Expert Discusses Updated HPV Vaccine Recommendations

Lois Ramondetta, MD

According to the Centers for Disease Control and Prevention (CDC), incidence rates of HPV-associated cancers continue to rise, with approximately 39,000 new HPV-associated cancers now diagnosed each year in the United States. Although HPV vaccines can prevent the majority of these cancers, vaccination rates remain low.

In response to this, The University of Texas MD Anderson Cancer Center has united with the 68 other National Cancer Institute (NCI)—designated cancer centers in issuing a joint statement that endorses the recently revised vaccination recommendations from the CDC.

The updated guidelines recommend that 11- to 12-year-old boys and girls receive 2 doses of the 9-valent HPV vaccine at least 6 months apart. Adolescents and young adults 15 and older are recommended to continue to complete the 3-dose series.

OncLive: Please begin by summarizing these updated recommendations.

In an interview with OncLive, Lois Ramondetta, MD, professor of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, discusses the updated recommendations and the importance of advocating for lesser-known HPV-associated cancers.Ramondetta: The Advisory Committee on Immunization Practices voted on this in the early fall, and the Morbidity and Mortality Weekly Report came out in December, and it reported that kids who get the series started before age 15 only need 2 doses to have the same effectiveness as someone older than 15 who gets all 3 doses.

What are your thoughts on these updates?

So now, the rule is that you can start as early as age 9 and, again, still as late as age 26 to have it covered by your insurance company, but if you start it even a day before your 15th birthday, you only need 2 shots, and the difference for the 2 shots is that they might be separated by a minimum of 5 months. We recommend 6 months between the first 2 shots, but you could do it even a year apart; perhaps get your first shot at age 10, and the next shot at age 11.I am a gynecologic oncologist, and I work for MD Anderson Cancer Center, but I also work at the Harris Health System, which is a system that takes care of under-insured, sometimes uninsured, individuals, and what I see on a weekly basis are patients with advanced cervical cancer. To me, that’s my sole motivation. It’s terrible to be diagnosed with cancer, but add to that, that it could have been prevented with a shot, by screening, or Pap smears, or you could have even detected it early and then gotten rid of it, and had the patient have essentially a 100% survival rate. I’m seeing ladies come in with very large cancers, and they are losing their lives, or at least a significant quality of life. It’s appalling and sad that it’s happening everywhere in the world, but it definitely should not be happening in a developed country where we have access to everything we need to eradicate this.

On top of that, I’ve been fighting this fight for such a long time, and what we found over the last 10 years is that, the most quickly rising cancer associated with HPV is that of oropharynx cancer, and specifically, the tonsils and back of the tongue. The people who are being diagnosed are men between the ages of 55 and 65. The interesting thing about that is that these are usually insured men, and it’s not necessarily associated as much with smoking and drinking.

Fortunately, there are men out there who are raising awareness about HPV-related disease, and we’re really appreciative of that, because we haven’t been able to get the attention that we wanted. You can imagine talking to a bunch of legislators about uninsured women versus men in that specific age group; that makes their ears go up a little more.

We also know that HPV causes about 90% of anal cancers. All of these issues are things that are helping to raise awareness.

Do you think there’s a widespread lack of awareness about the associations between diseases like anal cancer or oropharynx cancer and HPV?

For my involvement in this, I felt like I had something to offer pediatricians and the family practice doctors by saying, “This is happening. This is not something that only happens to a particular type of person. This is something that 80% of the world will be exposed to at some point in life. We need you to pay attention, we need you to vaccinate, and it’s your job in standard of care to vaccinate and eliminate this disease.”Yes, I do. I think people have only associated HPV with cervical cancer, and perhaps the marketing of the vaccine is partly to blame.

Here’s the tricky part. There’s a precancerous lesion that you can detect in both anal cancer patients and in cervical cancer patients. But at this point, we have not been able to detect precancerous lesions in the throat or tonsils. There may be 1, but it’s so far back, no one has ever found it. So most men who get diagnosed just have a lump in the neck.

Because of that precancerous lesion, they were able to show that you can use the vaccine, and it will prevent not just the infection, but the precancerous lesion too, because you have this endpoint to look for.

In terms of FDA approval, the vaccine is approved for prevention of vulvar, cervical, and anal cancer. Anal cancer is relatively rare, and in fact, we’re having a hard time finding patients with anal cancer who are willing to learn how to be better advocates. That may be because of the rarity of the disease, and maybe also the stigma. Think about Farrah Fawcett; she never told anybody about her anal cancer, and now the Farrah Fawcett Foundation is really involved.

So we have this approval, but we don’t have it for oropharynx cancer, and that might be part of why it doesn’t have as much awareness.

People think, “Well, only girls need to be vaccinated, because it’s all about cervical cancer.” What they need to know is that, by 2020, we expect more cancers in men related to HPV than women. It’s everybody’s problem, it’s a human condition, it’s something we pass to each other, and it’s 8 out of 10 people. It’s not about risky behavior; it’s the same behavior that causes pregnancy. It’s just part of intimacy, and that intimacy could be intercourse, but in many cases, it’s oral sex, or sometimes, sadly, many younger girls experiment with anal sex, because there’s that belief that a person is still a virgin even after that type of intercourse.

How are major cancer centers helping to raise awareness about research findings and best practices in this space?

It’s in the mouth, too; depending on the type of kissing, you could potentially contract the infection in that way. We have the opportunity to prevent all of this, and it’s simply inexcusable that we haven’t eradicated it yet.The CDC and NCI offered a grant to NCI-designated cancer centers to do an environmental scan in their area of facilitators and barriers related to vaccination, and that really got a lot of people motivated. In fact, 18 institutions were given the grant, but there were so many more centers that wanted to be involved. Then this ongoing conversation started, and they ended up having the first summit at Moffitt Cancer Center, where we got together to talk about how we would all be doing this. Then the second one was held at MD Anderson Cancer Center in November 2015, and we presented the results of our scan, and we talked about what we were doing locally. We also talked about what opportunities we had to make a statement, and that’s where the first statement came from.

The third meeting was at The Ohio State University. From there, we said, “Let’s talk about what each center can do locally, not just make a national statement. How can they partner with their state immunization partnership and their state health department?” We’ve been given a bunch of suggestions on how people can do that. And that’s where we are now; the fourth summit is scheduled for South Carolina in May.

This has really motivated a lot of people. For us, when we did our environmental scan of MD Anderson and saw what was happening here, we asked, “Are we even vaccinating our own kids?” We realized we’re not doing it anymore as a community than anyone else in society overall. So we’ve done this kind of 1 year of a large campaign to raise awareness.

Looking ahead, what progress do you hope we’ve made in terms of awareness and getting more people vaccinated?

We also asked people, “Why aren’t you vaccinating?” Convenience factors were definitely part of it. In May of last year, we started an employee vaccination clinic, and we’ve never really done this before, but now, on the second Saturday of every month, we have a clinic at MD Anderson in the morning for employees under the age of 26, or employees’ children. It was really easy because we all accept our employee health insurance. We have had anywhere from 15 to 25 people come once a month, we’re tracking them, putting their information into the state immunization registry, and we’re doing this educational campaign. If we’re going to go out into the community to talk about this, we need to be spokespeople.I think it’s going to be a very exciting 5 to 10 years. Within that time, we’ll definitely see a decrease in cervical cancers, because it takes about 10 years to get a diagnosis once you’re infected.

It’ll be awhile, decades still, before we see a decrease in anal cancer, mostly because it takes to age 65 for the average age of those patients, and probably another decade or so for seeing a decrease in the oropharynx cancer rate.

We’ll also learn how to detect oropharynx cancers better. There are a number of studies looking at ways to look for HPV type 16 in the mouth, and these are being done at many centers. MD Anderson has 1 study called the HOUSTON study, which will look at HPV in the mouth as well as serial scans, so that will be exciting.

I also think we’re going to see so much less dysplasia, because we’ve already seen a 65% decrease in the incidence of HPV infections in the age group that is being vaccinated, even though our vaccination rate is still pretty low. For completing the series of 3 doses, our rates were 42% last year, which is pretty pathetic. We’re somewhere in the 50% range for girls getting 2 shots, and around 29% for boys getting all 3 shots.

In the next decade, we’ll also be moving toward more HPV DNA testing as a primary way to test for cervical cancer. Overall, we’re just going to learn so many other things about it. Because so many people have the infection, we’ll learn which people are at higher risk for developing cancer. I think it’s a really exciting time.

MD Anderson and nation’s cancer centers jointly endorse updated HPV vaccine recommendations [news release]. Houston, TX: University of Texas MD Anderson Cancer Center; January 11, 2017. https://www.eurekalert.org/pub_releases/2017-01/uotm-maa_1011017.php. Accessed January 24, 2017.