Current Opinion in Obstetrics & Gynecology:
GYNECOLOGIC CANCER: Edited by Anne O. Rodriguez
Rodriguez, Anne O.
The author says she is no longer affiliated to the University of California Davis
Correspondence to Anne O. Rodriguez, MD, Coastal Communities Cancer Center, Ventura and Santa Barbara, CA 93003, USA. Tel: +1 805 642 4830; fax: +1 805 642 3852; e-mail: Anne.firstname.lastname@example.org
I have been surprised and disappointed at the numbers of young women still presenting with established cervical cancer. Within the last year, my partner and I have seen more than 10 new cervical cancer patients, at least five of whom have been under the age of 35. Theoretically, the reasons for cervical cancer are many, including lack of screening and incomplete screening and follow up. However, a few of the new patients we have seen this year are patients who could have been targeted by the human papilloma virus (HPV) vaccine program but were not. I routinely ask my young patients under 26, and my older patients with children in the age range of 9–26, if they or their family members have been vaccinated for HPV. Overwhelmingly commonly, the answer is no, and often the answer is just a blank stare representing that no one has ever brought it up before. So it has me wondering what is hindering this vital primary prevention from occurring?
The two currently available HPV vaccines, Gardasil: Merck, and Cervarix: Glaxo-SmithKline, were approved by the US Food and Drug administration in 2006 and 2009, respectively, to protect against the two most prevalent oncogenic HPV types 16 and 18, and in the case of Gardasil, to protect also against HPV 6 and 11, which are associated with anogenital warts. The vaccines consist of virus-like particles, capsid proteins with no viral DNA. Because they are identical to the normal HPV virus antigens, they are highly effective in creating a host immune response. Several large randomized clinical trials have shown high efficacy of the vaccines at preventing HPV-related infection and disease, with high degrees of safety [1–3]. The Females United to Unilaterally Reduce Endo/Ectocerical Disease Investigators (FUTURE I) study in 5455 women ages 16–24 demonstrated 100% effectiveness in preventing cervical intraepithelial neoplasia (CIN) 1, 2, 3 and carcinoma in situ (CIS) for the quadrivalent HPV vaccine . The Papilloma Trial against Cancer In young Adults (PATRICIA) study in 18 000 women ages 15–25 demonstrated 92.9% efficacy for the prevention of CIN 2, 3, CIS or cancer for the bivalent HPV vaccine .
Safety monitoring has shown very low rates of adverse events reported, approximately 54 per 100 000 distributed vaccine doses, similar to other vaccines . Additionally, there are other potential benefits to vaccination other than cervical cancer, including possible prevention of anal cancer and oropharyngeal cancer.
The Advisory Committee on Immunization Practices currently recommends vaccination for girls, age 9–26, and as of 2011, also recommends vaccination for boys, age 11–26 . Yet many surveys show that only about half of eligible girls receive even a single dose of the HPV, and fewer still complete the series, with black and Hispanic rates even lower [6,7]. Questionnaires given to parents included the following reasons for not vaccinating their daughters: 19% lack of knowledge of the vaccine, 19% lack of perceived need for the vaccine, 18% belief that their daughter was not sexually active, and 13% clinician not recommending vaccination . It would seem that better clinician provided education and stronger and more consistent recommendation would counter almost all of those reasons for not choosing to vaccinate. An Italian study this year of 987 young women showed that the main sources of information about vaccination in over 18 year olds included magazines, books, and TV (43%) compared with health professionals . A shocking study from India among 150 medical students reported that 50% were unaware of the association between HPV and cervical cancer . Australia instituted a free HPV vaccine school-based program for girls, age 12–17, starting in 2007. Clinics that provided ‘catch-up’ vaccines to women who had not received the free school-based immunization assessed whether or not they had seen a health-care provider recently and whether HPV vaccination had been recommended, and only 37% reported receiving the recommendation .
I would not suggest that it is always easy to discuss and recommend vaccination. Family practitioners and pediatricians often have to build rapport with their adolescent patients, which may be difficult depending on the adolescent's demeanor/receptivity, and may take time . Targeting parents of children in the 9–12-year-old range with comprehensive education and recommendation would be ideal. But healthcare providers who treat the parents of children, adolescents, and young adults could also improve HPV vaccine adoption rates by providing education and strong recommendation, as many studies show that parental influence is paramount .
Smith et al. recently published the recommendations from a national cervical cancer summit called Cervical Cancer-Free America, which brought together over 120 experts to develop a national agenda for reducing cervical cancer morbidity and mortality in the United States. Low use of HPV vaccines was one of four broadly identified challenges to reducing cervical cancer, and of the 12 concrete recommendations they formulated toward the goal of eliminating cervical cancer, five related to the HPV vaccine specifically, including better education of providers, patients and the public, as well as expansion of school-based, and alternative location-based provision of vaccine.
We have the opportunity to reduce cervical cancer and cervical dysplasia by great proportions, and if future vaccines with greater strain cross-reactivity are developed, possibly eliminate these diseases entirely. We must not lose our momentum.
Conflicts of interest
The author has no conflicts of interest to declare.
1. Garland SM, Hernandez-Avila M, Wheeler CM, et al. Females United to Unilaterally Reduce Endo/Ectocerical Disease (FUTURE I) Investigators. Quadrivalent vaccine against human papillomavirus to prevent anogenital disease. N Engl J Med. 2007; 356:1928–1943.
2. Paavonen J, Naud P, Salmeron J, et al. HPV PATRICIA Study Group. Efficacy of human papiloomavirus (HPV)-16/18 ASO-4 adjuvanted vaccine against cervical infection and precancer caused by oncogenic HPV types (PATRICIA): final analysis of a double-blind, randomized study in young women. Lancet. 2009; 374:301–314.
3. FUTURE II Study Group Quadrivalent vaccine against human papilloma virus to prevent high-grade cervical lesions. N Engl J Med. 2007; 356:1915–1927.
4. Jin Xian W, Lipold L, Sikon A, Rome E. Human papillomavirus vaccine: safe effective, underused. Cleve Clin J Med. 2013; 80:49–60.
6. Dorell CG, Yankey D, Santibanez TA, Markowitz LE. Human papillomavirus vaccination series initiation and completion, 2008–2009. Pediatrics. 2011; 128:830–839.
7. Centers for Disease Control and Prevention (CDC) National and State Vaccination Coverage Among Adolescents Aged 13-17 years-United States, 2012. MMWR Morb Mortal Wkly Rep. 2013; 62:685–693.
8. LaTorre G, DeVito E, Ficarra MG, et al. HPV Collaborative Group Is there a lack of information on HPV vaccination given by health professionals to young women? Vaccine. 2013; 31:4710–4713.
9. 2013; Mehta S, Rajaram S, Goel G, Goel N. Indian J Community Med. 38:92–94.
10. Weisberg E, Bateson D, McCaffery K, Skinner SR. HPV vaccination catch up program: utilisation by young Australian women. Aust Fam Phys. 2009; 38:72–76.
11. Sussman AL, Helitzer D, Sanders M, et al. HPV and cervical cancer prevention counseling with younger adolescents: implications for primary care. Ann Fam Med. 2007; 5:298–304.
12. Mullins TL, Griffioen AM, Glynn S, et al. Human papillomavirus vaccine communication: perspectives of 11-12 year-old girls, mothers, and clinicians. Vaccine. 2013; 31:4894–4901.
13. Smith JS, Brewer NT, Saslow D. Recommendations for a national agenda to substantially reduce cervical cancer. Cancer Causes Control. 2013; 24:1583–1593.