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.