In an unprecedented move, 69 NCI-designated cancer centers have come together to advocate for HPV vaccination as a preventive measure against many HPV-related cancers.
“HPV vaccination is our best defense in stopping HPV infection in our youth and preventing HPV-related cancers in our communities,” the centers said in a consensus statement published Jan. 27. “The HPV vaccine is cancer prevention.”
According to a 2015 CDC report, only 40 percent of girls and 21 percent of boys in the U.S. are receiving the recommended three doses of the human papillomavirus vaccine. This falls far short of the HHS goal of 80 percent by the end of this decade. The goal is a part of the HHS Healthy People 2020 mission.
“Together we, the NCI-designated cancer centers, recognize these low rates of HPV-vaccination as a serious public health threat,” the cancer centers said. “HPV vaccination represents a rare opportunity to prevent many cases of cancer that is tragically underused. As national leaders in cancer research and clinical care, we are compelled to jointly issue this call to action.”
The effort stems from an NCI initiative in the 2014 fiscal year to fund research on HPV vaccination, focusing on the barriers to uptake as well as opportunities for encouraging immunization.
Eighteen competitive awards were made to academic cancer centers, which eventually formed a “consortium of interests,” said Cynthia Vinson, a health science administrator for implementation science at the NCI Division of Cancer Control and Population Sciences.
“It was a one-year supplemental fund to the cancer centers, and the cancer centers themselves decided to organize meetings so that they could learn from each other,” Vinson said to The Cancer Letter. “There were two meetings: the first one was held at Moffitt in January 2015, and then in November, MD Anderson hosted a meeting so that the cancer centers could come together to talk about what had happened during their one-year supplement.”
This month, cancer centers across the country received invitations from MD Anderson President Ronald DePinho to support HPV vaccination.
This is the first time NCI-designated cancer centers have endorsed a joint statement on public health, said Ernest Hawk, vice president of cancer prevention and population sciences at MD Anderson.
“To me, the exciting thing is to see NCI-designated cancer centers come in together as a community to advocate for prevention and control, which is our best approach to the disease,” Hawk said to The Cancer Letter. “That really hasn’t happened, together, previously in this way, and that’s the big news here. What you’re seeing through this action and excitement that’s generated in the cancer community is the idea of awakening these centers of excellence to another important component of their mission—this is advocacy on behalf of the public we serve.
“That’s the most exciting form of advocacy. It’s science-based, it’s credible, and it’s powerful, because it’s not just this center or that center acting in isolation, but truly coming together. That’s new and novel.”
The 69 NCI-designated cancer centers urge parents and health care providers to “protect the health of our children” through these actions:
• “We encourage all parents and guardians to have their sons and daughters complete the three-dose HPV vaccine series before the 13th birthday, and complete the series as soon as possible in children aged 13 to 17. Parents and guardians should talk to their health care provider to learn more about HPV vaccines and their benefits.
• “We encourage young men (up to age 21) and young women (up to age 26), who were not vaccinated as preteens or teens, to complete the three-dose HPV vaccine series to protect themselves against HPV.
• “We encourage all health care providers to be advocates for cancer prevention by making strong recommendations for childhood HPV vaccination. We ask providers to join forces to educate parents/guardians and colleagues about the importance and benefits of HPV vaccination.”
NCI officials say that while promoting HPV vaccination is a high priority, the institute does not endorse or promote specific guidelines.
“We are funding as much good science as we can to understand how to do it better,” said Sarah Kobrin, a behavioral research program director in the NCI Process of Care Research and Science of Research and Technology Branches. “We are enthusiastic about saving people from cervical and other HPV-related cancers. That’s our goal, to generate the evidence.
“NCI doesn’t make policy statements; we generate the evidence on which statements can be based. We’re not policymakers, we no longer send guidelines as we did a couple of decades ago. That’s a different time. It’s just not our job.”
NCI no longer participates in policymaking, because of controversy over breast cancer screening in the 1990s, said Otis Brawley, chief medical officer of the American Cancer Society and a former NCI cancer prevention expert.
“NCI has been like this since the early 90s, when they made a statement that breast cancer screening saves lives for women 50 and over,” Brawley said to The Cancer Letter. “It was not a statement against screening women in their 40s, but [then-NCI Director Samuel] Broder got in trouble and said, ‘Fine, we won’t endorse anything, that way we can’t get in trouble for endorsing things.’
“It was [then-Republican] Sen. Arlen Specter [of Pennsylvania], at that time, who threatened to cut the budget of the NCI. That’s when NCI backed off and said, ‘We’re not going to do this anymore, save the money for all those R01s.’”
The American Cancer Society recommends HPV vaccination for girls ages 11 to 12, and as early as age 9. At this time, the society has no recommendation regarding the use of HPV vaccines in boys or men. The evidence for the use of HPV vaccines in males is being reviewed and updates to the society’s recommendations will likely be published in 2016.
NCI’s Kobrin said the NCI-designated cancer centers decided to work together, because they recognized an opportunity in cancer control.
“The fact that we are a cancer community working together to understand how to promote a vaccine is why there’s so much interest,” Kobrin said to The Cancer Letter. “It’s a different area for us; it’s not another cancer screening test as we have done for decades, it’s not another prevention behavior. Immunization is a whole other world of medicine, and people who are familiar with cancer prevention and control research have needed to make linkages with immunization research communities.
“We’ve been fortunate to do that our CDC colleagues—they also are working with their cancer prevention people and their immunization people. It’s understandable why the cancer community feels the need to gather together, because it’s a new kind of topic for us.”
While MD Anderson led the initiative, the credit belongs to all cancer centers, Hawk said.
“Moffitt, right at the inception, sponsored a collaborative meeting involving NCI, CDC, and these 18 centers to figure out how to do that work and to learn from one another,” Hawk said. “And then, as it evolved over the course of the year, we thought, ‘Wouldn’t it be fantastic to come back together—these 18 original centers—but also invite all centers to the table to hear the results of these scans, so we could forge stronger ties across the cancer center community?’”
NCI-designated cancer centers operate independently of one another in most research areas, Hawk said.
“The centers of excellence do outstanding work in research, patient care, education, training, and some of them in cancer prevention and control, but they largely are funded as independent entities,” Hawk said. “They largely do what they’re funded to do; create excellence in those areas independent of one another. And then there are opportunities where they may come together around a particular topic such as NIH funding to sustain cancer research or the latest immunotherapy or something.
“So, whether it’s cooperative groups or collaborations among centers, they take joint action and try to advance some aspects of their mission. But it really hadn’t happened in cancer control, previously, to my knowledge, and that’s the big opportunity that we saw.
“We invited everybody to the table—yes, it was MD Anderson-led, but it was certainly supported by all the centers—and we designed that meeting with the help of NCI, CDC and Moffitt, with the idea of putting together what have we learned and how can we work together.”
Cancer control is a local issue requiring individual implementation strategies, Hawk said.
“What we’ve seen is, in every case, implementation of effective strategies require a local tailoring to the needs—that was one message coming out of the studies,” Hawk said. “Health care providers, mainly family medicine physicians, pediatricians, may have been suggesting vaccination, but they weren’t really advocating for vaccination, and so there’s an opportunity to educate and try to motivate and support primary care physicians in their efforts to educate parents and move them towards vaccination.”
Who Will Benefit?
The populations that stand to benefit most from HPV vaccination are those that are not currently being screened for cancer, NCI officials said.
“Generally speaking, it’s the people who have the lowest access to routine health care, so the people who live far away, who don’t have the money for good health insurance, who live in geographic areas where there are very few of the appropriate health care providers available for a community that’s spread too thin,” Kobrin said. “It’s not a new story about health care access, it’s those same people.”
HPV vaccination is especially important for women who do not regularly screen for cervical cancer screening, Kobrin said.
“It’s certainly true that we have a pretty effective cervical cancer screening system already in the United States, and we’ve succeeded in getting up to 80 or 85 percent of women to participate in cervical screening over their lifetimes in the U.S., which is the big reducer of cervical cancer diagnoses and death,” Kobrin said. “But the remaining population of people persistently—and for decades we’ve been trying to understand; we can think who they are, but how to reach them has been an unresolved problem. Reaching them meaning, not talk to them, but actually get them to participate in screening.
“One of the challenges with screening is that you can’t just do it once. Screening reduces mortality when it’s a lifetime pattern of screening at the appropriate intervals, and so, from a public health perspective, it’s most urgent for us to bring the vaccine to the communities that are not being well screened. And that’s where the biggest opportunity for cervical cancer mortality reduction comes.
“A number of other cancers and diagnoses of the other cancers that can be HPV-related are increasing, so at this point, each year, as many non-cervical HPV-related cancers are diagnosed as cervical HPV-related cancers. And for none of those other cancers do we have any available screening test. So this primary prevention with the vaccine is really the right approach.”
No one in the scientific community disagrees with HPV vaccination as a necessary public health measure, Kobrin said.
“There are no voices of dissent in the scientific community or medical community,” Kobrin said. “Some pediatricians have expressed reservations talking to parents. They perceive that they might end up talking about sexual activity with parents of young children. Part of what CDC is doing, and we’re trying to provide evidence to help them do, is teaching doctors how to make the recommendation just as they would for any other vaccine.”
HPV vaccination rates have not kept up with other CDC vaccine recommendations, Vinson said.
“The reason why looking at HPV vaccination is so important is CDC has been tracking HPV vaccination data, and when guidelines come out, immunizations generally follow a trend where they’re implemented rapidly for the population,” Vinson said. “HPV hasn’t followed the normal trend for other adolescent vaccine, so we’re seeing a difference between HPV and the other adolescent vaccines.”
Kobrin said CDC is “puzzled” by the behavior of the population in its uptake of the HPV vaccine.
“Two other recommendations for the same age groups—both recommended and approved about the same time—and the rates of uptake for the two gone straight up to the 75 to 85 percent rate, while within the same period of time, the HPV vaccine has been lagging,” Kobrin said.
ACS’s Brawley attributes the slow uptake to the cost of the vaccine as well as misperceptions about the vaccine’s impact on youth sexual behavior.
“The HPV vaccine hasn’t taken off in the U.S.—one, because it’s expensive, and two, because many people are concerned they’ll promote promiscuity,” Brawley said.
“Literally, a large number of people who are against the HPV vaccine are against it because they view it as encouraging promiscuity. The truth is, the HPV vaccine has the tremendous ability to prevent a number of head-neck, cervical and anal cancers.”
MD Anderson’s Hawk said that the NCI-funded studies found that parents are still concerned about HPV vaccination as promoting promiscuity.
“That was an old concern, but now data has emerged since then showing that HPV vaccination really doesn’t promote promiscuity,” Hawk said. “It’s an old wives’ tale. There’s an opportunity to move beyond that through effective public education.
“And of course, in isolated settings, there are individuals in the population that are still concerned about vaccine safety. However, those concerns aren’t science-based so much as they are emotionally or individually based. That told us that there was an opportunity still in public education.”
NCI officials said researchers are working on identifying the efficacy of the vaccine in reducing cancer incidence.
“Efficacy of the vaccine in reducing infection rates is extremely well substantiated,” Kobrin said, “However, it’s a little too soon to be looking at cancer data, because the vaccine was approved in 2006, and we’re talking about children.
“There are data on precancerous endpoints and there are data on infections and transmissions, for example, in Australia, they actually now have such good population level uptake that they have been able to document the decrease in infections.
“We don’t have that kind of data and uptake, and it’s soon to have actual cancer diagnosis outcomes because of that—girls who have been vaccinated at age 11 in 2006 and are not old enough even to have cervical cancer.”
Public advocacy by NCI-designated cancer centers is important for encourage uptake of the HPV vaccine in their local communities, Vinson said.
“The cancer centers are uniquely poised, because of their expertise and their presence in their local community, to start pulling those things together,” Vinson said. “We have a chance to potentially eliminate HPV-related cancers, and this is the first time that we have this opportunity.”