Close up of cancer cells in the cervix. Cancer of the uterine cervix, the portion of the uterus that is attached to the top of the vagina. (Photo by American Cancer Society/Getty Images)

Israel Bucks Regional Trend of High Cervical Cancer Mortality

Country has a lower rate than many others in the region, particularly North Africa

Cervical cancer as a result of the human papillomavirus virus (HPV) is a leading cause of death among women in the Middle East and North Africa, according to the Non-communicable Disease Alliance (NDA), a Switzerland-based nongovernmental organization that provides policy initiatives to address such diseases.

Cervical cancer is the third deadliest cancer in Morocco, according to data the NDA cited from the World Health Organization (WHO)’s International Agency for Research on Cancer. In Afghanistan and Libya, cervical cancer is the 10th most prolific terminal cancer.

Based on mortality rates adjusted for the distribution of ages in the population, cervical cancer is also one of the top 10 deadliest cancers in Oman, Bahrain, the United Arab Emirates and Tunisia.

The high mortality rates have created an urgent push to provide HPV vaccinations to girls, and more recently to boys. Vaccinations might prevent certain stains of cervical cancer and other diseases, but most places lack the infrastructure to administer them.

However, neither the high rate of cervical cancer deaths nor the institutional problems preventing administration of the vaccine pertain to Israel.

Dr. Diana Flescher, an internist whose subspecialty is women’s health, told The Media Line that, “Cervical cancer is not the leading cause of death in Israel; it’s not even in the top 10.”

Dr. Uzi Beller, professor of gynecology at the Hebrew University of Jerusalem, told The Media Line that Israel has “one of the lowest [rates of cervical cancer] in the world,” with approximately 200 cases each year.
Still, no one knows why Israel’s cervical cancer rate is low.

“At some point there was a theory related to circumcision, but that was probably not the case,” Beller said. “It may have to do with sexual habits.”

Data provided to The Media Line by Israel’s Health Ministry indicate that while Arabs and Jews both have a low incidence of cervical cancer, Arabs have it less often than Jews. The latest available figures, from 2016, indicate that the age-standardized rate (ASR) of incidence per 100,000 population was 2.9, while the ASR among Jews was 5. ASR is a way to more evenly compare populations, as it is adjusts for age distribution.

In the US, according to the American Cancer Society, the ASR between 2011 and 2015 was 7.6.

HPV vaccinations are institutionalized in Israel’s school system. The vaccine, given in two doses, is available to all eighth graders with Israeli citizenship. The program has continued to expand since it began during the 2013-2014 school year, initially inoculating only girls. In a statement provided to The Media Line the Health Ministry said, “Beginning this year, eighth graders will receive the vaccine containing nine strains of human papillomavirus; until now they received the vaccine which contains four strains.”

According to the ministry’s Department of Public Health Nursing, during the 2017-2018 school year, 54.7 percent of the students received the first dose of the vaccinations, and 48% received the second.
Dr. Flescher finds the gap in coverage noteworthy.

“If it’s a school-based vaccine, then I would not expect the rates of the second dose to be lower than the first, unless the parents or the children themselves decided they would not go forward with the vaccine due to adverse reactions or because they changed their mind,” she told The Media Line.

In the US in 2016, according to the Centers for Disease Control and Prevention, 65% of girls and 56% of boys received the first dose of the HPV vaccination, and 50% of girls and 38% of boys received all the doses of the vaccine. In October of that year, the CDC changed its recommendation from three doses to two.

The HPV vaccination is controversial because it might prevent a disease that is acquired through sexual activity.

Vaccination rates subsequently vary within the sectors of Israeli society. Secular Jews have a higher vaccination rate than religious ones, who according to Flescher, want to at least delay implementation.

“There was resistance in the religious community to the vaccine when it first came out, because it is considered to be a sexually transmitted virus. Most exposure occurs when you start sexual activity.
“They are saying,” Flescher continued, “why would we vaccinate a girl at the age of 13 when she is not going to start being sexually active at the age of 15 or 16, like many people are in the secular world.”

Flescher said that the religious community questioned the necessity for the vaccine, given the fact many of the religious married once and as virgins, and are thus were unlikely to get HPV.

“[They think:] why are we giving a vaccination to a couple with no previous sexual experience?” Flescher said.

In addition, according to Dr. Sharon Galper Grossman, a lecturer on women’s health and Halacha (Jewish law) at the Israel-based Matan Women’s Institute for Torah Studies and the Eden Center, a non-profit organization that tries to enhance the mikveh (ritual bath) experience for women, parents are sometimes under the erroneous impression that getting the vaccine will promote pre-marital sex.

“Parents may be uncomfortable with the vaccine since one effect of the vaccine… could lead to discussions regarding promiscuity,” she told The Media Line. “There is no evidence that the vaccine increases promiscuity among those who are vaccinated.”

Jews do not have the highest coverage rate among the Israeli population.

“The compliance rate is higher in the Arab population with vaccines and the HPV vaccine than in the Jewish population,” Baruch Velan, vaccination compliance researcher at the Gertner Institute for Health Policy and Epidemiology in Tel Hashomer, told The Media Line.

“The [Arab HPV vaccination rate] surprised me. You would think that they would be more reluctant to get inoculated, but they were not,” he said. Velan attributes this to cultural factors.
“They tend to be more compliant with the recommendations of the doctor.”

The effectiveness of HPV vaccines is still contested. Studies indicate that while the vaccine significantly decreases the incidence of pre-invasive cervical cancer (cancer that has not penetrated beyond the surface of the cervix), doctors do not yet know the vaccine’s impact on invasive cancer, which according to the Hebrew University’s Dr. Beller will take time and coverage rates of 70% to 80% of the population.

“We still don’t have strong evidence that the vaccine has done something to decrease cancer rates. I know many people want to hear that it does, but if you want to be honest, there is none,” he said.

This is one of the reasons Dr. Flescher does not recommend giving the vaccine to her patients. She believes that the Health Ministry does not use its budget effectively to lower cervical cancer rates, for which she recommends regular Pap smears.

“The Ministry of Health has invested millions of shekels in a vaccine that still has not shown it can prevent cervical cancer, and they wouldn’t spend any money on the mothers of these girls reminding them to get a Pap smear.

“I still have women who come to my clinic who have never had a Pap smear or haven’t had a Pap smear in 10 years, and these are the women that are going to die each year of cervical cancer,” Flescher said.

The Matan Institute and Eden Center’s Galper Grossman, who recommends the vaccine, contended that although there was not yet evidence that the vaccine prevented invasive cervical cancer, the research appeared to be going in that direction. “All the evidence in the scientific community suggests that the vaccine will significantly reduce the incidence of invasive cervical cancer,” she said.

“The question is what do we do until we get the data,” Galper Grossman said. “Given that the vaccine is effective before one is exposed to strains of the disease, we can wait [which might be too late], or we can administer the vaccine now assuming based on the evidence we have so far that the vaccine will lead to a reduction in cervical cancer.”

(Tara Kavaler is an intern in The Media Line’s Press and Policy Studies)

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