Sociobiology and Cervical Cancer

Letter to the Editor

The April 1995 issue of Oncology featured an article that presented sound
information on the state of viral interactions and cervical cancer, along
with several excellent reviews. Cancer of the uterine cervix is a
significant health and emotional problem that can have devastating effects
on the patient's life, personal relationships, and body image. In
particular, localized cervical cancer treatment can seriously disrupt the
patient's personal and physical life, and the impact of systemic therapy
is no less severe.

The sociobiology of intimate contact also is a problem oncologists need to
address. To condemn such contact is to forget why we are alive and to deny
the realities of American life. Meanwhile, medicine appears to hail
barrier prophylaxis as the "magic bullet," owing to the device's effect on
just one virus.

Latex condoms are presumed to significantly reduce the transmission of
viruses during intimate relations, and current national statistics even
suggest that teenage pregnancies are decreasing--a trend ascribed to the
use of condoms. Actually, even expensive con- doms are still a most
imperfect form of birth control. The 1-year risk of unwanted pregnancy
with higher quality barrier prophylaxis is the better part of 10%.

Cancer physicians need to know more about the facts of condom use since,
to paraphrase the old adage, "an ounce of prevention is worth pounds of
trouble." First and most obviously, condoms can slip, fall off, or
rupture. With just one such accident, a range of viruses can be
transmitted to the sexual recipient. Industrial product testing of
condoms' capability to inflate against force is not necessarily equivalent
to the stresses posed by actual use. To receive FDA approval, a year of
testing for such devices is about the norm, but big business, politics,
and bureaucracy make it somewhat difficult for the intelligent doctors of
that agency to make any fast, intelligent judgements; they are on the
"recipient end" of such issues.

Second, the chemicals on the surface of condoms can cause serious
inflammation (probably due to talc) in women. Also, even with thorough CDC
re-review of minority heterosexuals in New York City, a significant
proportion of women without other risk factors are turning up HIV
positive. Such is the efficacy of many condoms in the complexities of
everyday life.

Whether individuals at risk of sexually transmitted viral infections are
actually using condoms is another important issue. The increased cost of
condoms may be as much a factor in deterring their more widespread use as
is lack of education.

Five hundred thousand new cases of cervical cancer worldwide should be
cause for concern by the oncology profession. Health-care practitioners
can only be as effective in preventing this disease as the agents and
devices suggested for prophylaxis. Some believe that barrier
contraceptives are an imperfect solution to tremendous cancer problems.
The medical track record with regard to the elimination of viruses is not
terribly strong. In fact new viruses emerge, reemerge, or mutate with
alarming frequency. In part, prophylaxis will be used consistently if it
is effective, noninjurious, and socially acceptable. The next generation
depends on it for health reasons and current generations suffer from the
effects of a variety of "intimate" viruses. An effective polyvalent
vaccine can hardly be described as "just around the corner."

Medicine may want to rethink its unconditional support of barrier
prophylaxis. The market has expanded so that whole stores are dedicated to
condom sales. Does the public know about the complexities of these
imperfect devices?

Certainly there is country-specific variation in education and quality
control regarding condom use and, in turn, in the rate of viral
transmission. The United States is not near the top of the list. As with
firearms, we are not terribly picky about other "loaded guns." There are
now even condoms on the market with slogans that seem specifically geared
to the African-American population. A teenager can purchase a condom of
uncertain synthetic material, and worse yet, can buy condoms designed to
look like lollipops that guarantee nothing. Big business has moved into
the marketplace with its usual bottom line. The medical bottom line is
unnecessary death.

Disease prevention is not a laughing matter, and yet condoms of all
qualities are sold more freely than tobacco in this country. More
responsible efforts, such as high-quality female condoms are worthy of
some commendation, although unlike the diaphragm, they are fitted far
outside a doctor's office. Overall, the specifications of what is emerging
as a medical necessity are not under the control of those who know the
molecular biology of the problem.

In general, medicine could step in where salespeople now control the
action. Specifically, oncologic problems include a number of disorders
that are infectious in origin and are unknowingly transmitted through
intimate contact. As oncologists, we should be aware of the issues from
the street to the laboratory bench.

Thomas E. Goffman, MD, FACP
Washington, D.C.