Human papillomavirus enigmas and persistent questions

Abstract

Since the 1970s the association between cancer and the human papillomavirus (HPV) has been known. Zur Hausen’s belatedly awarded Nobel prize bears testament to this. We know that HPV is associated with cervical cancer, vulval cancer, anal cancer, vulvovaginal warts, and other non-gynaecological cancers. The place of HPV in the modern management of gynaecology may at first seem clear. Vaccination with the bivalent vaccine against HPV 16 and 18 (Cervarix, GlaxoSmithKline (GSK)) may prevent cervical, vulval and some anal cancers; vaccination with the quadrivalent vaccine (Gardasil, Merck) may prevent those conditions plus warts. The 9-valent vaccine (Gardasil 9, Merck) is currently recommended, as are the other two, by the American College of Obstetricians and Gynaecologists (ACOG).[1] The UK initiated vaccination with the bivalent vaccine and now recommends the quadrivalent vaccine.[2] So far studies have demonstrated a significant decrease in dysplasia and warts, particularly in HPV- naive subjects. Whether these benefits translate to the prevention of cervical and other cancers has not yet been shown, but if one considers the natural history of the progression of dysplasia to cancer, this is quite reasonably presumed.