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.