St. Jude’s Heather Brandt: NCI cancer centers must leverage community trust to boost HPV vaccine uptake in children

Consider these facts on HPV vaccine uptake in adolescents from 2020: 

• In Australia, 80.5% of females and 78% of males aged 15 years were reported to have received the full course of the HPV vaccine.
• In the United States, only 56.4% of females and 52.6% of males aged 13 to 15 years had received two or three doses of the HPV vaccine.

Although coverage has increased to 62% in 2021, local estimates vary dramatically, said Heather Brandt, director of the HPV Cancer Prevention Program and co-associate director for outreach at St. Jude Comprehensive Cancer Center.

“We’re at about roughly 75% for one or more dose coverage, but that’s not the case on the local level,” Brandt said. “Here in Memphis and Shelby County in Tennessee, we’re at about 36% coverage.”

Australia is in the 90th percentile for population-level coverage of HPV vaccination.

“When I say 90th percentile, I mean among those from the time the vaccine was first available to today, that 90% plus of those who were eligible have received the vaccine,” Brandt said. “And it has been for many years, because when they started their program, they really focused on school-based and school-located, and they focused initially only on girls.”

In the U.S., the Mountain West has low coverage, but also a lower burden of HPV cancers, compared to the rest of the country.

“Contrast that with the South and Southeastern United States, where we have low HPV vaccination coverage, really high burden of disease, the highest rates of cervical cancer, the highest rates of oropharyngeal cancers, the highest rates of these HPV cancers,” Brandt said.

“It’s a perfect storm as we watch that unfold.”

St. Jude’s Path to a Bright Future, an HPV awareness and vaccination campaign with nearly 160 partners, is aimed at reducing that disease burden by targeting children in a crucial age range.

“What I think is most disturbing to me is that parents and caregivers—those who make vaccination decisions for children today—are missing out on an opportunity to protect their kids from six types of cancer and other HPV diseases when they’re older,” Brandt said. 

“We are always welcoming campaign partners, and people can join us on this Path to a Bright Future for our awareness and education campaign that’s focused on on-time HPV vaccination in this age group of 9 to 12. 

“This builds on a tradition of NCI-designated cancer centers developing and issuing a kind of ‘all of us together’ message to say, this is what we think about HPV vaccination as a really important cancer prevention tool.”

Brandt spoke with Matthew Ong, associate editor of The Cancer Letter.

Heather Brandt: Well, I’m not sure there’s a simple single answer for what’s causing the decline in general awareness and understanding of the link between HPV and cancer, but it’s certainly disturbing and something that we should better understand.

Our program at St. Jude Children’s Research Hospital is focused on helping to promote awareness and build confidence in HPV vaccination for cancer prevention. And so, through our efforts to do that, we are providing information on what exactly HPV is, what HPV vaccination is, and which cancers are linked to HPV.

What I think is most disturbing to me is that parents and caregivers—those who make vaccination decisions for children today—are missing out on an opportunity to protect their kids from six types of cancer and other HPV diseases when they’re older.

And I worry that these parents and caregivers will look back in 20 years, when maybe their child has developed cervical cancer, anal cancer, or oropharyngeal cancer, which could have been prevented if they had made the decision today to protect them.

So, I worry a little bit about that. I worry about the guilt and regret that comes from that. A driver of our campaign is to make sure that parents and caregivers have the information they need to make an informed decision.

Here in the United States, you just noted the declines in awareness, and what a tragedy to see that unfold. And again, we do need to explore more deeply about what’s driving that. I think there’s some general concerns about vaccinations overall, particularly with the COVID-19 vaccine.

That’s really factored in here, but what’s really happening there? How can we identify effective messages and interventions to really turn the tide and see that trend increase over time?

But while we are doing that in the United States, in Australia, they’re on track to eliminate cervical cancer by the year 2035. They are on track to have no cases of cervical cancer, which is one of the six types of cancers.

And in the U.S., oropharyngeal cancers among men are the most common HPV cancer and have been for the last couple of years. HPV affects everyone and has the potential to cause cancers in anyone, and so, what an easy decision to push for HPV vaccination. It’s safe, it works, and it provides long-lasting protection.

And it prevents more than 90% of all cancers related to HPV.

HB: Yes.

I think it’s absolutely fascinating that you bring up Australia as an example. I mean, here in the U.S., we are 25% away from our target of 80% coverage by 2030?

HB: Right, with vast differences by geography among people living in rural areas and even within those high coverage and low coverage areas. So, it’s the perfect storm because the Mountain West has really low HPV vaccination coverage. However, they currently have low HPV cancers in comparison to the rest of the country.

Contrast that with the South and Southeastern United States where we have low HPV vaccination coverage, really high burden of disease, the highest rates of cervical cancer, the highest rates of oropharyngeal cancers, the highest rates of these HPV cancers.

It’s a perfect storm as we watch that unfold.

What is the population-level coverage for Australia in terms of HPV vaccination?

HB: It’s in the 90th percentile.

Whoa.

HB: Yes. And it has been for many years, because when they started their program, they really focused on school-based and school-located, and they focused initially only on girls.

There’s a really nice timeline that the Daffodil Centre has published that shows they started focusing only on girls, then added boys, and now they just see tremendously high coverage.

And when I say 90th percentile, I mean among those from the time the vaccine was first available to today, that 90% plus of those who were eligible have received the vaccine.

And you just said in the United States, we’re at about roughly 75% for one or more dose coverage, but that’s not the case on the local level. Here in Memphis and Shelby County in Tennessee, we’re at about 36% coverage.

For one dose?

HB: Oh yeah. This is a thing with HPV vaccination. The best data source we have nationally that is used for Healthy People 2030 goal tracking is called the NIS (National Immunization Survey) Teen Data Survey. This includes ages 13 to 17. It’s a cross-sectional look back every year at whose being vaccinated.

Each year, your pool could be slightly different. It’s a very useful data set for monitoring trends over time. However, when you look at state-level data through state immunization information systems, many of which still have some gaps, you’re going to find vast differences.

So, in Tennessee, we’re supposedly in the 60th percentile for one or more doses, but our second-largest metropolitan area is at 36%. There’s just a lot of uncertainty with some of the data sources.

The NIS teen data definitely show us good trends, and I do think we’re heading in the right direction. I don’t doubt that, but I think the full level of protection or coverage is just probably not where we hope it is today, but hopefully heading in the right direction.

HB: Certainly, awareness and knowledge are important. However, knowledge is only as important as how it’s acted on and given the opportunity to act on that knowledge. People know a lot of things that they do or don’t do.

I always use an example related to smoking. I mean, show me someone who doesn’t know that smoking is bad for them—everybody knows that—but people still engage in that behavior.

So, awareness and knowledge are only as powerful as how they can be acted on. I think that’s a piece of it and that’s important, and especially in this era of COVID-19, we need to build and rebuild confidence in vaccinations. I think that’s incredibly important and worthy of our efforts.

The single most important predictor of whether or not someone’s been vaccinated is a healthcare provider recommendation. Did the healthcare provider for that person or child recommend HPV vaccination? 

Through our campaign, Path to a Bright Future, our primary audience are the vaccine decision makers, parents and caregivers. We also have resources for healthcare providers, including tools to help healthcare providers make recommendations, and to address hesitancy that they experience.

If a parent or caregiver pushes back, “My child’s too young and my child doesn’t need this,” this would actually give them some straightforward messages to incorporate into their routine, to be able to make the recommendations. 

Now, those can work in combination meaning awareness and knowledge. If we do a good job on the awareness and knowledge building, then when presented with the opportunity by a strong provider recommendation, hopefully that supply and demand come together and result in same day recommendations and complete coverage.

There are some other factors. We know that there’s a link between Medicaid expansion and HPV vaccination. And if you look at the map, just like we were talking about earlier, those Southeastern states where we see the deficits in HPV vaccination, eight of those states—well, now seven because of North Carolina—they still need to pass implementation, but those states have gaps.

So, I think access to HPV vaccination can continue to be a challenge, but not for kids—I want to be very clear—children under 18 in the United States have full access to HPV vaccination in that 9- to 18-year-old window. There are very few gaps there and that’s because of the Vaccines for Children’s Program, the federal vaccine program that exists.

That’s also because states have stopgap funding for routinely recommended vaccines. And then there are vaccine donation programs, and that’s in addition to commercial or private insurance that universally are covering these vaccines. 

If people miss out on on-time HPV vaccination in that range, as adults, it’s much harder to access HPV vaccination. Of course, the effectiveness drops as well because of the likelihood of exposure and not getting the full benefits of this really important cancer prevention tool.

Awareness and knowledge are a piece of it. The healthcare provider recommendation is the strongest predictor of whether or not someone’s been vaccinated.

And we have to think creatively about access too. What have we learned from the COVID-19 vaccine delivery process? Are there other ways we might make this vaccination available, outside of what has traditionally been a pediatric setting, whether that’s pediatricians, advanced practice providers, family providers, or others?

Pharmacies have emerged as a potential space. Pharmacies working with healthcare provider offices or medical homes. So, those are just a few of the potential reasons why we don’t see higher coverage or some of the intervention strategies that have been shown to be most effective are addressing those different areas.

HB: Sure. Our program does not address screening. We understand that it’s going to take screening to get to elimination someday, however, our program doesn’t focus on that.

In terms of a general landscape, we’ve seen some disturbing trends in cervical cancer screening, which is the only type of HPV cancer for which routine screening is recommended by the U.S. Preventive Services Task Force.

And we’ve seen some disturbing trends over the last 20 years, where there’s been almost this steady shift downward in cervical cancer screening. And that could be explained in several different ways.

One could be that the data just simply are not giving us the complete picture. And part of why that could be the case is because the screening guidelines have evolved. As we learn more about the etiology of the way in which cervical cancer develops and manifests, we can adjust and modify the screening intervals.

Also, as we have more tools available, HPV testing as a primary test has been shown to be very effective and appropriate, and then entering follow-up care. So, with screening, we’ve seen some unfortunate declines, and that could be because the guidelines are confusing.

I mean, I think back to when I started studying cervical cancer in the early 1990s, you start getting a Pap test every year when you turn 18. That was the guideline. That’s really simple when you think about it. And that’s how healthcare providers were trained, and that’s what consumers were trained to know.

So, people with a cervix turn 18 and start getting screened. Well then, fast-forward into the evolution of liquid-based collection, now we can suspend the cells versus fixate them on a single slide. And so, now you have new technology, it’s better, it’s more accurate in terms of its ability to identify changes to the cervical cells that are going to potentially turn into cancer or are pre-cancerous.

Now we can extend the interval; it doesn’t have to be every year anymore. Maybe you can go to three years and then, eventually, where we are today, which is if you use traditional cytology, there’s a shorter interval, but if you use the new tools, it’s a longer interval. It’s five years if you don’t have a history of abnormalities.

So, I think there’s been some confusion about what exactly the guidelines are and so people are more transient. If you miss out on an appointment, who knows what that interval will look like. I think it’s confounded by a number of different factors that are on a lot of different sides here. There’s the healthcare provider side and implementing the latest guidelines.

I know you mentioned implementation science earlier. There actually have been a number of studies focused on de-implementation of the old cervical cancer guidelines.

So, how do you de-implement and replace with the new guidelines? And that would seem really easy, but it’s not necessarily that easy in a clinical setting, especially when people are still working there who remember, when you turn 18, you get a Pap test every year.

We’ve seen some declines in cervical cancer screening rates, which are unfortunate. And some of those declines have been among people who have a cervix, who come from minoritized, marginalized, and vulnerable groups. That’s concerning, because when you look at the data of who is getting cervical cancer and who’s dying of cervical cancer, it is people from those same groups.

So, there are folks who are really focused on ensuring that people understand the recommendations for screening and that healthcare provider systems are delivering that screening effectively.

There also is some innovation happening. About 20 years ago in the U.S., researchers first started looking at self-sampling studies. Some of these studies were led by colleagues at the University of Alabama in Birmingham in the Mississippi Delta.

This is because this was a hotbed of cervical cancer incidence and deaths, and just really part of it was an access issue. I mean, people had to drive for hours to go have a test and then drive hours to follow up if something came back abnormal.

So, they started using these mailed self-sampling kits and it was quite successful, but just never received approval and didn’t go any further. Well, now that self-sampling is really becoming the primary screening tool there definitely is more interest.

And there actually are, through the Cancer Moonshot Initiative, a number of people who are doing that research and trying to better understand how to integrate a self-sampling approach—that’s really ideal for people who have a lot of competing demands on their time to be able to get screened.

Another thing about screening that I’ll mention is it continues to be true today that about half of all cervical cancer deaths are among those who are rarely and never screened. So, there is this group that just have not been reached, and that’s been a pretty consistent statistic since I started studying cervical cancer many years ago.

Fifty percent is pretty compelling.

HB: I think so. There still are people who have never been screened. And with that said, we also want to be cautious about overscreening, because overscreening has detrimental effects. As our understanding of the etiology and as the tools and technology came on the scene, that really was a driver of the decision making to extend intervals.

Also, if something comes back showing a problem that needs to be followed up on, we really need to be careful and cautious in how the follow-up care looks like. Because damage to the cervix can cause all sorts of repercussions down the road. It can cause scarring that makes it very difficult to conceive, it can cause scarring that the cervix will not stay closed, it’s also called incompetent cervix during childbearing times, and also, the cervix won’t efface during delivery.

There are several possible effects on fertility and other GYN and reproductive health for people who choose that. And there are people who are trying to make sure there’s no overscreening and there’s no overtreatment, because it could result in some of these downstream effects.

HB: I do think access to care continues to be a factor. And when we think about access, there’s this old framework of the five As about access to healthcare, that it’s not just having a place to go. That’s only one piece of it.

There’s the affordability dimension, accommodation, and acceptability. So, when you think about the different As that are in place here, do we have that opportunity for people who are in need of a home for HPV vaccination or in need of a home for screening? Which again, is not necessarily the focus of our program. Does that exist for them in a way that’s going to meet the way we live today?

I think in rural areas in particular, there may be fewer access points, and fewer access points means fewer appointments, fewer appointments mean more demand for those services. And it really underscores this notion that prevention is a privilege.

I mean, getting a vaccine; somebody is having a diabetic episode, somebody has uncontrollable hypertension—these acute conditions that are maybe underlying other chronic conditions take precedent in those settings where there are stressors on access to care. And that could be the case.

We know there are far too many rural hospital closures and fewer providers who are serving rural communities, maybe less likely to offer vaccinations, even stock them. They’re like, “No, go to the health department. No, go to the pharmacy.”

And so, now you’ve taken vaccinations out of the medical home where there’s the opportunity for the healthcare provider to give that strong recommendation and then vaccinate in that same day.

So, I do think that access to care is a lot more complex and complicated. It’s particularly the case in Medicaid non-expansion states. And it is hard sometimes on a national level, where the discourse is like, “Oh, we passed that. There’s no access issues.”

There are profound access issues in states that have not expanded Medicaid—not for children in general, very few holes there—but definitely for adults in that 18- or 19- to 45-year-old age range. And HPV vaccination is routinely recommended for 19- to 26-year-olds, even though that’s a late or catch-up population, but yet, access to vaccines I think are just really not, as easy as people might think.

And not to mention that preventive services are under attack in the judiciary as we speak.

HB: Yes, they are, in fact. Yes, for sure.

You mentioned the Path to a Bright Future program, and you are partnering with a wide network of organizations and cancer centers—up to 140? Could you walk me through the nuts and bolts of the program, and how you ensure your endpoints can be achieved?

HB: Sure. Path to a Bright Future is our program’s public awareness campaign. And I want to just take a moment to talk about this Path to a Bright Future concept. 

So, when children are growing up, parents want the best for them. They want them to have greater success than maybe they could ever even imagine for their children. And they definitely don’t want their children to grow up to be cancer patients.

How can we connect this desire for parents and caregivers to want their children to be successful, have this bright future, with this moment of prevention that happens in this age? The campaign is built around that appeal to parents and caregivers about their desire to have their children set on this trajectory for a bright future.

It’s also predicated on the notion that HPV vaccination is cancer prevention, that this is a safe, effective vaccination that can provide long-lasting protection against cancers and figure out how to connect that appeal with that long-term desire for that moment today.

And we are focused on on-time HPV vaccination, and so, that means completion of the series by the 13th birthday.

In the United States, we continue to follow the CDC ACIP guidelines for HPV vaccination, which is two doses if you start before the 15th birthday and three doses thereafter. And of course, three doses, always, if somebody is immunocompromised.

Our primary target is really parents and caregivers, but we also recognize the way in which St. Jude can build confidence in the general public, healthcare providers, and even those who are of the age to be vaccinated themselves.

And so, Path to a Bright Future is really based on those concepts. It’s that moment of prevention today that offers that lifetime of protection for the future.

We know trusted messengers have to be in this space. These trusted messengers with their messages are designed to address concerns—especially when it comes to HPV vaccination—concerns about safety, effectiveness, infertility, the age at administration and more.

We want to reclaim those messages as a trusted source and really push out accurate information that is meaningful and is also useful to parents and caregivers. These messages really are designed to do that, and healthcare providers and teams are a huge part of this. You’ve heard me talk a lot about the healthcare system, healthcare providers, and teams.

So, from check in to check out in a healthcare setting, every single person has the ability to support and promote a culture that supports vaccinations and recognizes the value of vaccinations. We know they play a huge role too, which is why some of our materials target them as well.

And we are closing in on 160 partners in the campaign, including many national partners as well as NCI-designated cancer centers who have joined our efforts.

We put out a suite of resources for them to access and use, and we’re currently conducting an evaluation of the campaign right now. It’s a little more than a year old. It was launched on March 4, 2021, which was international HPV Awareness Day.

So, it’s time now to do an evaluation to understand more about our messages. Are they hitting the mark? Are they useful? How can we freshen them up and update them? So, we definitely will have additional evaluation data to share in the future.

How should cancer centers respond to, say, the findings in the HPV and cancer awareness study that we started out talking about, and everything else that we discussed?

HB: Cancer centers play an incredibly important role in the communities that they serve. And of course, we call that their catchment area. But cancer centers, NCI-designated cancer centers are trusted centers. They’re trusted for the clinical care that they provide, which is state-of-the-art and state-of-the-science.

They’re trusted for the research that they conduct that helps generate the evidence that informs the clinical care, and also the outreach and engagement services that these cancer centers provide to those communities that they’re serving.

The campaign is built around that appeal to parents and caregivers about their desire to have their children set on this trajectory for a bright future. 

And so, as part of that service, embracing this opportunity to leverage the trust that comes from the NCI cancer centers into these communities that they serve, I think is incredibly important.

Also, cancer centers have the opportunity as much as they have the clinical infrastructure to provide vaccinations and take vaccinations to the people as much as they can. And when people are coming to them to offer HPV vaccination, increasing the access points, I think, also matters. Then, ensuring within the cancer center that everyone understands the role that they have to play in helping to normalize HPV vaccination as cancer prevention.

Everybody should do it. That can infiltrate and build this pro-vaccination culture that then exists. Building community happens from the inside out and so, as cancer centers are building their capacity and their best practices, helping to ensure that those they serve are able to connect with and embrace that same vision, I think is really important.

NCI cancer centers have been the leaders in this space. Recently, the NCI has reconvened an HPV consortium. So, we existed for several years, and now we’ve started up again and are starting to offer programming for cancer centers to come together.

The consortium is very focused on research activities in addressing questions like, where are the gaps in what we know today? How can we inform tomorrow? And, what type of collaborative research activities are possible?

Our cancer center has also led the development and implementation of various policy statements on HPV vaccination. This builds on a tradition of NCI-designated cancer centers developing and issuing a kind of “all of us together”” message to say, this is what we think about HPV vaccination as a really important cancer prevention tool.

So, I think using their voice to inform the clinical care space, the research space, and then, of course, the communities that we serve through our cancer center is an equally important and appropriate approach.

HB: Exactly. And we know that NCI cancer centers across the country have long been leaders in this space, that the researchers working in these cancer centers have been developing approaches, including the strong healthcare provider recommendation approach. There really are some cancer center researchers who really have honed, developed, and put that out into the space.

And we know others have been developing these with community clinical linkages and partnerships. So, there’s been a lot of really great research that’s come from NCI-designated cancer centers that certainly has contributed to what we know today, and also helping us learn today for what’s to come tomorrow.

Did we miss anything?

HB: I will mention that we are always welcoming campaign partners and people can join us on this Path to a Bright Future for our awareness and education campaign that’s focused on on-time HPV vaccination in this age group of 9 to 12. They can join us at our Bright Future website.

The last thing that I wanted to mention is recently, our program here at St. Jude worked with the American Cancer Society and with the National HPV Vaccination Roundtable to release a special issue of the Journal of Human Vaccines and Immunotherapeutics, where we focus on the importance of starting HPV vaccination at age 9 to help achieve higher on-time completion rates.

The articles that have been published so far really tell the story about how this offers a useful strategy and approach to starting at age 9. It pulls HPV vaccination out of the traditional adolescent vaccination platform at ages 11 to 12.

Earlier, I mentioned the impact of the COVID-19 pandemic and COVID-19 vaccines in this space. Other things we’re learning: Parents and caregivers do not want their 11- to 12-year-olds to get multiple vaccinations at that visit. And so, HPV is often the vaccine that falls off the list.

If you give HPV vaccination at age 9 and give the next dose at the next visit, you’ve then completed the series. Then, when your child is in that 11- to 12-year-old age range, they can get pertussis or Tdap in one arm and meningitis in the other. So, lots of benefits.

On-time approaches for 11 to 12 work for a lot of families, but they’re not working for everyone. And so, starting at age 9 can really be a strategy to help overcome the hesitancy that exists.

Thank you so much.

HB: Thank you.