Dr. Roach: Vaccines don’t always mix with compromised immune systems
Dear Dr. Roach: Your recent column on the shingles vaccine did not address those of us with compromised immune systems. I take Enbrel and could not take the original shingles vaccine. What is the protocol as of now with the new vaccine?
Dear C.H.: Unfortunately, there is still no consensus on giving the shingles vaccine to people with compromised immune systems. Most experts will give the new subunit vaccine Shingrix — it does not contain live virus — to people whose immune systems are only mildly affected, such as people taking low-dose prednisone, say less than 20 mg/day, or low doses of other immune system suppressing drugs like methotrexate or azathioprine. For people with more significant immunosuppressive therapy, like the Enbrel you are taking, or for people with a history of leukemia, lymphoma or stem cell or organ transplant, I can’t make a recommendation.
If possible, the vaccine should be given prior to starting therapy. Unfortunately, that doesn’t help the many people like you, deciding what to do while on immunosuppression. There just aren’t enough data yet to show both effectiveness and safety of the vaccine. Most of the evidence points toward safety, but the temporary increase in immune response due to the components of the vaccine could, in theory, make some conditions worse, such as rheumatoid arthritis or multiple sclerosis. For that reason, individuals need to discuss their particular case with their own doctors as we await the results of studies.
Dear Dr. Roach: At what age does a Pap smear become unnecessary? I’m 71, and my doctors have not done this for a few years now. What exactly is the purpose of this procedure?
Dear C.S.: The Papanicolaou smear is a screening test for cervical cancer. It is recommended for all women age 21 to 65. If a woman 65 or older has never had a Pap smear, she should have one; however, women with regular screening who have been negative may safely discontinue screening at age 65, even if they remain sexually active.
Women who have a history of cervical cancer need to be screened for life, even after surgical removal of the cervix. However, women who have had their cervix removed for a non-cancer reason, such as fibroids of the uterus, no longer need cervical cancer screening.
I feel that women over 65 should continue to have routine gynecological care; however, the Pap smear itself is no longer necessary since cervical cancer is very rare over the age of 65 in women who have had regular screening with normal results throughout their life.
The Pap smear has not been replaced, but rather augmented by newer testing for HPV, the virus that is the underlying cause of cervical cancer. Women may choose to be screened with Pap smears every three years, or for women between 30 and 65, with HPV screening every five years.
The rates of cervical cancer have been decreasing for decades due to screening, as women can be treated before abnormalities can progress to cancer. Moreover, the HPV vaccine for cervical cancer has already made an impact on the incidence of cervical cancer and its precursors in young women, with drops of nearly 30% in the U.S. following release of the vaccine. Australia, with an outstanding program to vaccinate, is on course to “effectively eliminate” cervical cancer.
Readers may email questions to ToYourGoodHealth@med.cornell.edu.