Protect Your Children with the HPV Vaccine

by Dr. Lindsay Kuroki

Parents grow up wanting their kids to be healthy and happy. And taking control of your child’s health may be easier than you think with evolving research. We know that with healthy eating, encouraging exercise, staying safe in the sun, and getting scheduled vaccinations your child is on the right path to having a lower cancer risk later in life.

What’s even better news is that within the past decade, a specific vaccine has also been created to protect against at least five different types of cancers. This vaccine, the Human Papillomavirus (HPV) vaccine, is now recommended for all girls and boys during their annual check-ups. 

HPV is a common sexually transmitted infection with over 100 different types of strands in existence. In fact, HPV is so common that an estimated nine out of 10 sexually active people will at some point be infected with HPV. Often times, HPV does not present with symptoms, which makes it hard to know when someone may be infected. For this reason, it is important to protect your child against HPV, as some forms of HPV can cause multiple cancers. At least two strands of the HPV virus have been shown to cause cervical, vagina, and vulva cancers in women, penile cancer in men, and head and neck cancer in both men and women. HPV can live for a long time in a person’s body, so someone may not know they have HPV, or an associated cancer, until years after being intimate with someone who carried the HPV virus. Sadly, HPV contributes to over 31,000 new cases of cancer each year, but we can reduce that number by protecting our children with the HPV vaccine.

Unfortunately, nationwide only 65 percent of girls initiate the HPV vaccination series and 49 percent receive the two recommended doses, while only 56 percent of boys initiate and 37 percent complete the series.

The good news is now the HPV vaccine is available for boys and girls to protect thems before they become sexually active. It’s also safe and over 90 percent effective. This success rate could prevent over 90 percent of HPV cases, or eliminate 29,000 new cancer diagnoses each year.

The Centers for Disease Control and Prevention (CDC) recommends that both girls and boys be vaccinated with a two-shot vaccine around ages 11 – 12. The second vaccine will be administered within one year after the first dose. The vaccine can be given until age 26, and being vaccinated after exposure to HPV will help reduce their risk of contracting future HPV infections. Adolescents and young adults, starting at age 15, who receive the HPV vaccine will require a three-dose vaccination series.

Protect your family against cancer, as it’s never too early to reduce your child’s risk. Talk with your pediatrician to schedule your child’s HPV vaccination.

Benefits of the HPV Vaccine for Girls and Boys

Only two doses now needed for most youth, instead of three

By Katy Henke

HPV, or human papillomavirus, is an increasingly popular health topic these days. Not only are there news stories about HPV and the HPV vaccine just about every week, but there's a push across nearly all levels of healthcare -- from federal agencies to local healthcare providers -- to encourage parents to vaccinate their children against the cancer-causing virus. And for good reason. The Centers for Disease Control and Prevention (CDC) estimates that almost all adults in the United States will have an HPV infection at some point in their lives. 

Most of these infections will clear on their own, but some can persist. And the CDC reports that over 90% of cervical cancer and anal cancer cases are caused by HPV, as are 60% of penile cancers and 70% of head and neck cancers.  It is a much broader list than many people may understand (see table).

But it's not all doom and gloom.  In fact, the fight against HPV-related cancers is one of the bright spots in cancer prevention, with huge potential for benefit. Since 2011, both girls and boys have been able to receive the HPV vaccine, which protects against HPV and reduces the risk of developing future cancers. What used to be a three-dose vaccine is now an easier two-dose vaccine. 

Boys and girls ages 11-12 should receive the two doses six months apart to be most effective. HPV is a sexually transmitted disease, and often times doesn’t have any symptoms, so it’s important to take preventative measures before your child becomes sexual active.  

Older teenagers and young adults (up to 26 years of age) can also benefit from the HPV vaccine. Specific recommendations can vary based on age, gender, and other factors. So, it's important to see a healthcare provider for details.

The HPV vaccine is a safe and great way to prevent cancer later in life. And most insurance plans cover it. For more information, visit the CDC’s HPV website.

HPV vaccination is a simple step to help protect our future generations.

---

Back to School Vaccinations: Don't Forget the HPV Vaccine

by Katy Henke

With Labor Day weekend bringing summer vacation to a close, parents are putting the finishing touches on preparation for the impending school year. In addition to school supplies and new clothing, parents should also be vaccinating their children prior to school starting. Vaccinations help prevent possible future infections and diseases. Prevention through vaccines is one of the best ways to help your child stay healthy during their lifetime and is recommended by multiple health organizations, such as the Centers for Disease Control and Prevention, the World Health Organization, and the National Cancer Institute.

Some of the more common vaccines parents may have heard of, and that some schools in the United States require, include Tdap, which protects against diphtheria and tetanus; IPV, which protects against polio; and MMR, which protects against measles, mumps, and rubella. These diseases have decreased in children and young adults throughout the years thanks to the use of vaccines. Influenza (flu) is another common virus that can help be reduced and infection prevented when children, teens, and adults receive the flu vaccine. Research continues to show that vaccines are important, safe, and effective for children and teens, and should be administered at appropriate ages. The CDC offers a quick vaccine guide for parents based on a child’s age.

A more recent vaccine, and one that’s often overlooked by many parents and doctors, is the human papillomavirus (HPV) vaccine. This vaccine protects against a specific strand of viruses that can cause cancer. The HPV virus affects one in four people. It’s estimated that 14 million people each year contract the HPV virus, which can lead to cervical and vaginal cancer in women, and penile cancer in men. More than 90 percent of sexually active men and 80 percent of sexually active women will contract a form of HPV at some point in their lives. Most HPV infections do go away on their own, but some don’t. The HPV vaccine helps protect and reduce these infection rates

The HPV vaccine series is recommended to both preteen boys and girls beginning around age 11 or 12, prior to when they would contract the HPV virus. This vaccine is a three-part series for both girls and boys, with the second shot given at one to two months after the first shot, and the final third shot given around six months after the first shot. Teenagers and young adults can also receive the vaccine up until age 26, so talk with your doctor today. The HPV vaccine will be most effective when the person being vaccinated receives all three shots.

Research continues to show that the HPV vaccine should very successfully prevent later adult cancers in preteens and young adults. Close to 100 percent of people who receive the vaccine will be protected against the types of HPV targeted by the vaccine. And studies have found that vaccination cuts the risk of cervical pre-cancer in about half.

The HPV vaccine is a safe and effective way to reduce the risk of cancer, yet vaccination rates are still low due in part to lack of knowledge and other barriers. Talk with your child’s doctor or your doctor today to learn if the HPV vaccine may help reduce their risk for cancer in the future.

Making Strides Against Cervical Cancer While Reducing Burden - HPV Vaccination and HPV Testing

By Sydney Philpott

Human papillomavirus (HPV) is a very common sexually transmitted infection. According to the World Health Organization (WHO), most sexually active women and men will have an HPV infection at some point in their lives. While HPV infections usually go away on their own, certain types persist and then serve as the primary cause of cervical cancer. Globally, HPV leads to about 600,000 new cases of cervical and genitourinary cancer each year, with about 26,900 cases in the United States alone.

In 2006, HPV vaccination became available worldwide and was recommended by the WHO and the Centers for Disease Control and Prevention (CDC) for girls age 9-26 and recommended for boys of the same age group in 2011. After just 5-6 years, studies in the United States found that HPV infections in girls age 14-19 dropped 64 percent, risk of cervical pre-cancer was lowered by 47 percent, and there was a 61 percent reduction in treatment for genital warts (infographic). The WHO estimates that two-thirds of new cases of cervical cancer could be prevented if 80 percent of those age-eligible were vaccinated worldwide.

Despite these improvements, vaccination rates in the United States have remained low. On average, only 60 percent of girls age 13-17 initiate the HPV vaccination series and 39.7 percent receive all three recommended doses, while only 41.7 percent of boys initiate and 21.6 percent complete the series. Additionally, there are clear racial and socioeconomic disparities for vaccination in the United States – but these often move in a direction opposite from many health behaviors. Among adolescent girls age 13-17 in 2014, 66 percent of blacks and Hispanics had at least one dose of the HPV vaccine, while 56 percent of whites did. Similarly, 67 percent of those below the poverty line started the series, while only 58 percent above did.

These numbers, though, change a bit when looking at the percentage of girls completing the full three-dose series once they start it, suggesting that efforts that drive initiation of the vaccine fall off in certain groups when it comes to completing the entire series. Of girls who started the series, 68 percent of those living below the poverty level and 69 percent of those living above went on to complete the 3 doses – nearly identical numbers. Similarly, over 70 percent of Hispanics and whites completed the series once they started, whereas only 62 percent of blacks did.

While the relatively high vaccination initiation rate in African Americans is heartening, it's also important to ensure that as many girls as possible get subsequent doses so they are as protected as possible in the future. Currently, African American women are more likely to be diagnosed with cervical cancer at later disease stages and die at almost twice the rate compared with non-Hispanic white women. Improving rates of HPV vaccination and completion across all groups can help narrow such cancer disparities.

Furthermore, recent systematic reviews examining efforts to increase HPV vaccination use in the U.S. have conflicting conclusions, and the relative success of these interventions fell short of national averages and stated vaccination goals.

Compared to the United States, other countries have had considerably more success achieving high HPV vaccination rates. Through implementation of school-based vaccination programs, Scotland reported 81 percent three-dose vaccination in 2011, England reported 76 percent in 2010 and Australia 73 percent in 2014. In 2013, the United States reported that only 37.6 percent of adolescent girls age 13-17 had all three vaccine doses.

These discrepancies may be due to the three-dose requirement remaining a substantial barrier to successful HPV vaccination in the United States. However, recent evidence indicates that fewer than three doses may be protective. Brotherton et al. found that less than three doses provides some protection against cervical disease in Australian women, even when measured within 5 years in a population including those who were sexually active at the time of vaccination. Therefore, adolescents in the United States, and other regions with low vaccination rates, may benefit from even partial vaccination. Updated recommendations for less than three doses could also lead to reduced costs for developing countries as well as broader uptake and access to vaccination. In the United States, nearly half of girls age 13-17 have received two doses of the HPV vaccine.

The ability to also test women for HPV is changing the approach to screening for cervical cancer, especially as more and more women are being vaccinated against HPV.

Since HPV is the direct cause of nearly all cervical cancers, women who are found to have HPV can be followed more closely to see if they clear the infection, or if they have or develop cancer or pre-cancer.

In the United States, the HPV test is most often recommended along with a standard Pap test in women 30 and older. This is called co-testing. In 2014, however, the FDA approved the stand-alone HPV test as a method of cervical cancer screening, and certain professional organizations now strongly suggest that the HPV test can be used on its own as an effective alternative to standard Pap tests in most women being screened for cervical cancer.

In Australia, the National Cervical Screening Program will implement a switch in 2017 from Pap testing every two years for those age 18-69, to HPV screening alone every five years for those between the ages of 25-74. This screening transition is expected to continue to reduce cervical cancer mortality while vastly reducing the burden on women.

Fewer numbers of doctor visits and stressful, time-consuming follow-ups for positive screening tests will be a major saving for women. Improving our ways of summarizing such benefits of HPV vaccination across life from 18 to 69 could help frame vaccination as a benefit to women far beyond just reducing cervical cancer incidence.

Benefits TODAY from the HPV Vaccine (Infographic)

While the ultimate goal of the HPV vaccine is to prevent cancer, that benefit can feel very far off in the future, especially since vaccination ideally takes place in eleven and twelve-year-old girls and boys.  But studies looking at the five to six years after the vaccine was approved and became widely available show that it has real - and it seems impressively big - benefits over the short term.  For more details on the HPV vaccine and recommended vaccination schedule, visit the CDC's HPV page.

(PDF version)

Big Drop in Cancer-Causing HPV Following Vaccination, But Rates of Vaccination in US Lag

by Hank Dart

Thirteen years ago, in an earlier incarnation of Cancer News in Context, we wrote our very first post about the potential of the HPV vaccine following the release of a promising study in the New England Journal of Medicine. That post - "A Shot in the Arm for Cervical Cancer Prevention" -  concluded:

"While much work remains before there is any sort of widespread cervical cancer vaccination program in the U.S. or abroad, the results of this initial study spawn a realistic hope that over the next decade or so great strides will be made in preventing cervical cancer the world over."

Well here we are, that decade or so on from the original post, and the latest news on the HPV vaccine - as reported in today's New York Times - is quite positive, but with a number of important caveats.

HPV (human papillomavirus) is a common sexually transmitted infection, and certain types of HPV are a primary cause of cervical cancer. It's estimated that nearly all adults - men and women - are infected with HPV at some point in their lives. While the body naturally clears most of these infections, some can persist, increasing the risk of cervical (and a number of other) cancers.

New national data, as reported in the Times and published in the journal Pediatrics today, show that in the six years after 2006, when the HPV vaccine became available for girls, rates of infection with four main cancer-causing types of HPV(6, 11, 16, and 18) have dropped dramatically - as much as 64 percent in younger females (age 14 - 19), the age group that had been the most widely vaccinated.

Though only time, and data, will tell for sure, such findings seem likely to translate to significantly lower future rates of cervical cancer in today's groups of vaccinated girls and young women.

Alongside such positive news, however, is the fact that the HPV vaccine remains frustratingly underused in the United States.  As we wrote about in 2014, vaccination rates for the HPV vaccine are much below those of other childhood vaccines.  The most recent numbers show that only 38 percent of girls in the United States receive the complete 3-shot series of the HPV vaccine.  Boys' numbers are even lower - at 14 percent.  And low as these are, they are modest improvements from pervious years.

In comparison, in Australia, where the vaccine is offered for free at schools as part of its national immunization program, rates of full 3-dose HPV vaccination in girls is over 70 percent by age 15.

No such integration into systems has happened in the United States, and HPV vaccination remains in many ways on the fringe.  Though it has huge potential to prevent cervical cancer - as well as to lower the risk of anal, throat, and penis cancers, as well as genital warts - many physicians aren't proactive in suggesting vaccination, many parents don't know to request it,  and both groups may not be perfectly clear on its safety, effectiveness, and ultimate purpose of preventing cancer.

Clearly, there has been a lot of progress since our post in 2003 but perhaps not surprisingly it has been at a pace slower than hoped.  To be sure, there have been some "great strides" in further developing the vaccine, in documenting its safety and effectiveness, and - in certain countries - developing model vaccination programs.

But there is still a great deal of work to do before we tap the HPV vaccine's full potential in the United States - as well as worldwide.  This latest study shows the likely benefits of developing a better-integrated HPV vaccination program.  Let's use it to spur on coordinated efforts toward that important end.

Screening for Cervical Cancer: Is the HPV Test a Good Alternative to the Pap Test?

By Sarah Cortez

New guidelines from two professional medical organizations strongly suggest that the HPV (human

Pap test micrograph. Photo: Flickr/euthman

papilloma virus) test can be used on its own as an effective alternative to standard Pap tests in most women being screened for cervical cancer.

For seventy years, the Pap test has been the standard tool used to screen for cervical cancer. And it’s been one of cancer’s great success stories, with rates of new cases and deaths from cervical cancer dropping significantly both in the United States and abroad since it was first introduced. The Pap test finds abnormalities in the cells of the cervix that may be cancer or pre-cancer. These abnormalities can then be treated or followed closely over time.

The HPV test has been used alongside the Pap test for a number of years but was only recently approved by the FDA as a stand-alone test that could be used by itself, in place of the Pap test or Pap test plus HPV test combination.

As we’ve written about here on Cancer News in Context,  HPV causes the vast majority of cervical cancers. It is acquired through sexual contact and is actually very common. Over 75 percent of sexually active adults will get HPV at some point in their lives. Most healthy individuals successfully fight off the virus, but in some cases the virus lingers for years causing cervical changes that can ultimately lead to cervical cancer. So for the same reason that the HPV vaccine has the potential to prevent cervical cancer, an HPV test can help identify who is not clearing the virus and has the potential to develop cervical cancer.

The new guidelines from the Society of Gynecologic Oncology (SGO) and the American Society for Colposcopy and Cervical Pathology (ASCCP) appear in the journal Gynecology Oncology and state that, starting at age 25, doctors could use the HPV test as an alternative to the Pap test for cervical cancer screening.

Panel members from the ASCCP, SGO, as well as numerous other societies, reviewed eleven recent papers about the HPV test to answer the question: Is HPV testing by itself a safe, effective alternative to Pap testing?

They concluded that the HPV test is more accurate at ruling-out cervical cancer than the Pap test, meaning the HPV test is very good at telling when you don’t have cancer or pre-cancer.

They also concluded that it is just as good as a Pap test at finding those women with cancer or pre-cancer. However, the HPV test is also more prone to false positive screens – telling women there may be a problem when there isn’t one. As we stated before, most sexually active women acquire HPV at some point, but it usually goes away on its own. Since the HPV test simply detects HPV, it can identify women who have HPV but who do not have pre-cancer or cancer. As you can imagine, a false positive can cause a lot of anxiety as well as the need for extra testing to determine that the woman does not have pre-cancer or cancer.

So how does the panel recommend we manage women who are found by the test to have HPV? For these women, the panel states that the next step is to determine the specific type of HPV they are carrying. Two known types of HPV are much higher risk than others. These are HPV 16 and HPV 18, and they are responsible for over 70 percent of all cervical cancers.

• If you have an HPV type that is not HPV 16 or 18, then you are followed up with a standard Pap test. 

• If you do have HPV 16 or 18, then you are followed up with a colposcopy, which is the standard test after an abnormal Pap test. In a colposcopy, a doctor looks at the cervix with a special light and takes a tissue sample if something looks abnormal.

The panel found that using this screening approach increased the number of pre-cancers detected by 54 percent, but at the cost of doubling (200 percent) the number of colposcopies performed on women. This is a large increase in follow up colposcopies, and we do not know if the extra pre-cancers detected by HPV screening would have actually become cancerous.

Are there arguments against using the HPV test by itself to screen for cervical cancer? 

In short: yes.  Not all physicians or professional organizations endorse the new guidelines. At this point, the American College of Obstetricians and Gynecologist does not support the use of the HPV test as a main screening tool because they feel it will yield too many false positives - and bringing with them increased anxiety and follow up tests. Some physicians also worry that the HPV test could miss those rare cases of cervical cancer that may not be caused by HPV.

Even those not convinced that the HPV test should currently be used as an alternative to the Pap test, see its future potential.  Dr. Stewart Massad, Washington University Gynecologic Oncologist, sees a potential benefit in using the HPV test in those women who have previously received the HPV vaccine.

“Benefits of primary HPV screening will probably be greatest for young women who were vaccinated against HPV prior to initiating sexual activity. These vaccinated women have a much lower risk of infection with high risk HPV types, so they should require many fewer colposcopies, biopsies, and treatments.”

The panel concludes that while screening with the HPV test is an acceptable option to the standard Pap test, screening with the Pap test is also perfectly fine.

Cervical cancer is a serious disease that kills more than 4,000 women every year. Studies will continue to look at the long-term impact of the HPV test on cervical cancer diagnoses and outcomes. As these details continue to be worked out and discussed, what remains most important is that women see their gynecologists, get screened regularly for cervical cancer (see current ACS recommendations below), and vaccinate their adolescent children (both boys and girls) against HPV.  If you have questions about cervical cancer screening or HPV, your doctor is always the best source of information.


American Cancer Society - Cervical Cancer Screening Guidelines
Source: American Cancer Society Guidelines for the Early Detection of Cancer

Cervical cancer screening (testing) should begin at age 21. Women under age 21 should not be tested.

• Women between ages 21 and 29 should have a Pap test every 3 years. HPV testing should not be used in this age group unless it is needed after an abnormal Pap test result.

• Women between the ages of 30 and 65 should have a Pap test plus an HPV test (called “co-testing”) every 5 years. This is the preferred approach, but it is also OK to have a Pap test alone every 3 years.

• Women over age 65 who have had regular cervical cancer testing with normal results should not be tested for cervical cancer. Once testing is stopped, it should not be started again. Women with a history of a serious cervical pre-cancer should continue to be tested for at least 20 years after that diagnosis, even if testing continues past age 65.

• A woman who has had her uterus removed (and also her cervix) for reasons not related to cervical cancer and who has no history of cervical cancer or serious pre-cancer should not be tested.

• A woman who has been vaccinated against HPV should still follow the screening recommendations for her age group.

Some women – because of their health history (HIV infection, organ transplant, or DES exposure, etc.) – may need to have a different screening schedule for cervical cancer. Talk to your doctor or nurse about your history.

More CNiC posts on HPV

References

Huh WK, et al. Use of primary high-risk human papillomavirus testing for cervical cancer screening: Interim clinical guidance. Gynecol Oncol (2015)

Frumovitz, M. Invasive cervical cancer: Epidemiology, risk factors, clinical manifestations, and diagnosis. UpToDate (2014).