Opposition to HPV Vaccine Misguided

To the Editor: In the June 2007 issue, Dr Sarah Pressman Lovinger's article and Group Editor Dalia Buffery's column draw attention to the recent controversy regarding the Gardasil vaccine, which culminated in the Texas state legislature rescinding Governor Rick Perry's heroic executive order mandating the vaccine in public schools. Both writers highlight certain developments that merit further explication. A recent JAMA study (2007;297:813-819), citing an overall low prevalence of the high-risk human papillomavirus (HPV) strains 16 and 18, has been used as ammunition against the impact Gardasil will have. What people fail to mention is that point prevalence of HPV strains may not be reflective of past infection that may have already cleared. Furthermore, the fact that HPV strains 16 and 18 account for 90% of cervical cancer cases, despite their low prevalence, is reason enough to champion this vaccine. All proposed mandates allow exemptions for parents who do not wish their child to be vaccinated; the chief opposition to this vaccine is not scientifically based, but is faith based. Gardasil is a path-breaking vaccine, whose introduction is an unmitigated good. Opposition to it is reminiscent of the Catholic Church's opposition to condoms for the prevention of HIV.

—Amesh Adalja, MD
Butler, Pa

The True Concept of Ordering Tests

To Dr Alper: Your June article "It's the Money…" re-emphasized (though perhaps not as intensely as I would have) the true concept of ordering tests—they merely increase or decrease the pretest probability of disease. The second part of ordering tests is what to do with the information provided. Would it have altered the management outcome? The third aspect of ordering tests involves test reconciliation. So many physicians (and patients) still hold onto the concept that no news is good (or bad) news, when in fact, no news is no news. Our practice is one of immediate action and notification to the patient of the test results. I do not believe in the so-called minimalist approach, when it comes to ordering tests. There is really no such concept. One orders tests when appropriate, that is, when the pretest probability is intermediate, the likelihood ratio of the test is high, and the outcome changes the management.

I cringe when the house staff orders "routine" or "baseline" tests, or says, "We'll order everything and see what we find," also known as the "Dr House approach" to expensive medicine.

—Sam Wong, MD, FACP