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Refocusing public narrative necessary to raise ‘alarmingly low’ HPV vaccination rates
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Greater uptake of HPV vaccination should be a priority to reduce the worldwide cancer burden, according to an ASCO policy statement.
The statement aims to increase awareness of the vaccination’s efficacy and refocus the discussion of HPV vaccination on its ability to prevent cancer deaths. Oncology professionals can play a role in increasing vaccination uptake by encouraging accurate public discussion about HPV vaccination, and by addressing barriers to vaccine access and acceptance.
“Our communities, public officials and health care systems should work to move the narrative surrounding the HPV vaccine so that it focuses on cancer prevention, not about other concerns,” Howard H. Bailey, MD, director of University of Wisconsin Carbone Cancer Center, professor at University of Wisconsin School of Medicine and Public Health and co-author of the ASCO statement, told HemOnc Today. “My hope and expectation is that, as cancer providers, we would have some gravitas behind us when we say, ‘Vaccination is a way to lessen the number of people dying of these cancers and to keep these infections from occurring.’”
In 2014, the CDC recommended that all boys and girls aged 11 to 12 years undergo HPV vaccination. Vaccination also is recommended for men through age 21 years and women through age 26 years if they were not vaccinated as children.
Still, only 36% of girls and 14% of boys aged 11 to 13 years have received all three vaccine doses, according to results from the 2011 National Immunization Survey. Rates are even lower for children in high-risk populations, such as those who are Hispanic, black or from lower socioeconomic status.
Overall, the current uptake rate of HPV vaccination is 34.8%, which suggests the Healthy People 2020 goal of 80% vaccination completion for girls aged 13 to 15 years is unlikely to be met.
Bailey and co-authors of the ASCO statement highlight challenges and barriers to HPV vaccination and propose solutions oncologists can undertake to address this issue.
Need for greater uptake
The effects of HPV infection can be devastating.
More than 99% of cervical cancers, 91% of anal cancers, 75% of vaginal cancers, 69% of vulvar cancers, 63% of penile cancers and 60% of oropharyngeal cancers are caused by HPV.
Incidence of cervical cancer — the most common HPV–related cancer and fourth most common cancer in women — has declined steadily over the last 40 years. However, Kish and colleagues conducted a study, published in Journal of Global Oncology, that showed this decline slowed between 2005 and 2009, the most recent years studied.
Incidence of cervical cancer was highest in states with the lowest rates of HPV vaccination coverage (< 33.9%).
HPV–related cancers affect both men and women. Men are three to five times more likely than women to contract HPV–related oropharyngeal cancers, “which emphasizes the importance of HPV infection and eradication as non–sex-specific issues,” Bailey and colleagues wrote.
The ASCO statement follows a call to action issued in January by 69 NCI–designated cancer centers that urged an increase of vaccination to prevent cancer. According to that report, 14 million new HPV infections occur yearly, and 27,000 HPV–related cancers are diagnosed each year in the United States.
“HPV vaccination represents a rare opportunity to prevent many cases of cancer that is tragically underused,” Ernest Hawk, MD, vice president and division head of cancer prevention and population sciences at The University of Texas MD Anderson Cancer Center, said in a press release. “This is one example of actions that can be taken today to make a very big difference in the future cancer burden.”
Increasing three-dose HPV vaccination coverage to 80% could prevent an estimated 53,000 additional cases of cervical cancer, according to a 2012 CDC report.
Burger and colleagues conducted a modeling study, published in April in Cancer, that showed increasing the rate of HPV vaccination to that of Tdap coverage, which is at least 85% across racial and ethnic groups, would reduce the risk for dying of cancer across all groups, thus reducing the cancer disparity gap. For instance, high vaccination coverage led to a 60% reduction in risk for mortality from an HPV–related cancer among men.
“Even as we make advances in therapy, the number of people who we are curing is not going up rapidly,” said Bailey, who specializes in cancer prevention. “But, preventing viral-associative cancers has a big impact and leads to a big jump in the number of lives saved.”
Challenges of vaccination
Greater HPV vaccination uptake is complicated by several obstacles in the United States.
Because the narrative regarding HPV vaccination has focused on sexual behavior associated with infection, rather than vaccination’s efficacy, there have been “misplaced parental attitudes toward and understanding of the vaccine,” Bailey and colleagues wrote.
Parents may feel the young age at which vaccination is recommended promotes sexual promiscuity in their children.
However, the age recommendations are related to clinical data, not sexual activity, Bailey said.
“There are data that suggest whether a boy or girl gets the vaccination at the age of 12 years has no bearing on when they start having sex or how much sexual activity they experience,” he said. “The immunoreactivity response is much greater in an 11-year-old than it is in an 18-year-old.”
In a study published in March in JAMA Pediatrics, Hofstetter and colleagues found greater risk reductions for abnormal cervical cytology when girls received one dose of the quadrivalent HPV vaccine (Gardasil 4, Merck) when aged 11 to 14 years (HR = 0.41, 95% CI, 0.11-0.1.63) compared with those who received one dose when aged 15 to 16 years (HR = 1.45; 95% CI, 0.88-2.37), 17 to 18 years (HR = 1.03; 95% CI, 0.77-1.39), or 19 to 20 years (HR = 1.07, 95% CI, 0.81-1.42).
Cost also remains an issue.
The total cost of all three recommended vaccine doses in the United States is approximately $390. In addition to health care time and staff to administer the vaccine, there is inadequate insurance reimbursement, according to Bailey and colleagues.
Further, public awareness regarding HPV vaccination and cancer prevention remains low.
“This is about preventing incidence of cancer,” Bailey said. “In the State of the Union addresses over the last 10 years, when the presidents mention cancer, they usually reference prevention.”
ASCO recommendations
Improving access and limiting out-of-pocket costs are key to increasing HPV vaccination uptake, according to the statement.
Bailey and colleagues compared the HPV vaccination situation with hepatitis B virus (HBV) — one of the most common cancer-inducing viruses worldwide — vaccination in the 1980s.
Initially, three HBV vaccine doses cost $100. The price eventually fell to 20 cents per dose, likely due to increased advocacy, expired patents and vaccine development outside the United States. The Global Alliance for Vaccine and Immunization estimates that 3.7 million HBV–related deaths have been prevented by vaccine programs created between 2000 and 2011.
“HBV infection and vaccination provide a potential roadmap for wider acceptance, application and corroboration of the likely impact of widespread HPV vaccination,” Bailey and colleagues wrote.
Like with HBV vaccination, programs to help target low- and middle-income countries should be used to improve HPV vaccination rates globally.
“The areas where the vaccination rates are the highest globally are the areas where public officials and health care officials work together to recommend and offer the HPV vaccine in settings outside of the health care system, [such as] school public events,” Bailey said.
HPV vaccination rates are higher in Australia (75%), the United Kingdom (84% to 92%) and Rwanda (93%), according to a press release.
The Affordable Care Act, which covers preventative services, should raise vaccination rates over time in the United States, according to the statement.
Still, education and awareness are necessary for health care professionals, policymakers, patients and the public to show that the cost of cancer far outweighs the cost of vaccination, Bailey said.
“I cannot say that I am overly optimistic that public policy is going to change overnight,” he said. “I expect there is still going to be pushback and it will be politicized more than I would like.”
Oncologists have an opportunity to use their interactions with patients and other health care providers to raise awareness of HPV–related cancers and the safety and efficacy of vaccination.
“We are not the ones who can implement this, but we are the ones who, community by community, can show people how important this is,” Bailey said.
Fostering additional research is another way to improve HPV vaccination uptake. Future studies should assess the relationship of antibody levels and the number of delivered immunizations, the effect of immunization at earlier ages and cost-effectiveness in low-resource areas.
“With safe and effective vaccines readily available, no young person today should have to face the devastating diagnosis of a preventable cancer like cervical cancer,” Julie M. Vose, MD, MBA, FASCO, ASCO president, said in a press release. “But unless we rapidly increase vaccination rates for boys and girls, many of them will. As oncologists, we see the terrible effects of these cancers first hand, and we have to contribute to improving today’s alarmingly low vaccination rates.” – by Nick Andrews
References:
Bailey HH, et al. J Clin Oncol. 2016;doi:10.1200/JCO.2016.67.2014.
Burger EA, et al. Cancer. 2016;doi:10.1002/cncr.30007.
Hofstetter AM, et al. JAMA Pediatr. 2016;doi:10.1001/jamapediatrics.2015.3926.
Kish JK, et al. J Glob Oncol. 2016;doi:10.1200/JGO.2015.001677.
For more information:
Howard H. Bailey, MD, can be reached at hhb@medicine.wisc.edu.
Disclosure: Bailey reports no relevant financial disclosures. Hofstetter reports receiving support for a separate investigator-initiated study from the Pfizer Medical Education Group.
Perspective
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Barbara Burtness, MD
The ASCO statement regarding HPV for cancer prevention is a very welcome call to action: Safe, highly active and available vaccines protect against high-risk HPV types associated with cervical, oropharyngeal, anal and vulvar cancer and genital warts. And yet, vaccination rates are under 40% for girls and young women and under 20% for boys and young men in the United States.Medical professionals and governments should heed this call for education, access and research to optimize the scale of cancer prevention that can be achieved with these vaccines.
As Bailey and colleagues review, HPV–related cancers are prevalent worldwide. With respect to cervical and genital cancers, lower income and less educated patients are disproportionately affected by HPV–associated cancers. This is not the case for HPV–initiated oropharyngeal cancers, which occur at younger median age, are less associated with lower socioeconomic status and less likely to be linked to comorbidities than are tobacco-associated, HPV–negative head and neck cancers. In the United States, oropharynx cancer will shortly overtake cervical cancer as the most common HPV–associated malignancy.
In countries with cancer care capacity, many of these cancers are successfully treated, although not without significant morbidity. In the case of HPV–associated oropharynx cancer in the United States, 5-year cure rates are over 80%, but the majority of cured patients have durable sequelae affecting swallowing, speech or employment.
Many research questions remain, as thoughtfully highlighted in the ASCO statement:
• For those vaccinated in childhood, are boosters required, and on what schedule?;
• Should the nonavalent vaccine be preferred, and should it be given as a supplement to previously vaccinated individuals?; and
• Are alternate HPV types more important in other parts of the world? If so, what are the implications for cancer screening and future vaccination for immigrants living in the United States, and for global health?
In the meantime, lack of awareness about HPV–associated cancers and misconceptions about the behavioral consequences of preadolescent vaccination interfere with the widespread application of what should be a powerful tool to combat these cancers.
If you have young patients, or patients who have preadolescent and adolescent children, talk to them about vaccination.
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