Sociobiology and Cervical Cancer

The April 1995 issue of Oncology featured an article that presentedsound information on the state of viral interactions and cervicalcancer, along with several excellent reviews. Cancer of the uterinecervix is a significant health and emotional problem that canhave devastating effects on the patient's life, personal relationships,and body image. In particular, localized cervical cancer treatmentcan 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 oncologistsneed to address. To condemn such contact is to forget why we arealive and to deny the realities of American life. Meanwhile, medicineappears 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 transmissionof viruses during intimate relations, and current national statisticseven suggest that teenage pregnancies are decreasing--a trendascribed to the use of condoms. Actually, even expensive con-doms are still a most imperfect form of birth control. The 1-yearrisk of unwanted pregnancy with higher quality barrier prophylaxisis the better part of 10%.

Cancer physicians need to know more about the facts of condomuse since, to paraphrase the old adage, "an ounce of preventionis worth pounds of trouble." First and most obviously, condomscan slip, fall off, or rupture. With just one such accident, arange of viruses can be transmitted to the sexual recipient. Industrialproduct testing of condoms' capability to inflate against forceis not necessarily equivalent to the stresses posed by actualuse. To receive FDA approval, a year of testing for such devicesis about the norm, but big business, politics, and bureaucracymake it somewhat difficult for the intelligent doctors of thatagency 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 seriousinflammation (probably due to talc) in women. Also, even withthorough CDC re-review of minority heterosexuals in New York City,a significant proportion of women without other risk factors areturning up HIV positive. Such is the efficacy of many condomsin the complexities of everyday life.

Whether individuals at risk of sexually transmitted viral infectionsare actually using condoms is another important issue. The increasedcost of condoms may be as much a factor in deterring their morewidespread use as is lack of education.

Five hundred thousand new cases of cervical cancer worldwide shouldbe cause for concern by the oncology profession. Health-care practitionerscan only be as effective in preventing this disease as the agentsand devices suggested for prophylaxis. Some believe that barriercontraceptives are an imperfect solution to tremendous cancerproblems. The medical track record with regard to the eliminationof viruses is not terribly strong. In fact new viruses emerge,reemerge, or mutate with alarming frequency. In part, prophylaxiswill be used consistently if it is effective, noninjurious, andsocially acceptable. The next generation depends on it for healthreasons and current generations suffer from the effects of a varietyof "intimate" viruses. An effective polyvalent vaccinecan hardly be described as "just around the corner."

Medicine may want to rethink its unconditional support of barrierprophylaxis. The market has expanded so that whole stores arededicated to condom sales. Does the public know about the complexitiesof these imperfect devices?

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

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

In general, medicine could step in where salespeople now controlthe action. Specifically, oncologic problems include a numberof disorders that are infectious in origin and are unknowinglytransmitted through intimate contact. As oncologists, we shouldbe aware of the issues from the street to the laboratory bench.