Category Archives: HPV & Cervical Cancer

03.13.09

Jade Goody – Are There Lessons to be Learned?

Dr Crippen, aka The NHS Blog Doctor, has written a very thoughtful response to my recent post on Jade Goody’s cervical cancer. Dr Crippen practices in the UK, and corrects my misperceptions of how low-income folks get care in his country.
No Margaret. You are confusing the UK with the USA. God knows, the NHS is creaking, and we have problems enough, but we do not have “public clinics” for the impoverished poor. In the USA, the impoverished poor, aka the unemployed working class, predominantly black and Latino, may need “public clinics”. In the UK everyone is entitled to a “primary physician” as of right, independent of status and means. Yes, yes, before someone, or no one, or “angry from Tonbridge” writes in, a few people slip through the net, and a few people have incompetent GPs, and there is a difficulty with the homeless who are of no fixed abode, and so on and so forth but by and large most people have a GP. God knows, I do not hold back on criticising the failings of the NHS, but I become amazingly protective when people try to suggest that we have problems akin to those experienced by the medically uninsured in the USA.

I encourage you to head on over and read his post, which includes a description of the cervical cancer screening program in the UK.

Dr Crippen also thinks I went too far in hoping that someone

personally called, warned, cajoled and hollered at [Jade] countless times, until finally, as a last ditch effort, they sent her a certified letter.

You know what? He’s right. I doubt I would have called “countless times”. I was being a bit hyperbolic, probably because I was feeling particularly saddened and frustrated by the fact that a preventable death was about to occur in a young mother of two children.

But I like to think that I would have called Jade at least once if she failed to respond to her letter. Probably twice if I know myself well. And I suspect from reading Dr Crippen’s post that he would have done the same.

So don’t worry, Dr Crippen – you and I are in full agreement that the medical profession does not need anyone breathing down our backs to force patients to accept medical care that they have been duly informed that they need. I was in no way trying to insinuate that the medical profession bore any legal responsibility in Jade’s tragedy. They sent her a letter, she ignored it. Her bad.

That said, the question that remains is simply this – Did anyone call Jade when she failed to follow up on that last abnormal pap smear?

Which is not to imply that they were required to do so, or that the government should mandate it. I’m just speaking as one human being to another. It seems like it would have been the right thing to do.

And I hope someone did it.

That was really all I meant to say.

10 Comments
02.26.09

The Tragedy of Jade Goody

Jade Goody, the controversial star of British reality TV, is dying of cervical cancer at age 27. This young woman, who has lived her life in front of the camera for the last 7 years, will die for the camera as well, having sold the rights to film her last days in an ongoing reality show.

Whatever you think of Jade, the publicity generated by her illness has led to a 20% upswing in the number of women getting Pap smears in Britain.

And this is a good thing. Because if Jade’s story causes even one young woman to get the smear that saves her life, it will mean Jade’s death will not have been in vain.

The Irony

Unlike Eva Peron, whose death from cervical cancer occurred in the years before we had access to screening, Jade did get pap smears.

Jade had more than one pap smear, starting in her teens. At one point, she was even treated for precancerous changes of the cervix. And went on to have more follow up smears after that.

But when those follow up smears showed a recurrence of abnormal cells, Jade ignored letters that were sent to her advising her to come in for follow up and treatment.

Why? Because she was scared..

“They had sent a letter to me ages ago, telling that I needed to go in for an operation, but I had been too scared to do anything about it,” Goody confessed.

So Jade put the whole thing out of her mind and pretended it never happened. Until repeated episodes of pain and hemorrhage became symptoms she could no longer ignore. But by then, the tumor had spread beyond the cervix to her uterus. And while a radical hysterectomy and chemotherapy staved the cancer off for awhile, it returned this past month with a vengeance.

And now Jane Goody is going to die.

Let me stop beating around the bush

What has been on my mind all week since I first read about Jade’s story, and what I want to ask is simply this -

Did any health professional ever actually call Jade and try to get her in for treatment in all that time after her Paps came back abnormal? A nurse? A doctor? Anyone?

Please don’t tell me the only contact ever made with this frightened young woman was a series of letters, each one scarier than the next. Please tell me someone called her personally and tried to get her in.

Look, I know Jade was stupid.

No one, even Jade, I suspect, would say otherwise. Ignoring multiple abnormal Pap smear letters was not the first or the last stupid thing Jade Goody ever did. This is a kid who, in front of millions, stripped nude during a game of poker, made an ass of herself shouting racial slurs to an Indian housemate and then gave a blow job under the covers to another housemate. We’re not talking rocket scientist here.

But I’ve seen Jade in interviews that I’ve watched over the past few days, trying to wrap my head around this tragedy. This kid doesn’t hold anything back. She is completely genuine, self-effacing and ready to admit her shortcomings. She’s an idiot, but she knows it. And she is anything but unreachable emotionally. I just can’t believe that someone couldn’t have convinced her to come in sooner if they’d just talked to her.

Please tell me someone tried to reach her.

Jade seems to have had multiple interactions with the health care system during those years between the abnormal smears and her ultimate diagnosis. Times when she visited doctors for pain or gastrointestinal symptoms that were probably related to her growing cancer.

Did these doctors know about her abnormal smears? Did Jade think to tell them? (Probably not…) Were the letters being sent from the NHS cervical cancer screening program separate from Jade’s actual ongoing medical care?

Heck, did Jade even have a source of ongoing care, or, god forbid, a primary physician? I doubt it. This is, after all, a lower class girl from a very rough upbringing – someone, I suspect, whose only contact with the health care system was in public clinics and ERs. She probably bounced around ER’s and hospitals during those years, failing follow up appointments, checking out AMA so she could appear in one or another publicity venue, denying that there was really anything wrong. (Update – Dr Crippen corrects my misperceptions of the British system…)

She even tried to delay her surgery after her diagnosis so she could stay on TV, till they told her she’d be dead in 3 weeks unless she went into the hospital right away.

So maybe I’m completely off base.

Maybe, just maybe, there were docs and nurses who tried to help Jade. Folks who personally called, warned, cajoled and hollered at her countless times, until finally, as a last ditch effort, they sent her a certified letter. Health professional who really cared about Jade and wanted to help her, although ultimately she refused their help.

Maybe Jade was just really that stupid.

I hope so. Because otherwise, the tragedy is not just Jade’s, but all of ours.
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Update –
Dr Crippen reponds to my post with a very thoughtful post of his own regarding Jade.
I respond to Dr Crippen.

For more information about cervical cancer, see these sites -

Jade Goody Photo from Wikimedia

36 Comments
05.16.08

Eva Peron, Cervical Cancer and the Pap Smear

Eva and Juan Peron, October 1951 (Image from Wikipedia)
Fat Doctor writes that she can never think of Argentina without thinking of the music from Evita, the musical that was inspired by the life of Eva Peron.When I think of Argentina, I too, think of Eva Peron. But there’s no musical accompaniment. Just sorrow.Because I can never think about Eva Peron without thinking about cervical cancer, Pap smears and HPV. And the tragedy that was Eva’s death, and the deaths of so many women from cervical cancer.Eva died from cervical cancer in 1952 at the young age of 33 years. Although George Papanicolaou invented the Pap smear in 1942, this life-saving test was not widely used in Argentina until the 1960′s. Thus, Eva’s cancer was at an advanced stage when it was diagnosed after she began having vaginal hemorrhage. She received radiation treatment to control the bleeding, probably right around the time of that photo up there, and then a radical hysterectomy in November 1951. Despite treatment, the cancer progressed rapidly and she succumbed to it just 8 months later.

Don’t be surprised if you did not know that Eva had cervical cancer – she herself never knew. Her diagnosis was kept from her at her family’s request, and the public never told, even after her death. The subterfuge was so extensive that when they brought in an oncologic surgeon from Memorial Sloan Kettering to perform a radical hysterectomy, he never met his famous patient until she was asleep under anesthesia, and Eva never knew that her surgeon was anyone other than her own doctor. It’s an amazing story of paternalism and politics.

Eva’s husband, dictator Juan Peron, also lost his first wife to cervical cancer at the young age of 28 years. Did Peron carry a particularly aggressive strain of HPV, the virus that we now know causes cervical cancer, and unknowingly transmit the infection to both his wives? Or did Evita contract HPV elsewhere, having been sexually active with multiple partners from the young age of 15? We will never know for sure.What we do know today is that Evita’s death due to cervical cancer would likely never have happened if she had had a Pap smear. This simple test, in which cells from the cervix are collected with a brush and examined microscopically for abnormalities, can detect precancerous changes up to 10 years before cervical cancer develops. Ten years during which developing lesions can be treated before they become cancerous.This week is the 125th anniversary of the birthday of George Papanicolaou, the inventor of the Pap smear. A man whose contribution to medicine has saved millions of women’s lives.Happy Birthday, George. If there is a heaven, you are surely in it. And thank you for your wonderful Pap smear – one of the most effective cancer screening tests ever created.

If only Evita had had one.
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For more reading about Evita see –

For more information about cervical cancer, pap smears and HPV see these sites –

10 Comments
02.25.08

HPV and Breast Cancer? Interesting, but too soon to say

Read a fascinating post in Aetiology regarding the potential role of HPV in the etiology of breast cancer.

Although we are nowhere near proving a direct causation, studies have found HPV DNA in anywhere from 20-85% of tumors studied. (Types 16, 18 and 33 most commonly) However, some studies have found HPV DNA in normal breast tissue as well. So is HPV a cancer-causing agent in the breast or just a bystander? It’s too soon to say. Lots more work is needed on this one, folks.

The data are at odds with known risk factors for breast cancer, such as never having been pregnant. And if there is a link, one should see that breast cancer risk is increased with number of sexual partners, which as far as I know, is not the case.

So be careful before making the leap between hypothesis and recommending HPV vaccination for breast cancer protection. It’s way, way to soon…

Comments
11.18.07

HPV and Oral Cancer

Increasing evidence suggests that HPV infection of the mouth and throat, presumably acquired through oral-genital contact with an infected partner, can lead to squamous cell cancers of the tongue and tonsils.

You know what HPV is, right? Human Papilloma Virus. The same virus that can cause cervical cancer in women and anal cancers in both men and women.

Scientists have been suspecting for years that this virus might be responsible for squamous cell cancers of the oral cavity. Turns out that it is, though it may be a more recent phenomenon related to the increasingly widespread nature of HPV infection.

What is the Evidence?

1. The incidence of certain oral cancers is rising

Doctors and dentists are seeing increasing numbers of tonsillar and tongue cancers in young men and women, even as rates of other oral cancers and the use of tobacco, a factor typically associated with increased risk of oral cancer, have declined, and rates of oral sex have increased.

Confounding factors may be an increase in binge drinking, another risk factor for oral cancer, and the fact that tonsillectomies are no longer regularly performed. But upwards of one quarter of individuals with oral cancer these days do not have a history of drinking or smoking, suggesting that another risk factor is emerging. That factor appears to be HPV.

2. HPV DNA is found in oral cancer cells

Somewhere between 40 and 75% of tongue and tonsillar cancers contain HPV16 DNA. HPV 16 is the HPV genotype most frequently found in cervical and anal cancers, and is known to be sexually transmitted.

Scientists testing tumor samples from Sweden’s tumor registry in 2007 found that the rate of HPV DNA presence in tonsillar cancers increased from 23% in 1975 to 68% in 2002.

3. The risk for oral cancer increases with number of oral sex partners

Having more than 6 lifetime oral sex partners is associated with a greater than threefold increase in oral cancer risk. (NEJM) This risk appears independent of the risk imparted by smoking and alcohol, which is associated with HPV-negative cancers. Again, this suggests that there are separate pathways to oral cancer, one mediated by HPV and the other via some other factor modified that is by alcohol and nicotine.

What is Your Risk for Getting Oral Cancer?

It’s really, really low. According to the SEER database, the the annual incidence of oral cancer is about 10 per 100,000 annually (6 per 100,000 for women and 16 per 100,000 for men.)
So extrapolating from the research, having had oral sex with more than 6 partners would raise the annual risk of oral cancer in a male to 48 per 100,000.
Of course, that’s just the annual risk. The lifetime risk of getting oral cancer is considerably higher, about 1%, give or take, depending upon how old you live to be.
So, if these numbers hold for HPV related cancers as well, and you have more than 6 oral sex partners, your lifetime risk for oral cancer by age 70 will be about 3 %. Which looks like this -
But, the risk of dying from oral cancer is much, much lower, about 2.5 per 100,000 annually, and ranges from 1.3 per 100,000 in individuals under age 65 to about 12 per 100,000 in those age 65 and older. Since HPV cancers are less aggressive than other oral cancers, I don’t think we can extrapolate historic mortality data, so I won’t. But I would suspect that the risk of dying from an HPV-related oral cancer is even lower than the numbers I just quoted.

(This is rough math, and probably not statistically proper, but it’s the best I can do with the data I have. Others who are better at statistics, please feel free to comment and correct this estimate and I will revise if need be.)

By comparison, the annual incidence of cervical cancer in women is about 7 per 100,000 and the mortality about 2.5 per 100,000. The lifetime risk is about half that of oral cancer in males, due, I suspect, to Pap smear screening in women.

Are There Other Risk Factors?

HPV is only one risk factor for oral cancer, though given the advent of the HPV vaccine, it is sure to be the one that gets the most press.

Smoking, excessive alcohol intake and poor dental care are also very important risk factors, as is a diet low in fruits and vegetables. In one study in Poland, 56% of oral cancers could be attributed to smoking, 31% to excessive drinking, 47% to poor dental hygiene and dental care, and low fruit intake to 12%.

These other risk factors appear to be independent of HPV infection in causing oral cancers, and scientists hypothesize two separate paths to oral cancer, one driven by HPV and the other by these other risk factors. Supporting this idea is the fact that HPV-related oral cancers tend to be less aggressive and have better prognosis than those without HPV. In addition, tobacco and alcohol appear to be synergistic in promoting cancers that are negative for HPV, but not in cancers that test positive for the vurus, again suggesting separate mechanisms for malignant transformation.

What Can You Do Now to Prevent Oral Cancer?

1. Don’t smoke
2. Drink to moderation
3. Brush your teeth and see your dentist regularly.
4. Add fruits and vegetables to your diet.
5. Limit your number of oral sexual partners

Will HPV vaccination be added to that list? I expect it will be. The vaccine prevents HPV 16, the subtype most often found in oral cancers.

Merck, the manufacturer of the vaccine, is conducting clinical trials of their HPV vaccine in young men. I would anticipate a “Tell someone” campaign about oral cancers directed at this population sometime in the near future. Time will tell, and only Merck’s marketing department knows for sure.

In the meantime, be careful out there, okay? Oral sex is a very intimate activity. Why not reserve it for those you love? That would limit your partners quite nicely.

12 Comments
11.10.07

Cervical Cancer and Birth Control PIlls

A recent meta-analysis has confirmed that use of birth control pills slightly increases the risk of cervical cancer. But before you stop your pills, take a deep breath, relax and read further.

Because the risk is really small. How small? Well, if you live in a developed country (meaning you have access to Pap smears), use of the pill for 10 years increases your chance of having cervical cancer from 3.8 per 1,000 to 4.5 per 1,000.

Remember that the real cause of cervical cancer is not birth control pills. It’s infection with the Human Papilloma Virus (HPV).

But estrogen metabolites of the pill may make your DNA more susceptible to changes induced by the HPV virus. The pill can also make the glands of the cervix more exposed to infection by the HPV virus. The other big factor may be that women taking the pill may use condoms less frequently, thus making them more likely to get HPV.

The good news is that once you stop the pill, the increased risk of cervical cancer goes away. That means that when you get older and don’t need birth control, you won’t be paying the price for your decision to use pills when you needed them to prevent pregnancy.

Bottom line – limiting your number of sexual partners and getting pap smears regularly are the most important things you can do to prevent cervical cancer. There is also a vaccine to prevent HPV, but remember that it only protects against 2 of the 12 subtypes of HPV that cause cervical cancer, so it’s not a panacea.

And remember, the pill cuts the risk of ovarian cancer, a protective effect that lasts up to 20 years after you stop the pill. It also reduces your risks of endometrial cancer. And keeps your menstrual cycles shorter, lighter and less painful. Not to mention it prevents pregnancy.

A Gynecologist’s Perspective

I’ve been a practicing gynecologist for 20 years now. In that time, I can remember only 1 case of cervical cancer in my private practice, in a woman age 60 who was completely cured with a hysterectomy. (The cancer was so small they could not find it in the hysterectomy specimen because I had removed it all with my office biopsy.)

I recall many more cases of cervical cancer from my residency, most during my oncology rotation, and all in women who had not had pap smears in years. I remember vividly the woman who presented to the ER bleeding from a large cancer on her cervix. She had not seen a doctor since giving birth to the last of her 7 children, who was now 25 years old. I don’t think she ever took birth control pills.

On the other hand, I’ve lost count of the number of unplanned pregnancies that have occurred among my patients, and the number of my patients who have had abortions for an unwanted pregnancy.

Given this experience, I see no reason for woman to stop taking the birth control pills because of concerns about cervical cancer.

I can think of only one situation where I might tell a woman to stop the pill for this reason. That is the rare patient with recurrent cervical dysplasia and persistent HPV infection that does not clear. I had one such patient, and I changed her to the progesterone-only pill. She is doing well.

20 Comments
09.16.07

HPV Vaccine – The Canadian Response

A well-considered position against universal HPV vaccination in Canada has been published in the Canadian Journal of Medicine. The authors, who are part of the Canadian Women’s Health Network, argue the following:

  • Cervical cancer is far from epidemic in their country, with only 400 deaths yearly, a rate that has been steadily declining;
  • Most HPV infections resolve spontaneously;
  • The vaccine was not trialed sufficiently in adolescents, the group being targeted for univeral vaccination;
  • The long-term efficacy of the vaccine against cervical cancer in the population has yet to be proven, in light of the fact that it protects against only two of the subtypes that cause cervical cancer and its duration of effect is not known;
  • The vaccine is too new and the clinical trials were all industry-sponsored;
  • The true costs are not determined.

The Canadian Government apparently had a different opinion on the matter – they recently allocated $300 million for HPV vacination. The Canadian health service is rolling out a mass HPV innoculation campaign with the beginning of this year’s school year, the first such innoculation campaign since the polio vaccine in the 1950′s. (CBC.Canada has a very well-done segment on the vaccine initiative.)

Opponents of universal HPV vaccination in both Canada and the United States are focusing on reports of Guillain Barre syndrome occuring after Gardasil administration, expecially when administered along with the meningococcal vacine Menactra. This is typical of anti-vaccine strategies – to focus on rare adverse events that are unlikely to be caused by a vaccine. Similar publicity around a since-debunked theory that the MMR vaccine causes autism has been blamed for recent outbreaks of measles in Britian.

Here in America, the lawyers are already jumping into the Gardasil fray.

Basically, here is the situation – Merck is frightening women about cervical cancer, then using slick marketing campaigns to sell them their vaccine. The anti-vaccine folks are frightening the public that this vaccine has severe side effects, an approach they basically take with all vaccines.

But well-reasoned and informed views such as those expressed by the Canadian Women’s Health Network deserve attention and discussion. Unfortunately, such views do not lend themselves to catchy slogans or soundbites, and don’t frighten anyone. Which makes it unlikely that anyone will hear them.

My position? (Like I haven’t beat this drum enough already…) I pretty much agree with the position of the Canadian Women’s Health Network. I believe that the HPV vaccine is safe, but not yet appropriate for universal vaccination. Like all new pharmaceuticals, only time will tell if there are rare effects not found in clinical trials. I do offer the vaccine to patients who express interest in it and who understand its limitations, mostly adult women who are having multiple partners over time. I am opposed to universal or mandatory vaccination in young adolescents, and abhor the marketing and lobbying tactics being used to promote this vaccine.

14 Comments
08.14.07

HPV Vaccine – Defining the Limits

In a study published today in JAMA, HPV vaccination did not improve clearance of HPV 16/18 in women ages 18-25 who were already infected with the virus.


our results demonstrate that in women positive for HPV DNA, HPV-16/18 vaccination does not accelerate clearance of the virus and should not be used for purposes of treating prevalent infections.

In this study, conducted in Costa Rica, 41.3% of women were infected with HPV at the time of study enrollment. Just another reminder of how common this virus really is.

What do these results mean for patients? If a woman already has an abnormal pap or infection with HPV, vaccination will not be useful in treating her current infection. However, until we have a test to determine which of the 40 HPV subtypes our patients are infected with, vaccination may still be reasonable in such women for preventing future infections with types 16/18/6/11.

The CDC currently recommends vaccination before sexual debut as the most effective means of preventing HPV infection. The older a woman is, the greater the chance she will already have been infected with HPV.

Don’t Misread the Hype

The hype over the HPV vaccine may be misleading, leading some women to believe that the vaccine will make them immune to all HPV infection. Products like the HPV thong (seen below) do little more than promote this misunderstanding.

To be correct, here’s what that thong should look like…

Remember that the currently marketed vaccines only target 2 of the 12 known strains of HPV that cause cervical cancer. Pap smears are still critical in screening for cervical cancer and detecting precancerous lesions before they become life-threatening.

8 Comments
02.21.07

Merck Suspends Lobbying for Mandatory HPV Vaccination

Merck today reported that they are suspending their lobbying efforts for mandatory HPV vaccination. (Thanks to Main Mama for pointing this out to me.)

“Our goal is about cervical cancer prevention, and we want to reach as many females as possible with Gardasil,” Dr. Richard M. Haupt, Merck’s medical director for vaccines, told The Associated Press.

“We’re concerned that our role in supporting school requirements is a distraction from that goal, and as such have suspended our lobbying efforts,” Haupt said, adding the company will continue providing information about the vaccine if requested by government officials.

I’m not sure what exactly suspending lobbying means. Merck has been funneling funds through Women in Government, whose members have been the driving force behind mandatory HPV legislation. Both Merck and the WIG have declined to say just how much money has changed hands between them.

If the WIG’s members are the “government officials” Haupt is referring to, then I assume it means the relationship with the WIG remains in place. From what I can see, the majority of Merck’s work with the WIG has been done – boilerplate legislation has been crafted and the WIG members trained to introduce the legislation. At this point, Merck can sit back and let the WIG do it’s job for them, and deny that they are lobbying. (I know, I know. I’m just so cynical…I think I’m just getting really good at reading between the lines of these corporate press releases disguised as news.)

The vaccine, which costs about $360, has been projected to have the potential to generate $3 billion a year in sales. According to that pie up there, that’s almost $2 billion in profit for Merck. Gardasil revenue in 2006 totaled $155 million (The vaccine was approved in June 2006).

Pie Data from Baltimore Sun.

1 Comment
02.13.07

The HPV Vaccine Controversy

Should HPV vaccination be mandatory for young girls? And, more pointedly, is it appropriate for the governor of Texas to bypass the legislature by using an executive order to mandate the vaccine in Texas?

Very interesting discussions on this issue over at DB’s Medical Rants. And in Dinosaur Musings. And on NPR. And in the letters section of the New York Times.

My thinking on this issue is colored by what I have come to know about Merck’s funding of the group called Women in Government (WIG), whose members have introduced most of the HPV legislation around the country. As you may recall, I wrote in December about the financial relationship between Digene, Merck and WIG. The Baltimore Sun broke the story in January, and then the AP picked it up, as did Fox News, Forbes and others.

In their reporting on the Texas mandate, the NY Times pretty much glossed over the flow of lobbying dollars from Merck into Texas. Merck declined to tell the Times how much they actually donated to Women in Government, which, by the way, carries a non-profit status.

Since then, Merck has been mysteriously removed from list of Business Council members at Women in Government. (Don’t worry – the old cached pages are still around).


“Members also play an integral role in planning for future growth, have the ability to attend our regional conferences, and support the financial stability of the organization.”

to this:


“Business Council members support the overall mission of Women In Government.

Fascinating.

Much of the opposition to mandatory HPV vaccination is coming from the usual anti-vaccine groups and the religious right. That’s unfortunate, because it is distracting the media from seeing the real story, which is the unprecendented influence of Big Pharma in legislating healthcare. And the use of Pharma-funded consumer “advocacy” groups to push Pharma’s agenda when the healthcare community does not respond fast enough for the shareholders. The push for mandatory HPV vaccination is not coming from any organized medical lobby that I have seen – it is coming from Merck.

Right now, because the HPV vaccine does more good than harm, the healthcare community and the media seem to be willing to let Merck slide on this one. But I believe it is a very slippery slope upon which we are allowing them to ride. They still need to get better at covering their tracks, but their recent absence from the WIG website proves they are fast learners in this regard. If they get any better, then a day will come when we will no longer know from where the influences are coming. And if the product being pushed is not the HPV vaccine but another Vioxx, I don’t want to imagine the outcome…

I will state again that I believe the HPV vaccine to be a good thing. And so far, I have trusted the CDC and the professional organizations who have recommended for use of this vaccine. I have even begun giving my patients the vaccine.

But in lobbying for making Gardasil mandatory less than one year since its FDA approval, I think Merck has gone too far in trying to assure the market for their vaccine. And when I see them covering up their relationship with the WIG and declining to say how much money they have given this group which is lobbying all over America for mandatory HPV vaccination, I find myself wondering what else they are hiding.

And that’s not a good way to feel about a company whose vaccine you are administering to your patients.
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Update: The American Academy of Family Physicians and the Texas Medical Association have both issued statments against mandatory HPV vaccination.

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