver of the population and the biggest risk is from cervical cancer which currently has a survival rate of 92% with early detection and 71% for detection at all stages.

Yes – HPV is very infectious but statistically it’s not killer.

So why? Why the huge ad campaign? Why make us feel that something is terribly wrong when the number don’t really support it?

Viruses evolve with their hosts – that said HPV has been around for a very long time – infecting us for millions of years.

The odds are that it will continue to be an occasional problem and general nuisance. A lot of viruses are in a push-me-pull-you state with their hosts. They come. They go. And Leave immunity in their wake.

Which makes me wonder if there is any indication of reinfection with HPV? You know like the common cold – you get it and then get it again and we never seem to get much better at fighting it. But the raw data – just the numbers that we’ve looked at suggest that infection happens – is cleared – and then you have your own immunity. 

Is it the right thing to do? Why are so many women talking about this and wondering what they should do? Well… remember the ads?

Let’s look at the issue another way.  

If we become convinced, as a society, that the guidelines should be adhered to there are an estimated 4.5 million children born every year in the US. Imagine half of them are girls…2.25 million. That means that if we go by the America Cancer Society guidelines and vaccinate every young woman, right now, between the ages of 11 and 18 that is an estimated18 million young women.

Gardasil goes for $120 a dose and three doses are required for immunity so that is $360 per woman.

18 million young women multiplied by $360 per treatment is $6.5 billion…with an additional $900 million possible every year thereafter.

If they succeed in making us believe… what? That we are doing a disservice to our young women not to vaccinate them – this may be a “nice to have” but I just can’t classify it as a “need to have”.  

Oh, and on the American Cancer Society website they have a section that interests me in their FAQs. “Did the American Cancer Society play a role in the development of the HPV vaccines?”

The answer… Yes. One of the four teams received funding from the ACS in the mid 1990s – the grant could be anything from a little to a lot…  

And you wonder why you’ve seen all the ads. I don’t. This is economics driving healthcare – and I have to admit I’m rather sad about it.

But there is a flip side… I was talking to another friend who has decided to immunize her daughter. She did it because she and another mother she knows had been one of the 10% – the ones with some sort of problem with their vaginal wall cells caused by HPV. The treatment was painful and my friend felt that since her insurance was paying for it she would rather not take the risk of there being a genetic predisposition.

Another woman said that she would have done it – her daughters are older now – just because it was one less thing to worry about.

Yet another said that since there are very few “wins” when preventing cancers of any kind that it was just nice to know you were doing something.

So where are we?

A drug company is going to make billions off our sense of responsibility? This will be a choice each of us will have to make. The risks are low yet it seems this is a bizarrely difficult decision to make.

What about you?  

 ~ Tess

At Our Bodies Our Blog this week, I cover the CDC’s new vaccination criteria for U.S. immigration, which removed HPV and zoster (chicken pox) from the required vaccines. I also have a bit about why the HPV vaccine requirement was problematic, links to previous related posts, and links to organizations for women of color that issued a statement applauding the change.

Meanwhile, C’s post on the new mammogram recommendations has useful explanation of the change and a lively comments section.

(Getty Images)

FRIDAY, Nov. 20, 2009 (Health.com) — Young women should have their first Pap test no sooner than age 21, regardless of when they become sexually active, say new guidelines from the American College of Obstetricians and Gynecologists (ACOG). Earlier screening for cervical cancer may lead to unnecessary and possibly harmful treatments for an increasingly rare cancer, according to ACOG, the leading U.S. professional organization for obstetricians and gynecologists.

After age 21, women should have a Pap test every two years, instead of every year. At age 30, if a woman has no history of cervical cancer and has had three normal Pap tests in a row, she can be screened every three years, rather than every two to three years. (Women with certain risk factors, such as those who are HIV positive or who have a suppressed immune system, may need to be screened more often.)

However, annual pelvic exams—which are necessary for performing a Pap test—won’t necessarily be going away. ACOG says it may still be appropriate for women to visit their doctor annually for a pelvic exam, even if a Pap test isn’t performed. And sexually active adolescents shouldn’t wait until age 21 to see a gynecologist for the first time. (Such visits don’t necessarily have to include a pelvic exam.)

The guidelines were published this week in the journal Obstetrics & Gynecology.

ACOG had previously recommended that women receive their first Pap test three years after having sex for the first time, or no later than age 21, with annual checkups after that.

Why the change? Rates of cervical cancer, which is caused by the sexually transmitted human papillomavirus (HPV), have declined by 50% since the 1970s. Cervical cancer is now extremely rare, especially among women under the age of 30, the group most affected by the new guidelines. On average, just 14 cases occur nationwide in women between the ages of 15 and 19 each year, according to data from the Centers for Disease Control and Prevention. Among women ages 20 to 24, an average of 123 cases occur.

“The risk of invasive cancer is so exceedingly rare in this age group that to start screening at age 21 will still pick up the overwhelming majority of cases,” says Alan Waxman, MD, a professor of ob-gyn at the University of New Mexico School of Medicine, in Albuquerque, who led the preparation of the document spelling out the recommendations. “The incidence of cervical cancer in 15- to 19-year-olds has been reported at 1 to 2 per million girls. That’s a lot of unnecessary pelvic exams and unnecessary potential treatments that can be avoided.”

The cervical cancer rate will probably drop even further due to newer vaccines like Gardasil, which are now approved for HPV prevention in girls and women ages 9 to 26. However, ACOG says the vaccines won’t affect cervical cancer rates for 15 to 20 years, so they did not play a role in the new cervical cancer screening guidelines. Such vaccines don’t protect against all types of HPV that can cause cancer, so Pap tests are still necessary.

About half of all people are infected with HPV at some point in their lifetime, although the infection often goes away on its own. (Only in some cases does the virus damage cervical cells, causing abnormalities that can be picked up on a Pap test.)

Studies that ACOG consulted also show that screening older women every two to three years is nearly as effective as screening annually. And for women who’ve had healthy Pap tests for years, screening could probably be stopped around ages 65 to 70.

Next page: Guidelines not a major overhaul

Mark Einstein, MD, an associate professor of gynecologic oncology at Montefiore Medical Center, in the Bronx, N.Y., and a spokesman for the Society of Gynecologic Oncology, says the new guidelines are a “data-driven fine-tuning,” not a major overhaul.

“It’s important for patients to realize that the science behind the guidelines is strong,” Dr. Einstein adds.

ACOG’s revisions reflect a trend toward a more conservative approach to managing the cervical abnormalities that sometimes lead to cancer.

Cervical lesions are common, especially among adolescents. About 1 in 5 Pap tests in that age group will turn up an abnormality, but the vast majority of low-grade cervical lesions—up to 90%—will get better on their own within three years. Among older women, the rates are lower, but low-grade lesions still rarely progress to the precancerous stage.

Moreover, a series of studies in recent years suggests that women who have cervical lesions surgically removed or burned away with a laser may be at a higher risk of giving birth to a premature or underweight baby. As a result, ACOG and other organizations now recommend monitoring the condition rather than immediately treating it when some types of lesions are found.

Scaling back the schedule for Pap tests will minimize unnecessary and potentially harmful procedures, the guidelines say. Although they also cite the expense of screening and the anxiety and “emotional impact” caused by abnormal Pap tests, “the risk of treatment was the driving factor” behind the changes, says Dr. Waxman.

ACOG’s recommendations come less than a week after the U.S. Preventive Services Task Force (USPSTF), an independent panel of experts that advises the federal government on preventive care, released new guidelines for breast cancer screening. The USPSTF recommended that women begin mammograms at age 50, not 40, and decrease the frequency thereafter.

Both the mammography and Pap test guidelines are part of a broader, evidence-based shift toward less screening, says Karen Soren, MD, the director of adolescent health services at Columbia University Medical Center, in New York City.

“We always used to feel that the more screens you get, the better. And I think there’s a new philosophy,” says Dr. Soren, who has studied Pap tests in adolescents. “The whole medical community in general is saying, ‘Perhaps we’re overscreening.’ And that relates to mammography as well.”

By changing its guidelines, ACOG is breaking ranks with the other main authorities on cervical cancer. The American Cancer Society (ACS) and the USPSTF both recommend that women get their first Pap test within three years of having sex, or at age 21.

The ACS recommends that women ages 21 to 30 should be tested every one or two years, depending on whether a conventional or liquid-based Pap test is used. Women over 30 with three consecutive normal Pap tests can be screened every two to three years, again depending on which tests are used. (The ACOG guidelines do not distinguish between the different types of testing.)

The USPSTF’s mammogram guidelines, which deviated from those of the ACS, caused an uproar and have sowed confusion among women, but experts agree that the ACOG recommendations aren’t likely to have the same effect.

In fact, the ACOG committee that assembled the guidelines believes it will help eliminate confusion and simplify care. “Now age 21 is there as a landmark point in a young woman’s lifetime: ‘Gee, I’m 21, now it’s time to get my Pap test,’” says Dr. Waxman.

The hope, he says, is that the ACS and the USPSTF will head in the same direction with their own recommendations. “It’s very frustrating when you have three major professional organizations saying three different things,” Dr. Waxman says.

Setting a woman’s first Pap test at age 21 is clearer than pegging it to sexual activity, says Dr. Soren. “The recommendations have been changing and evolving, and people have been slow to catch on,” she says. “Patients have been asking for different things. I think the fact that there are concrete guidelines now is actually better.”

Fred Wyand, a spokesman for the American Social Health Association, a nonprofit organization that raises awareness about HPV and cervical cancer prevention, downplayed the potential for confusion among the public or health-care providers. The debate over the schedule for Pap tests is “not new,” says Wyand. “The guidelines are new, but the discussion that preceded it dates back years. So I don’t think anybody’s going to be caught off guard.”

Experts stress that annual pelvic exams may still be appropriate even though Pap tests will be performed less frequently. And, most importantly, women who have received the HPV vaccine need to stick to the same screening schedule as everyone else.

“It is number one on our list to make sure that patients know that vaccination doesn’t replace screening,” says Dr. Einstein. “We’re not ready to be making separate guidelines for vaccinated and non-vaccinated patients, and we won’t be ready to do so for some time.”

A few days ago I wrote this screed of disdain about David Brooks data-less, thoughtless complaint about the vapid sex lives of Kids These Days™.*  I have more than once commented on the evil consequences of marrying sexual queasiness to bad science, social or otherwise — and it struck me that  it is important to remember that Brooks’s queasiness about sex has a broader context and worse consequences.

The thought came to me as I was reading my pre-pub copy (what used to be called a galley) of Rebecca Skloot’s marvelous new book The Immortal Life of HEnrietta LAcks.  Rebecca has written a work that  is proximately the story of HeLa —  the most ubiquitous (some would say ferocious) human cell line used in modern biology — and the woman from whom those cells were derived, without her knowledge or permission.  It’s more than that, of course — an inquiry into race and its twisted history in America, family, medical practice and medical ethics, the autonomy — or lack therof — with which we all inhabit our own bodies, and much more besides.  I’ll blog about it properly closer to pub date, but put this one on your list.

Within all that, the factoid that got me thinking was Rebecca’s discussion of the particular type of cancer that killed Henrietta Lacks so swiftly and cruelly: cervical cancer, the sequel to her multiple infections with HPV-18, one of the most malign of the 100+ strains of Human Papilloma Virus.

HPV infection was and is an epidemic.  In 2008, the Centers for Disease Control reported that

HPV is the most common sexually transmitted infection in the U.S., with about 20 million people currently infected. Women have an 80 percent chance of getting HPV by the time they are 50. HPV is most common in young people who are in their late teens and early 20s.

That is:  about 7 percent, give or take, of the American population — closer to ten percent of the adult population**–are infected with a virus whose consequences range from nothing to death in predictable proportions.  The same CDC report tells us that each year 11,000 women are diagnosed with cervical cancer, and that 3,600 will die of it.

For those of you keeping score, the number of women who will die this year of the disease that killed Henrietta Lacks is about 80% of the total US military deaths in Iraq since 2003 — 4363, according to the latest AP count.  It is greater than the number of combat deaths in that period:  3,476.

There is this difference of course:  death is a necessary component of battle.  War is the imposition of national will by violence, in one short hand definition, and within that context, people will die.

By contrast, no one — or rather, within a generation, very close to no one — need die of HPV infection.  The HPV vaccine, approved by the FDA in 2006, protects against four of the strains of HPV, including those that cause genital warts and cancer.  It is effective, according to the CDC, and safe:

As of June 30, 2008 VAERS has received a total of 9,749 reports of potential adverse events following HPV vaccination. Ninety-four percent (94%) of these reports were about non-serious adverse events.

Six percent (6%) of adverse events reported for the HPV vaccine were considered serious, which is about half of the average number of serious reports for other vaccines. In comparison, the overall average in VAERS for any serious adverse event following vaccination ranges from 10% to 15%; therefore, the percentage of serious reports for Gardasil® is less than the overall average for other vaccines.

The CDC goes on to caution that the number of adverse events actually caused by the virus vaccine is almost certainly lower than that number, due to the post hoc ergo propter hoc problem.

The virus vaccine is recommended for girls aged 11-12.  Why?  Because this is before the age of likely infection, given that HPV is a sexually transmitted pathogen.

We all know where this goes.  The notion of protecting girls from a deadly disease transmitted in the context — oh get the fainting couch ready — of the sexual lives of their older selves is terrifying, at least to some.

So much so that  those terrified of especially female sexual appetite and expression (see for an allegedly respectable example, Chunky Reese Averse Ross Douthat) would rather kill people than acquiesce in the possibility that human beings might on occasion make the beast with two backs.

Recall:  Texas secessionist Governor Rick Perry wasn’t always 100% crazy.  Back when the loon quotient was down to no more than 95% or so, he actually, in a moment of clarity in 2007, signed an order that all require all sixth grade girls in Texas to receive the HPV vaccine.  The response?  As you’d expect.  Texas legislators “rushed to file bills that would override the governor’s order, which they said revokes parental rights and could encourage young girls to be promiscuous.”

To his credit Perry stood up for modern public health:

Providing the HPV vaccine doesn’t promote sexual promiscuity any more than the Hepatitis B vaccine promotes drug use,” Perry said Monday. “If the medical community developed a vaccine for lung cancer, would the same critics oppose it, claiming it would encourage smoking?”

Soon, though — damn soon — in fact, he lost.  Though he complained — accurately, that the legislators who had voted in favor of the bill overturning his executive order would rather tell women that  ”We could have prevented this disease for your daughters and your granddaughters, but we just didn’t have the gumption to address all the misguided and misleading political rhetoric,” he lacked the votes to prevent his veto from being overturned, and allowed the bill, unsigned, to become law.

Perry, it should be noted, still defends this decision.  I have no time for just about everything Perry stands for  – but on this one, he has it right.

So let’s recap:  we face a disease that kills more women in this country each year than have died in battle in the last six in our war in Iraq….

…that will be allowed to persist in the lives of our daughters because to some people it is more important to pretend that human beings don’t have sex with more than one person in their lives than it is to prevent wholly avoidable suffering.

So, finally, to return to why I find David Brooks’s maundering about the sex lives of New Yorkers so pernicious is not just because of the gaping crater of intellectual shoddiness at its heart:  it that he offers a well-spoken version of the attitude that declares, whatever may actually happen in real human experience, women shouldn’t have the temerity to uncross their legs.  Remember the corollary of that belief as well:  if they do, then, by gum, disease, distress and death are merely the appropriate consequences for such sin.

Last note:  when ever I hear the term “value voters” I throw up in my mouth.  The single central value of just about any ethical system, including those advanced by the sages of traditional religion, is that it is wrong to use other people as objects, rather than subjects, individuals of intrinsic value.  Requiring others to die to avoid unpleasant contradiction with one’s own value system is not a virtue.  It is, in the only true sense of the word, the very definition of a sin.

A pox upon them.

I mean that literally.

Oh — and one more thing.  If anyone wants to draw the obvious connection to the current health care debates (Joe Stupak, are you listening?  Senators?) then I think that is an entirely appropriate link.  The entire anti-health care movement is in the end a decision to allow innocents to die in large numbers in order to achieve other ends; it sacrifices individuals in the service of either or both abstract “values” and the financial interests of various elites.  Mere sin hardly covers the case; evil is more like it.

*I later found out that Brooks’ silliness was deeper than I thought, for I chanced across the original article in New York magazine in which the editors described the process by which they accumulated the sex diaries that so confounded the gentle Mr. Brooks.  These were, which I’m sure will surprise no one, wholly selected for maximum effect.  Producing social commentary on the basis of sought-and-found soft porn purveyed to prop up an at-risk publishing model is something only the credulous or the contemptuous-of-their-readers would attempt.  Consider this an exercise for the readers to decide which it might be.

**and yes, I know that plenty of under-18s will have HPV infections.  This is numerical shorthand here — an attempt to express scale.  It is not, as I hope the language makes obvious, a precise claim.

Update: minor but crucial edits above (for “virus” read “vaccine” twice) thanks to the eagle eye of  Lovable Liberal.

Images:  Albrecht Dürer, “The Revelation of St John: 4. The Four Riders of the Apocalypse” 1497-1498

Berthe Morisot, “The Balcony” 1872

Jeśli zastnawiałaś się lub ktoś z Twoich bliskich czy szczepić się na HPV, zobacz najpeierw ten materiał. Na zachodzie już dawno przestano promować te szczepionki jako cudowny lek, u nas w karju odwrotnie… Czemu się nami tak manipuluje?