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Provider confusion may contribute to poor HPV vaccination of childhood cancer survivors
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Childhood cancer survivors appeared significantly less likely to initiate HPV vaccination than their peers despite having an increased risk for HPV-associated cancers, according to a study published in Journal of Clinical Oncology.
Moreover, only 28% of childhood cancer survivors reported receiving recommendations for the HPV vaccine from their health care providers, according to researchers.
“One potential reason that the rates of HPV vaccination are lower in childhood cancer survivors has to do with a lack of clarity with regard to who is managing this aspect of care,” James L. Klosky, PhD, ABPP, director of psychological services in the cancer survivorship division of St. Jude Children’s Research Hospital, told HemOnc Today. “Primary care providers, who traditionally manage vaccinations, often believe that the oncology/survivorship team are managing the HPV vaccine administration [because] this is a vaccine that’s designed to prevent HPV-related cancers.
“The oncology/survivorship team may believe that the primary care providers are managing the HPV vaccination because, traditionally speaking, they manage all other vaccines,” Klosky added. “So, if we had to guess why the vaccine initiation rate is lower in the survivors relative to the general population, it may have something to do with confusion across providers as to who is responsible for this aspect of patient care.”
HPV is the cause of most cervical cancers and many oral, anal, vaginal, vulvar and penile cancers. An estimated 6.9 million adolescents and young adults in the United States are infected with HPV every year.
The CDC estimates that 90% of sexually active men and women will be infected with HPV in their lifetime. Most clear the infection on their own.
Survivors of childhood cancers are particularly susceptible to HPV infection because cancer treatments often suppress their immune systems. Leading health organizations, including ASCO, recommend that both girls and boys receive the HPV vaccine when aged 9 to 26 years.
Klosky and colleagues described this study as the first and most comprehensive study of HPV vaccination among childhood cancer survivors.
Researchers conducted a cross-section survey of 982 cancer survivors aged 9 to 26 years (median age, 16.3 years; 54.6% male; 65.5% non-Hispanic white) who had completed treatments within the previous 5 years (median, 4.1 years) at five NCI-designated cancer centers.
Median age at diagnosis was 12.2 years, and median time off therapy was 2.7 years. A majority of patients (59%) had leukemia or lymphoma.
The survey queried survivors regarding whether they had received the HPV vaccine, whether their health care provider had recommended the vaccine, and what their attitudes were toward vaccination.
Researchers compared results from survivors with general population data from the National Immunization Survey-Teen and the National Health Interview Survey.
Survivors of childhood cancer reported significantly lower HPV vaccination rates than the general population (23.8% vs. 40.5%; P < .001).
Only 13.5% of childhood cancer survivors completed the three-dose series of HPV vaccinations compared with 20.8% of their healthy peers, suggesting that 86.5% of young cancer survivors may lack protection against vaccine-preventable HPV.
Additionally, 72% of study participants reported that their health care provider did not recommend the HPV vaccine. Among those, only 5% received the vaccination. Of the 28% of study participants whose physicians recommended HPV vaccinations, 51% reported receiving them.
“We know that provider recommendation is a key predictor of HPV vaccination,” Wendy Landier, PhD, CRNP, associate professor at Institute for Cancer Outcomes and Survivorship of University of Alabama, said in a press release. “Because cancer survivors often receive medical care from primary care providers as well as subspecialists, clear communication between health care providers is essential to ensure survivors receive the vaccine that can protect them against HPV-related cancers.”
Perceived lack of health insurance coverage for the HPV vaccine also appeared to be a strong predictor for not getting vaccinated (OR = 7.5; 95% CI, 3.7-15.3) despite the fact the Affordable Care Act mandates that most insurance plans cover preventive services, including vaccines, without a copayment or deductible.
Survivors were at greater risk for vaccine noninitiation if they were male (OR = 2.87; 95% CI, 1.72-4.81); aged younger than 13 years (OR = 3.65; 95% CI, 1.75-7.63); or endorsed other barriers to vaccination, such as lack of transportation, vaccine costs or parental disagreement (OR = 2.69; 95% CI, 1.58-4.58).
Better communication among childhood cancer survivors, their parents and health care providers would help remove some of the barriers associated with the low rate of HPV vaccinations, according to Klosky.
“As a follow-up to this study, we aim to test interventions designed to increase health care provider recommendation for the HPV vaccine as a mechanism to increase the rate of vaccination among survivors of childhood cancer,” Klosky said. “If a patient or family has any questions regarding the HPV vaccine, they should talk to a trusted health care professional.”
Although childhood cancer survivors are living long lives after treatment, their health is more vulnerable, according to Merry-Jennifer Markham, MD, FACP, associate professor of hematology and oncology at University of Florida and an ASCO expert in cancer survivorship, who was not associated with the study.
“It’s concerning that the majority of survivors are not taking full advantage of HPV vaccination, which is widely available and can help them stay cancer free,” Markham said in an ASCO-issued press release. “Oncologists and primary care physicians are trusted resources for young survivors, and while barriers to HPV vaccinations certainly exist, this study suggests that starting a conversation can help break down at least one.” – by Chuck Gormley
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James L. Klosky, PhD, ABPP, can be reached at james.klosky@stjude.org.
Disclosures: The NCI, Merck and the American Lebanese Syrian Associated Charities funded this study. Klosky reports no relevant financial disclosures. Another researcher reports an advisory role with Merck.
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