Posted by: notdeaddinosaur | July 15, 2008

Is 70% Good Enough?

This is a patient conversation that I have had on many occasions:

Patient: I hear there’s this new vaccine available. Can you tell me about it?

Me: Sure. After a primary series of three shots, it provides 70% protection.

P: That’s it? I have a 70% less chance of getting the disease?

M: That’s right.

P: Does it mean I don’t have to worry as much about watching for it?

M: No. It doesn’t change the recommendations for surveillance at all. You still have to do the same things to screen for the disease.

P: Is the disease dangerous?

M: Well, if you let it go for a long time without doing anything about it, yes, it can be very dangerous. But if you catch it early, as it almost always is, it’s quite easy to treat. Treatment isn’t a picnic, of course; there are side effects with all treatments. But it’s completely curable if caught early.

P: Are there any other things I can do — besides getting the shots — to decrease my chances of getting the disease?

M: Absolutely! There are several recommendations.

P: So let me get this straight: after three expensive, painful shots, I still have to do regular screenings for the disease, which can be completely cured if treated early, and there are other ways to lessen my chances of getting it in the first place?

M: Yep.

P: Hm.

I’ll bet you all thought this was the discussion about the pros and cons of the new HPV vaccine Gardasil. Well, it is, but it’s also the EXACT same conversation about a vaccine few people remember anymore: LymeRx, the vaccine for Lyme disease sold by (then) SmithKlineBeecham. From April of 1999 through the end of 2001, I gave out 40 doses of it. Here’s my timeline:

4/99 – 12/99: 25
All of 2000: 12
All of 2001: 3

I live in an endemic area for Lyme disease. I see it and diagnose it frequently, before, during and after the time I was vaccinating against it. So what happened? SmithKline couldn’t make any money on it, because whenever I had the above conversation with my patients, it usually ended with the patient saying this:

“Given what you’ve just told me about the shot and the disease, I don’t think it’s worth it.”

Despite the abuse we usually heap on patients’ intelligence by complaining about how stupid they are, I think many of them are remarkably resistant to the marketing efforts of the vaccine manufacturers. They read, watch and listen, but then they come in and ask us doctors for our opinion. When couched in the terms above, it turns out — historically — that 70% wasn’t good enough for them; at least not for Lyme disease.

The calculation for Gardasil and HPV is remarkably similar. Once you sit down and explain the relationship between HPV infection and cervical cancer, much of the Gardasil marketing loses its punch; not because cervical cancer isn’t scary enough, but because its actual prevalence in this country doesn’t justify the hype. (Using global HPV incidence and prevalence figures to scare American consumers is like trying to get a kid to finish his dinner by telling him there are starving children in Africa. They’re very quick to pick up on the absence of logic in that one.) It’s so much less sexy to try to sell HPV immunization as “Reduces your chance of an abnormal pap by 70%.” My experience with the Lyme vaccine leads me to believe that Gardasil will probably suffer a similar fate eventually.

So there you have my take on Gardasil. Present patients with the options and let them decide for themselves if 70% is good enough.

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